Diagnosis of a thoracic inlet tumour by transbronchial biopsy.

A 67-year-old man presented to the pulmonary service with left shoulder and arm pain. Examination disclosed a left Horner's syndrome. Supraclavicular exploration at another hospital was not helpful. Transbronchial biopsy through a flexible fibreoptic bronchoscope retrieved tissues showing poorly differentiated carcinoma. There are no previous reports of the use of the technique in the diagnosis of a Pancoast tumour with a normal standard chest radiograph.     

Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis

Ten patients diagnosed with Pancoast tumor were studied retrospectively. The definitive diagnosis was made between 2 and 24 months after the onset of pain. Pain localization was hard to pinpoint; some patients reported pain in four different sites (neck, shoulder, arm, and scapula). Five patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. In the remaining five patients, the diagnosis was made during the first clinical visit. In three patients, an orthopedic surgeon made the diagnosis by viewing a standard anteroposterior (AP) cervical radiograph. The radiographic evidence arousing suspicion of a Pancoast tumor was the lack of pulmonary air at the top of the affected lung. Furthermore, a parallel study was conducted on 100 consecutive patients seeking treatment for neck pain. By examining the AP radiographs of their cervical spines, the third rib and the top of both lungs were observed in all cases. This study stresses the value of standard AP cervical radiographs in the diagnosis of Pancoast tumor.     

Pancoast''s syndrome associated with invasive aspergillosis.

The combination of lower brachial plexus root pain in the shoulder and arm and of ipsilateral Horner's syndrome was described by Pancoast in 1932 and is usually caused by a malignant tumour at the apex of the lung. We describe a case in which the syndrome occurred in an immunosuppressed patient and was due to invasive fungal infection.     

Shoulder impingement presenting as neck pain

BACKGROUND: Chronic neck pain can be a difficult problem to evaluate and treat, as it can have several different causes. We studied a series of patients with neck pain near the superomedial aspect of the scapula that was referred pain from inflammation of the shoulder secondary to chronic impingement. We postulate that some patients with specific clinical findings and neck pain can benefit from treatment of shoulder impingement. METHODS: We conducted a retrospective review of the charts of thirty-four patients with neck pain who met three criteria for the diagnosis of shoulder impingement syndrome: (1) a positive impingement sign with pain referred to the neck, (2) radiographic abnormalities, and (3) relief of neck pain after injection of lidocaine and cortisone into the subacromial space. Subjective pain scores were determined before and after the injection. RESULTS: Thirty of the thirty-four patients obtained immediate relief of the neck pain following injection into the subacromial space, and the remaining four had substantial pain relief when they were evaluated three weeks following the injection. Avoidance of the shoulder impingement position (forward elevation of the arm above 90 degrees ) subsequently minimized recurrences. CONCLUSIONS: In selected patients, chronic neck pain may be caused by shoulder impingement, which can be easily diagnosed with standard techniques. The difficulty in making this diagnosis is that the patient presents with neck pain rather than with the typical shoulder pain. The differential diagnosis of chronic lower neck pain should include shoulder impingement syndrome, which can be identified by classic physical and radiographic signs and can be treated with injection into the subacromial space and avoidance of the shoulder impingement position.     

Quadrilateral Space Syndrome: Case Report and Review of the Literature

The quadrilateral space syndrome is defined as tenderness over the quadrilateral space and shoulder pain radiating to the arm, secondary to compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. The symptoms are aggravated by forced abduction and extrenal rotation of the arm. The diagnosis is clinical and is documented by arteriography or angio-MR imaging with dynamic maneuvers. A 30-year-old woman presenting with this syndrome is described here, the differential diagnosis discussed, and the literature reviewed.     

Tuberculosis presenting as Pancoast tumor

A 48-year-old man presented with pain in his left shoulder radiating to the left scapula and a tingling sensation of the left arm with involvement of the fourth and fifth finger. Based on the clinical and radiologic findings, the diagnosis of Pancoast tumor of the left lung was made. Computed tomographic guided fine needle biopsy was not conclusive. A video-assisted thoracoscopic surgery was performed to obtain a biopsy. The histologic and microbiologic examinations established the diagnosis of tuberculosis (TB).     

A prospective, longitudinal study of pain in head and neck cancer patients.

