Thoracic outlet syndrome.

A 44-year-old woman presents with a chief complaint of neck pain with radiation of paresthesias into her left medial forearm, and fourth and fifth digits. She was involved in a rear end motor vehicle collision 2 years prior. Her symptoms are exacerbated by work (eg, typing, mousing), and combing her hair, and have remained relatively constant at 3 of 10 average, and 8 of 10 at its worst by visual analogue scale (VAS) scale. Her current physical examination reveals a moderate cervicothoracic kyphosis, head forward, rounded shoulder posture. She has a normal neurologic examination with absence of extremity edema, normal pulses, and no bruits with auscultation over the supraclavicular fossae. Spurling maneuver recreates local pain into the upper trapezius only. Roos, Wright, and Adson tests are positive bilaterally for reproduction of her medial forearm and digit paresthesias without diminished pulses. Cervical radiographs reveal elongated C7 transverse processes bilaterally without cervical ribs and magnetic resonance imaging 6 months after the injury showed mild to moderate spondylosis at C5-6 and C6-7 without central or foraminal stenosis. A Doppler ultrasound study performed 8 months after the injury was negative for upper extremity deep vein thrombosis and an electrodiagnostic test 8 months after the injury was negative for radiculopathy, plexopathy, or ulnar entrapment neuropathy. Treatment has included 3 months of chiropractic and 12 visits of physical therapy immediately after the accident including ultrasound, massage, electricl stimulation, and cervical traction, with each treatment offering only mild temporary relief. In total, her presentation is suggestive for thoracic outlet syndrome, but there is no distinct evidence for neurological or vascular impairments. Her primary care provider has suggested that this problem may be “in her head.” What is your clinical impression and what further assessment and treatment do you recommend? Guest Discussants: