Variability in electrodiagnostic findings associated with neurogenic thoracic outlet syndrome

Abstract

Introduction/aims: Neurogenic thoracic outlet syndrome (NTOS) is a heterogeneous and often disputed entity. An electrodiagnostic pattern of T1 > C8 axon involvement is considered characteristic for the diagnosis of NTOS. However, since the advent of high-resolution nerve ultrasound (US) imaging, we have encountered several patients with a proven entrapment of the lower brachial plexus who showed a different, variable electrodiagnostic pattern.

Methods: In this retrospective case series, 14 patients with an NTOS diagnosis with a verified source of compression of the lower brachial plexus and abnormal findings on their electrodiagnostic testing were included. Their medical records were reviewed to obtain clinical, imaging, and electrodiagnostic data.

Results: Seven patients showed results consistent with the "classic" T1 axon > C8 pattern of involvement. Less typical findings included equally severe involvement of T1 and C8 axons, more severe C8 involvement, pure motor abnormalities, neurogenic changes on needle electromyography in the flexor carpi radialis and biceps brachii muscles, and one patient with an abnormal sensory nerve action potential (SNAP) amplitude for the median sensory response recorded from the third digit. Patients with atypical findings on electrodiagnostic testing underwent nerve imaging more often compared to patients with classic findings (seven of seven patients vs. five of seven respectively), especially nerve ultrasound.

Discussion: When there is a clinical suspicion of NTOS, an electrodiagnostic finding other than the classic T1 > C8 pattern of involvement does not rule out the diagnosis. High resolution nerve imaging is valuable to diagnose additional patients with this treatable condition.

Keywords: brachial plexopathy; clinical neurophysiology; electrodiagnostic studies; nerve ultrasound; neurogenic thoracic outlet syndrome.

FIGURE 1

Nerve US of the right brachial plexus of patient 10. Elongated C7 transverse process (A, *) with enlarged C7 root (B, cross‐sectional area 0.17 cm²). Enlarged lower trunk of the brachial plexus (cross‐sectional area 0.17 cm²) with wedge sickle (C, protruding edge of the middle scalene muscle as a layer between the supraclavicular plexus and pleura) with kinking of the C8 root (D)

FIGURE 2

MRI of the brachial plexus of patient 10. A, T1 TSE coronal MRI showing right cervical rib with kinking of the C8 root below the cervical rib (arrowhead) (fibrous edge of SCM not visible). B, T2 STIR coronal MRI with visible deviation of the C7 root on the right over cervical rib (arrowhead)