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Case Series of MRI Neurography Used as a Diagnostic Tool for Neurogenic Thoracic Outlet Syndrome
Alexa De la Fuente Hagopian, MD1; Souha Farhat, MD1; Michael A Trakhtenbroit, MD2; Shari R Liberman, MD1; Anthony Echo, MD3
1Houston Methodist Hospital, Houston, TX; 2Houston Methodist, Houston, TX; 3Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX

Background: Thoracic outlet syndrome (TOS) is a sum of signs and symptoms that arise from compression of the neurovascular bundle that sits within the confined space between the first rib and behind the clavicle, also known as the thoracic outlet space1. Neurogenic TOS (nTOS) is most prevalent (90–98% cases)1,2. Often, it is a diagnosis of exclusion in which physicians rely on typical sensory and/or motor symptoms as well as nerve studies 1
The purpose of this case series report is to demonstrate that MRI neurography is a useful diagnostic tool to confirm the presence of neurogenic TOS in patients whose nerve studies failed to do so.
Illustrative Cases: Seven patients presented to the clinic with symptoms suggestive of nTOS. A thorough history was taken, and a focused physical examination was performed. The underlying cause of each patient’s nTOS varied in nature, symptoms they described were almost identical: paresthesias, burning sensation, pain. In all cases, results in EMG were normal or inconclusive for nTOS, denoting abnormal nerve conduction in the upper extremity, but failed to detect abnormalities in the brachial plexus pathway. MRI neurography radiologic findings proved the presence of nTOS. Surgery was then performed for brachial plexus decompression and/or neurolysis with occasional first rib resection, scalenectomy, pectoralis minor release and targeted muscle reinnervation, relieving most patients from the burden of their disease.
Discussion: Most patients with nTOS present with negative or non-conclusive EMG. MRI neurography is an emerging diagnostic tool for high resolution imaging of peripheral nerves.
Reports in literature support the common diagnosis pathway3. Nonetheless, these diagnostic tools are often insufficient4. Our case series demonstrates the power of MRI neurography in confirming the diagnosis of nTOS, allowing for appropriate management of this disease.
Conclusion: In conclusion, patients suffering from symptoms suggestive of nTOS would benefit from MRI neurography as a diagnostic tool. The diagnosis and management of nTOS remains a clinical challenge and the development of a consensus gold standard for diagnosis must be emphasized.
Reference

  1. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007 Sep;46(3):601-4. doi: 10.1016/j.jvs.2007.04.050. PMID: 17826254.
  2. Demondion X, Herbinet P, Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics 2006;26:1735–1750.
  3. Lee PP, Dorsi MJ, Belzberg AJ, et al. Magnetic resonance neurography-surgical correlation of neurologic thoracic outlet syndrome. Microsurgery. 2011 Nov;31(8):662–665.
  4. Brantigan CO, Roos DB. Diagnosing thoracic outlet syndrome. Hand Clin. 2004;20:27–36.

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