BACKGROUND: Little is known about the epidemiology of pain in head and neck cancer, the effects of curative treatment on this pain, and the impact that pain experience may have on patients' quality of life (QL). METHOD: The prevalence and severity of pain was studied in 93 patients who were first seen with a diagnosis of head and neck cancer, were treated, and remained disease free at two years. QL assessment utilised the life-satisfaction scale and the General Health Questionnaire as specific measures. Pain was assessed by a linear analogue scale anchored by words and numbers. RESULTS: Forty-eight percent had head and neck pain when first seen, whereas only 25% and 26% had such pain at 12 and 24 months. Approximately 8% of patients rated the pain as "severe" when first seen, whereas 3% had severe pain at 12 months and 4% at 2 years. The prevalence of shoulder and arm pain increased from 14% at diagnosis to 37% at a year and 26% at 24 months, but the percentage of patients with severe pain at any stage postoperatively was only 5% and 2%, respectively. Any pain (pain in either in the head and neck or shoulder and arm or both) at 2 years was strongly predicted by earlier posttreatment pain (at 3 months or at 12 months.) Shoulder and arm pain at 2 years was strongly correlated with surgical treatment of the neck, although no difference in pain experience was noted between those who had radical neck dissections and those who had more conservative procedures. There was no correlation between radiotherapy to the neck and subsequent shoulder and arm pain. Pain had an adverse effect on the general well-being and psychological distress of head and neck cancer patients who were free of disease. CONCLUSIONS: Pain is common among those presenting with curable head and neck cancer. Pain can be reduced by curative treatment but neck dissection may cause increased shoulder and arm pain. Ongoing pain is predictable and impacts adversely on patients QL.     

Parsonage-Turner syndrome and a localised swelling around the extensor tendons of the hand: A clinical sign indicating increased risk of rupture of the tendon

Abstract

Two patients presented with intense pain in the shoulder followed by weakness and paralysis of muscles in the shoulder and arm, together with a peculiar swelling on the hand. The swelling seems to predispose to rupture of the extensor tendon. If this tumour is a regular finding in Parsonage-Turner syndrome, it may also help in making a definitive diagnosis.     

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is an often misdiagnosed cause of neck, shoulder, and arm disability. Neurovascular compression may be seen in the interscalene triangle, costoclavicular space, or posterior to the pectoralis minor, although any cause of abnormalities of shoulder girdle alignment may cause a localized area of brachial plexus compression. Nerve compression in this way may lead to upper extremity weakness, pain, paresthesias, and numbness. A careful and detailed medical history and physical examination are essential to proper identification of thoracic outlet syndrome, which remains primarily a clinical diagnosis. Diagnostic testing may differentiate other causes of pain or neurologic symptoms of the upper extremity from TOS. Clinical management is often challenging.     

Screening for Head,Neck, and Shoulder Pathology in Patients with Upper Extremity Signs and Symptoms

Narrative ReviewConditions of the head, neck, thorax, and shoulder may occur simultaneously with arm pathology or produce symptoms perceived by the patient to originate in the elbow, wrist, or hand. Identification of the tissue disorder and associated impairments, followed by matching the rehabilitative intervention to address these issues, leads to optimal outcomes. With this goal in mind, the hand therapist needs to recognize clinical findings that signal potentially serious medical conditions of the brain, cervical region, chest, or shoulder. Additionally, less serious but potentially debilitating, musculoskeletal or neurogenic pain from proximal sources must also be differentiated from somatic pain originating in the elbow, wrist, or hand so that the clinician can decide to further examine and intervene or refer to an appropriate health care provider. This article describes clinical findings that suggest the presence of serious medical pathology in the head, neck, or thorax and presents a screening algorithm to assist in discriminating pain derived from local structures in the distal arm from referred pain originating in the more proximal regions of the shoulder, thorax, neck, or brain.Level of Evidence5.     

Thoracic outlet compression

In a review of his experience with thoracic outlet compression, the author attempts to define factors that will help select patients for operation. Fifty-three patients underwent 59 transaxillary resections of the first rib. In almost all cases the diagnosis was clinical, based mainly on the history. Aortography was useful only when intrinsic vascular disease was suspected. Nerve-conduction studies were not helpful and were used only to confirm a diagnosis of peripheral nerve compression. Of 44 patients followed up, 33 had good or excellent results. Of the 11 patients with poor results, 8 complained of persistent neck and shoulder pain. The author concludes that the diagnosis of thoracic outlet compression is clinical and is based mainly on the patient's history. Transaxillary resection is safe and effective, particularly for patients whose symptoms are mainly in the hand and arm. It is not effective for those whose predominant complaint is neck and shoulder pain.     

