RSD Puzzle #096

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

What is the relationship between RSD and Thoracic Outlet Syndrome (TOS)?

The Thoracic Outlet Syndrome refers to any symptom or sign related to impingement (encroachment) of the nerves of the brachial plexus and the subclavian-brachial artery exiting the thoracic outlet triangle. This triangle is on the lower lateral aspect of the neck, immediately above the clavicle (collar bone). This is a triangle made of SCM and scalen muscles, which makes the anterior aspects of the triangle, and the clavicle, which is the base of the triangle.

This syndrome is non-specific (it is not caused by any specific disease). It is one of the most over diagnosed and improperly diagnosed syndromes. In it's true sense, the artery exiting this triangle, which provides the circulation for the upper extremity, is impinged, causing poor circulation and weakness of the pulse in the upper extremity. In rare circumstances (very rare circumstances), a congenital extra rudimentary rib causing narrowing of the triangle and contributes to the development of the TOS.

Among the RSD patients, this syndrome is not uncommon. The TOS in RSD patients invariably is due to inflammation, a complication of RSD. RSD manifests itself by four principles:

1. Sensory nerve dysfunction with burning and /or stabbing pain.

2. Motor nerve response in the form of muscle spasm and constriction of blood vessels.

4. Stimulation of the limbic system (temporal frontal lobe) resulting in insomnia, agitation and depression.

The inflammation in RSD is the number one cause of impingement (entrapment) of the median nerve (Carpal Tunnel Syndrome), the ulnar nerve, Tarsal Tunnel Syndrome at the ankle and Thoracic Outlet Syndrome (TOS) at the thoracic outlet region.

Treatment consists of physical therapy, exercise, and nerve blocks. In more severe cases, instead of surgery, the condition can be relieved and corrected by the use of I.V. Mannitol, which selectively reduces the intracellular swelling of the nerves and corrects the edema.

The conventional surgery for TOS in RSD patients is risky due to the fact that the trauma of surgery contributes to the inflammatory response of the involved area. This results in further aggravation of the edema and spread of the RSD to adjacent areas. If at all possible, an RSD patient should not be exposed to any kind of major trauma of surgical procedures.

Finally, edema and subsequent TOS are relatively common complications of late stages of RSD. By then, the chronic and partially treated RSD loses it's classical clinical picture and becomes hard to diagnose. As a result, the patient is told that they do not suffer from RSD, but from TOS. This is a serious mistake because in the chronic stages of RSD the plasticity and power of healing of the part of the body that has become defective. Denying the diagnosis of the disease, and performing and unnecessary operation, will only seriously aggravate the severity of the RSD and will cause irreversible damages.

H. Hooshmand, M.D.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.