M*******, Nate
Date of Procedure: Friday, December 8, 2000 10:15
Procedure Code: ms4439 - MR Brachial Plexus
Bilateral Magnetic Resonance Imaging Of The Brachial Plexus: 12/8/2000
Clinical Indications: This is a muscular narrowed chest 29-year-old software engineer who developed progressive aching and stiffness in the forearms, related to prolonged typing. He plays numerous musical instruments, Because of the above complaints, he had to give up piano, guitar, and trombone. His symptoms apparently, were early in development in late 1998. They became worse by January 1999 and more severe in March 1999. His left hand was "nonfunctional". He tried several forms of treatment and was given a diagnosis of tendonitis. Physical therapy with Naprosyn was unrewarding.
Dr. Newkirk refers to his continuous problems of burning sensation over the dorsum of both hands with stiffness and tightness of the forearms increasing with activity as the cause for sleep distruption. Because of the above he sought acupuncture treatment which has not been definitive.
NEUROLOGICAL EXAMINATION BY DR. Newkirk: Positive for palpable dystonia in the forearm, extensor and flexors. No evidence of carpal tunnel syndrome. Mild fascial thoracic outlet syndrome is present with symptoms reproducible by neural immobilization. Edema was present over the left clavicle.
DIAGNOSES BY DR. Newkirk: Postural strain syndrome, left thoracic outlet syndrome, acquired limb dystonia, worse on right than left with postural strain changes over the neck and back. Because of suspected thoracic outlet syndrome, bilateral MRI of the brachial plexus was requested.
Pa Lateral Chest Radiographs: 12/8/2000
Findings: The thorax is narrow with anterior rotated clavicles bent over acute sloping ribs. The heads of the clavicles are present over the posterior fourth ribs, right slightly higher than left. The right shoulder droops as compared to the left. The right hemithorax is smaller than the left. The anterior left hemithorax extends beyond the right. The lungs are hyperaerated secondary to the thin narrowed thorax. The right transverse process of the first thoracic vertebra slopes right to the smaller right hemithorax.
Conclusions:
1) Bilateral asymmetric round shoulders, left greater than right.
2) Left concave scoliosis of the thoracic spine, T1-T5.
3) Thin narrowed thorax with bent clavicles as described.
4) No acute disease.
Technique: Bilateral MRI of the brachial plexus was conducted on the 1.5 Tesla GE Signa Unit, 5.7 software, 512 x 256 matrix, 44 x 44 cm field of view, saline water bags alongside the neck to enhance signal to noise ratio, 4mm thickness. Coronal, transverse, transverse oblique, sagittal, bilateral coronal abduction external rotation of the upper extremeties, 2D TOF MRA sequences were obtained. Selected reformat 3D reconstruction of the coronal, transverse and sagittal sequences were also evaluated. Selected enlarged images were obtained for physicians preview.
Coronal sequence TR 666, TE 8. The thin narrowed thorax and drooping right shoulder, right lower than left, with mild scoliosis of the upper thoracic spine, T1-T4, concave right, is displayed, images 1/49-21/49. The near straight thoracic and cervical spine reflect the narrowed anatomic thoracic outlet.
Generous muscles with narrow fascial planes throughout the neck, shoulder girdles and chest wall. The tense straight subclavian arteries and binding nerve roots acutely descend over the first ribs into the supraclavicular fossa, images 24/49-27/49. The left first rib is higher than the right, consistent with the larger left hemithorax. The clavicles and subclavius muscles compress the subclavian veins on the first ribs, left greater than right, images 27/49-29/49. The manubrium sterni slopes right to the smaller thoracic inlet, images 34/49-36/49.
Transverse sequence TR 500, TE 8. Anterior bowing of the left hemithorax, anterior to the right hemithorax; manibrium sterni slope to smaller right hemithorax reflects asymmetry of the near straight (flat) posterior and anterior chest walls, images 1/53-22/53. The asymmetric heads of the clavicles join the manibrium sterni, left anterior to right, image 13/53-15/53. The clavicles and subclavius muscles asymmetrically compress the right larger subclavian vein against the anterior scalene muscle as compared to the smaller left subclavian vein on the higher first rib, images 16/53-24/53. The subclavian arteries and binding nerve roots are compressed posterior to the anterior scalene muscles, right greater than left, images 22/53-24/53.
The close proximity of the sternocleidomastoid muscles to the carotid sheath compress the internal jugular veins which contributes to the gray signal intensity of the smaller left internal jugular vein and marked compression of the right internal jugular vein, at the bicuspid valves, images 23/53-32/53.
Left transverse oblique sequence TR 400, TE 8. This sequence confirms acute angulation compression of the right subclavian artery with binding nerve roots posterior to the intermediate high signal intensity of the compressed right internal jugular vein, image 1/19. Costoclavicular compression of the subclavian vein on the first rib against the tense straight course of the subclavian artery with binding nerve roots is displayed, images 2/19-6/19. The intermediate high signal intensity within the right internal jugular vein reflects greater compression of the right carotid sheath, image 12/19.
Right transverse oblique sequence TR 400, TE 8. The clavicle and subclavius muscle compress the larger subclavian vein against the neurovascular bundle over the first rib into the supraclavicular fossa, images 1/19-8/19.
