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Thoracic Outlet Syndrome from another perspective….

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Wladislaw Ellis M.D. – T.O.S. Specialist, writes…

TOS

My initial experience with this disorder also caused me a great deal of puzzlement until I began helping a surgeon during his thoracic-outlet dissections. It then became apparent that, in the vast majority of cases, the offending agents that kept these large nerve trunks irritated were coming from inside these nerves and that the surrounding tissues were only secondary, not primary, to the creation and worsening of symptoms. These agents produced scar like adhesions on the surface of the nerve covering, which (when examined under the microscope and with specific immune stainings) revealed the presence of pain-causing nerves in these same fibrotic tissues. Once these tissues were removed, the abnormalities in the nerve dramatically decreased.

Barring frank trauma, the primary cause for symptoms and dysfunction is, thus, a localized irritation of the brachial plexus with secondary sources of inflammation (fibrous bands or bulked, edematous, or transformed muscles), promoting a vicious cycle. This inflammation is unusual in that it does not respond to arachidonic cascade inhibitors, such as nonsteroidal anti-inflammatories or corticosteroids, and is largely cell-mediated in nature. This concatenation of observations emphasizes the importance and involvement of immune and supportive (glial) cells, which have been largely overlooked in generating these painful symptoms, swelling, adhesions, and concomitant disability.

Over the last decade, white blood cells, Schwann cells in the periphery, and microglia centrally have been implicated in the development of chronic pain through their reactivity and secretion of neuropeptides and cytokines, some of which I have documented as being present in the adhesions investigated intraoperatively, as mentioned above. These molecules are part of tight, intermeshed networks that control local inflammation and pain, and can be destructive. Their presence and continued secretion to minimal stressors brings about a vicious cycle of immune-cell activation, swelling, fibrosis, and various pains and abnormal sensations. Interestingly, this is not the only disorder in which this sequence of events occurs. Asthma, chronic regional pain syndrome, irritable bowel syndrome, possibly multiple sclerosis (as well as a number of others) are all initiated and maintained by this cascade of abnormal nerve reactivity and inflammation (neurogenic inflammation). In all of these, one finds abnormally reactive nerves, glia, mast cells, macrophages, and activated white blood cells perpetuating a dysfunctional vicious cycle.

What actually happens in the neurons themselves to cause this activation remains puzzling, but current favorite explanations include up-regulation of SNS-2Na voltage-related receptors and the K-Cl transporter KCC2 as underlying mechanisms.

In summary, whether the pain, abnormal sensation, and dysfunction are actually caused by direct trauma or microinjury engendered in repetitive work environments, the central fact of localized inflammation of the nerve, followed by extravasation, fibrosis, and the consequent ingrowth of inflammation-secreting nerves into these adhesive strands, is the central and perpetuating cause for the continued pain and disability, which in turn impinges on all of the adjacent structures in the area above the collarbone, often making them contributory, but secondary, actors in this drama. For more detailed information go to my article “Thoracic Outlet Syndrome as A Disorder of Neurogenic Inflammation”.

His entire site is informative, clearly written, and well presented. If you suffer from Thoracic Outlet Syndrome as I do, I suspect you might also find it well worth your time to visit. Lately, my TOS symptoms have become so painful that it has severely impacted what remains of my functionality. Typing this is extremely painful. My left hand is nearly useless, and slight movements of that hand or wrist usually make me yelp loudly with extreme pain. And I am hard core, used to living with high levels of pain. My neck is a mess, as well. Atrophy in both hands, which is increasing at a rate I find very alarming, could be related to this (it is allegedly rare, but possible, for TOS to cause hand atrophy, but this does not explain the sudden appearance of atrophy in the back of both thighs). Zebra Soup, indeed.

Literature

S. Sunderland

“Nerve injuries and their repair. A critical appraisal.”

Churchill Livingstone, 1991

D. Kline, A Hudson

“Nerve injuries; operative results for major nerve injuries, entrapments, and tumors”

W.B. Saunders Company, 1995

R. Sanders

“Thoracic Outlet Syndrome: a common sequela of neck injuries.” J. B. Lippincott Company, 1991

D. S. Buttler “Mobilization of the nerve system.”

Churchill Livingstone, 1991

D.Dawson, M Hallett, L. Millender

“Entrapment Neuropathies”, 2nd edition

Little, Brown and Company, 1990

“Thoracic Outlet Syndrome”. Hand Clinics. 2004 Feb; 20(1).

Saunders RJ, Hammond SL, Rao NM. “Diagnosis of thoracic outlet syndrome”. J. Vasc. Surg. 2007 Sept; 46(3): 601-4. Review.

* Physical Therapy recommended as described by David Butler in his “Mobilization of the Nervous System” and “The Sensitive Nervous System”

 


Filed under: Autonomic Function, Disorders of the Spine, Neurology, Research, Thoracic Outlet Syndrome Tagged: Articles, atrophy, chronic pain, CNS, Comorbid, Complex regional pain syndrome, Cranial nerves, Denervation, dermatome, dermatomes, hand, Irritable bowel syndrome, Nerve, nerve damage, nerves, Neurological Disorders, Neurology, Pain, pins and needles, radiculitis, Schwann, Schwann cell, spine, symptoms, Thoracic, Thoracic outlet syndrome, Wladislaw Ellis M.D

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