Surgical treatment of Pancoast tumours.

Due to its localisation in the apex of the lung with invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, a superior sulcus tumour causes characteristic symptoms, like arm or shoulder pain or Horner's syndrome. If rib invasion is the only feature, lysis of the rib must be evident on the chest radiograph; otherwise the tumour cannot be defined as a Pancoast tumour. It is important to adequately stage the tumour, because staging significantly influences survival. Survival is better for T3 than T4 tumours and mediastinal lymph node involvement has been found to be a negative prognostic factor. Also Horner's syndrome and incompleteness of resection worsen survival. The management of superior sulcus tumours has evolved over the past 50 years. Before 1950 it was considered to be inoperable and uniformly fatal. Shaw and Paulson introduced combined modality treatment and for many years, this combination of radiotherapy and surgery was the treatment of choice with a mean 5-year survival of approximately 30%. Postoperative radiotherapy or brachytherapy does not improve survival in patients with complete or incomplete resection. The tumour can be resected through the classic posterior Shaw-Paulson approach or the newer anterior transcervical approach, introduced by Dartevelle. This method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels. Regarding the extent of pulmonary resection, en bloc resection of the involved ribs with a lobectomy is recommended. Recent multimodality studies, involving chemoradiotherapy and surgical resection, show promising results regarding completeness of resection, local recurrence and survival, provided that appropriate staging has been carried out. However, careful patient selection and adequate perioperative management with protection of the bronchial stump or anastomosis are important to achieve reasonable rates of morbidity and mortality. As brain metastases remain one of the most common forms of relapse, further studies are needed to examine the role of prophylactic cranial irradiation in patients with complete resection. Also the addition of other chemotherapy agents or biologic agents such as angiogenesis inhibitors or tyrosine kinase inhibitors gives a new perspective in the treatment of Pancoast tumours.     

Diagnosis and co-management of temporomandibular joint disorders: a case study

Temporomandibular disorders are a common presenting complaint to both chiropractor and dental surgeon. They often have complex, multiple aetiologies with overlying psychological factors which require careful diagnosis and prioritisation. This case outlines the diagnosis and successful co-management of a 48 year old housewife who sought treatment for right-sided headaches, face, jaw and arm pain of five years duration. Onset was insidious but followed multiple dental extractions. The case illustrates that orthodontic outcomes can be dependent on chiropractic intervention and supports the concept of integrated care. The functional and anatomical relationship between the jaw, head, cervical spine and pelvic complex are discussed.     

Case Reports: Unusual Cause of Shoulder Pain in a Collegiate Baseball Player

The objective of reporting this case was to introduce a unique cause of shoulder pain in a high-level Division I NCAA collegiate baseball player. Various neurovascular causes of shoulder pain have been described in the overhead athlete, including quadrilateral space syndrome, thoracic outlet syndrome, effort thrombosis, and suprascapular nerve entrapment. All of these syndromes are uncommon and frequently are missed as a result of their rarity and the need for specialized tests to confirm the diagnosis. This pitcher presented with nonspecific posterior shoulder pain that was so severe he could not throw more than 50 feet. Eventually, intermittent axillary artery compression with the arm in abduction resulting from hypertrophy of the pectoralis minor and scalene muscles was documented by performing arteriography with the arm in 120° abduction. MRI-MR angiographic evaluation revealed no anatomic abnormalities. The patient was treated successfully with a nonoperative rehabilitation program and after 6 months was able to successfully compete at the same level without pain.     

Validity of clinical tests in the diagnosis of root compression in cervical disc disease

The purpose of this study was to test the validity of three clinical tests (the neck compression, the axial manual traction, and the shoulder abduction test) in the diagnosis of root compression in 43 patients with cervical disc disease. The validity was investigated regarding radicular pain, neurologic signs, and root compression signs in myelography. All tests were highly specific for the validity parameters. However, the sensitivity was low; it ranged from 26 to 50% for the three single validity parameters in roots C6-8, and from 40 to 64% for combined neurologic and radiologic signs. It is concluded that, despite low sensitivity, these tests are a valuable aid in the clinical examination of a patient with neck and arm pain.     

Management of chronic pain in whiplash injury

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by 'atypical' carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression.     

