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Musculoskeletal and Sports Medicine

(Kiosk 2) Right Hand Numbness and Weakness in the Setting of True Neurogenic Thoracic Outlet Syndrome

Thursday, November 16, 2023
5:00 PM – 7:00 PM CT

    Primary Author(s)

  • Kevin Liu, MBA, MD

    Resident physician
    University of Virginia Medical Center PM&R Program
    Charlottesville, Virginia

    • Co-Author(s)

  • Robert J. Maldonado, MD

    Interventional Spine and Musculoskeletal Medicine Fellow
    Emory University
    Dunwoody, Georgia

  • TR

    Travis Redmond, MD

    Resident Physician
    Emory University School of Medicine PM&R Program
    Atlanta, Georgia

  • JJ

    Jeffrey G. Jenkins, MD

    Professor
    University of Virginia PM&R
    Charlottesville, Virginia

  • Justin X. Tu, MD

    Assistant Professor
    Emory Healthcare, Dept of Orthopedics
    Decatur, Georgia

Case Diagnosis: 16-year-old male who plays center field presenting with right hand numbness and weakness.

Case Description or Program Description: A 16-year old male center fielder in baseball presented to Emory outpatient sports clinic with about one-and-a-half month’s duration of right hand numbness and weakness, as well as medial forearm numbness. Outside hospital right shoulder X-ray demonstrated a cervical rib. Physical exam was notable for decreased sensation to light touch in the right medial hand and forearm, with negative Adson’s test. The patient was referred for electrodiagnostic studies.

Setting: EMG clinic

Assessment/Results: Nerve conduction studies of the right upper extremity revealed significantly reduced median motor compound muscle action potential (CMAP) and medial antebrachial cutaneous sensory nerve action potential amplitudes (SNAP) compared to the left. The right ulnar compound muscle action potential and sensory nerve action potential amplitudes were moderately reduced compared to the left. Electromyography was notable for positive sharp waves and fibrillations in the abductor pollicis brevis, extensor indicis proprius, and first dorsal interosseous muscles. These findings were suggestive of a right lower trunk brachial plexopathy, consistent with neurogenic thoracic outlet syndrome. Right brachial plexus MRI ordered demonstrated marked thickening and hyperintense signal abnormality of the post-ganglionic T1 nerve root extending to the lower trunk. The patient was referred to vascular surgery for possible surgical intervention.

Discussion (relevance): True neurogenic thoracic outlet syndrome is reported to have a prevalence of about 1 per 1 million individuals. Interestingly, most individuals affected are young to middle-aged female adults. The lower plexus is stretched and angulated superiorly by a fibrous band. Initial management includes rehabilitation and pharmacological measures, but surgery is indicated if patients fail conservative management.

Conclusions: Although the prevalence of true neurogenic thoracic outlet syndrome is low, it is important to consider with a cervical rib, younger female adults, and/or overhead throwing athletes. Electrodiagnostic studies will demonstrate characteristic nerve conduction abnormalities.