Left sagittal sequence TR 400, TE 8 (1/71-41/82). The tense straight course of the first division of the small subclavian artery invaginates the pleura as it courses over the vertebral artery to enter the scalene triangle, images 37/80-30/78. The anterior rotated head of the clavicle compresses the subclavian vein on the pleura against the anterior scalene muscle, mildly compressing the subclavian artery and binding nerve roots within the scalene triangle, images 33/79-30/78. The close proximity of the clavicle and subclavius muscle to the junction of the subclavian and external jugular vein contributes to the compression of these two veins on the first rib, into the supraclavicular fossa, images 29/78-27/78. The low clavicle and subclavius muscle compress the axillosubclavian artery and vein with binding nerve roots lateral to the second rib, posterior to the pectoralis minor muscle, into the axilla. The descreased venous return is reflected by the high signal intensity of the cephalic vein, images 28/78-1/71.
Right sagittal sequence TR 400, TE 8 (images 42/82-82/82). The narrowed thorax is displayed, images 42/82-45/83. The anterior rotated head of the clavicle compresses the brachiocephalic vein and the internal jugular vein against the subclavian artery, image 51/84. The subclavian artery with binding nerve roots is mildly compressed within the scalene triangle, image 55/84.
The clavicle and subclavius muscle compress the gray signal intensity of the larger right subclavian vein as it joins the external jugular vein on the first rib, images 55/84-63/84. The gray signal intensity of the axillosubclavian vein in close proximity to the clavicle and subclavius muscle reflects compression, images 62/84-63/84. Close proximity of the clavicles and subclavius muscles to the pectoral muscles effaces the low signal intensity of the right axillosubclavian artery and vein on the first rib anterior to the first fascicle of the serratus anterior muscle, images 67/84-69/84.
2D TOF MRA GRASS technique 60, TR 45. The left neurovascular supply is displaced anterior to the right, stacked image 1/125. The tense straight course of the subclavian arteries and compression of the subclavian veins with collateral circulation over the left neck and right shoulder is displayed. The second division of the left subclavian artery and the subclavian vein are compressed on the same image with compression of the right subclavian vein and the second division of the right subclavian artery as described above. The compression of the right internal jugular vein cross reference with compression displayed on the transverse and sagittal sequences.
3D reconstructed coronal images confirm the stacked image. The second and third divisions of the right subclavian artery are mildly compressed with the subclavian vein. Proximal dilation of the axillosubclavian vein reflects the above, images 7/125-15/125.
The second division of the left subclavian artery is mildly compressed with proximal dilation of the left subclavian vein at the formation of the left innominate vein, images 7/15-12/125.
The right internal jugular vein compression proximal to its junction with the right subclavian vein reflects tension and compression between the sternocleidomastoid and the anterior scalene muscle, images 10/125-12/125.
A dilated left vertebral artery appears to exist the aortic arch posterior to the left subclavian artery, images 4/125-18/125.
Bilateral coronal abduction external rotation sequence TR 400, TE 8. The posterior inferior rotation of the clavicles and the posterior anterior medial rotation of the coracoid processes depress the neurovascular bundles within the scalene trangles and within the supraclavicular fossa. The subclavian and axillosubclavian veins are compressed bilaterally, images 1/25-18/25. The asymmetry of the anterior ribs, left higher than right, displays the accented costoclavicular compression, images 4/25-15/25. High signal intensity hepatic and internal mammary veins reflect decreased venous return, images 24/25-25/25.
Bilateral abduction external rotation sequence triggered complaints of a pulling sensation over the right shoulder with cold-like sensations and tingling throughout the right arm, more in the forearm than the upper arm, down into the fifth digit of the right hand. Left triggered complaints were similar and a pulling-like sensation developed over the left neck. The same sensations as above were experienced. There were no complaints within the lower extremeties, no rushing, swooshing or ringing in the ears, no blurred vision, and no nausea or dizziness.
Comment: This is a thin muscular male with narrowed fascial planes, bilateral round shoulders, and bent clavicles as described. Multiplanar T1 weighted MRI and 2D Time of Flight MRA cross reference and display costoclavicular compression of the brachial plexus, bilaterally. Bilateral abduction external rotation of the upper extremeties enhanced tension on the neurovascular bundles and triggered complaints as described above.
Conclusions:
1) Narrowed asymmetric muscular thorax, right hemithorax smaller than left.
2) Left concave mild kyphoscoliosis of the thoracic spine.
3) Left first rib longer than right contributing to the asymmetric backward displacement of the manubrium sterni and asymmetric compression of the neurovascular bundles within narrowed fascial planes over the first ribs into the supraclavicular fossa.
4) Marked compression of the right internal jugular vein proximal to the subclavian vein junction as displayed on the transverse and 2D Time OF Flight MRA sequences.
6) Bilateral costoclavicular compression (laxity) of the brachial plexus
7) Bilateral abduction external rotation sequence captured imaging documenting increased tension and the reflected comments of triggered complains.
8) Dilated left vertebral artery exists separate and posterior to the left subclavian artery?
The entire procedure was monitored by Dr. James D. Collins, at the imaging console.
[ebx]
James Collins, M.D. (P01825)
(signed 01/09/2001 at 19:34)
Dicated:
By: James Collins, M.D. (P01825)
Reference number: RA-12713865
Received: 1/9/2001 19:23
Document ID Number: 12713865
This page is from conquerrsi.com, a website written by former RSI sufferer Nate. Since the website is now inactive, Nate has given the PTPN permission to repost the content on the wiki. These pages may be out-of-date as they have only been updated sparingly. They are part of an ongoing effort by the PTPN to archive inactive TMS websites.
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