Endovascular Management of an Unusual Cause of Pancoast Syndrome

Vascular conditions presenting with Pancoast syndrome are rare. A case of vertebral artery pseudoaneurysm presenting with Pancoast syndrome is reported. The aneurysm was successfully treated by proximal coil embolization.     

Thoracic Outlet Syndrome Masquerading as Coronary Artery Disease (Pseudoangina)

Forty-four patients presenting with chest pain suggesting coronary artery disease had normal exercise stress tests and selective coronary angiography and subsequently were found to have an unsuspected thoracic outlet syndrome. Thirteen additional patients had both significant coronary artery disease and thoracic outlet syndrome. Esophageal and pulmonary disease were ruled out and the diagnosis of brachial plexus compression in the thoracic outlet established by a reduction of the ulnar nerve conduction velocity (UNCV) below normal, the normal value being 72 meters per second. Clinical improvement from thoracic outlet compression resulted either from physical therapy if the UNCV's were above 55 m./sec, or from transaxillary surgical extirpation of the first rib if the UNCV's were below 55 m./sec. Thirteen patients with coronary artery disease and thoracic outlet syndrome required therapy for both problems before improvement ensued. Although the usual symptomatology for thoracic outlet syndrome involves pain and paresthesias of the shoulder, arm, and hand, the chest wall is frequently involved. If the chest pain is predominant with minimal shoulder-hand symptoms, the diagnosis is not suggested clinically and can only be established by the high index of suspicion, positive UNCV reduction, and a normal coronary angiogram. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm.     

Antero-superior approaches in the practice of thoracic surgery

Objective: To review our experience using antero-superior approaches for resection of a heterogeneous group of tumors, both benign and malignant, involving the thoracic inlet and adjacent structures. These included Pancoast type bronchial carcinomas, primary neurogenic tumors, soft-tissue neoplasms, and metastases from a variety of primary sites. Methods: Between October 1993 and January 1998 we undertook 22 operations on 21 patients using a variety of antero-superior approaches. The anterior cervical-transsternal approach was used in 11 operations, the Dartevelle technique was used in five cases, the modification described by Nazari in one patient and that described by Grunenwald in five cases. Results: 21 of the 22 operations were considered to be complete resections with negative margins. There were no intraoperative or postoperative deaths. Major complications occurred in five patients; acute respiratory distress syndrome (n=4), and thrombosis of the arterial graft and acute respiratory distress syndrome (n=1). Chronic morbidity was observed in 12 patients; prolonged arm pain (n=1), arm edema (n=2), motor and sensory deficits (n=2), phrenic nerve paresis (n=1), disfigurement and instability of the pectoral girdle (n=4), and disturbances in shoulder girdle function (n=2). Conclusions: The anterior cervical-transsternal approach we previously described provides adequate exposure for the resection of neurogenic tumors originating in the brachial plexus and sympathetic chain, and for metastatic nodal disease at the base of the neck or in the superior mediastinum. We have found it to be associated with little morbidity, the postoperative stay has been short, and it has proven flexible enough to cope with the changed circumstances found at surgery. For Pancoast type bronchogenic carcinomas and other malignancies with extensive invasion of major structures at the thoracic inlet, we believe the best present option is the clavicle sparing antero-superior technique described by Grunenwald as a modification of the Dartevelle approach. When operating for lung cancer we presently feel that the antero-superior approach should be combined with a posterolateral thoracotomy, to accomplish complete intraoperative staging and undertake anatomical pulmonary resection under optimal conditions.     

Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity

The stinger syndrome is a common neuropathy caused by traction or compression of the brachial plexus. In general, it is seen in young adults involved in sport activities and a major contact trauma is the rule. An 11-year-old boy with bilateral glenohumeral joint laxity had pain in the left shoulder, numbness and decreased strength in the left arm that developed after striking against a wall while running, with the left shoulder in extension and the neck in minimal lateral flexion to the contralateral side. Physical examination showed extreme anteroinferior passive translocation of the humeral head in neutral rotation and a positive sulcus sign in the left shoulder. The diagnosis was made as brachial plexus neuropathy (stinger syndrome) resulting from traction trauma and shoulder joint laxity and a shoulder-arm brace was applied. After two weeks, atrophy was detected in the right deltoid, supraspinatus, and infraspinatus muscles, and active and passive motion exercises of the shoulder were initiated. At the end of three months, he achieved normal range of motion of the shoulder and muscle strength.