Episode 17 - All About Thoracic Outlet Syndrome
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Episode Summary
Besides cases of lower back pain, another common problem that most people face is neck pain. In severe instances, the pain shoots from the neck to the arm, which can lead to numbness and immobility. One condition that is often difficult to diagnose is the Thoracic Outlet Syndrome (TOS).
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by Carolina Neurosurgery & Spine Associates’ nurse practitioner Emily Tucker and physical therapist Jay Murugavel in this roundtable discussion on TOS. Drawing from his expertise, Jay dives into what the thoracic outlet is and what causes pain in this particular spinal region. He talks about the various occupational risk factors connected to this condition, including certain sports like baseball and swimming, and working for long periods in awkward positions. You should also look out for things such as predisposing injury and congenital anomalies that can exacerbate
Treatment options such as surgery and physical therapy were also described, which are going to vary depending on the assessment of the patient’s clinical state. The goal is to minimize stiffness in the muscles and promote joint mobility. Breathing patterns also play a huge role in recovery and Jay encourages regular diaphragmatic breathing.
Emily provides valuable insight as well by sharing her personal experience with TOS, from diagnosis to treatment, and how she continues to manage her pain. She highlights the importance of listening to your body and your physicians and being compliant with the treatment plan devised by your medical team.
Key Moments in the Episode
Emily's experience with thoracic outlet syndrome 03:47
Consulting with a specialist 08:40
Course of treatment 11:16
What is the thoracic outlet 13:56
Occupational risk factors 15:11
Anatomical structures that lead to TOS 17:21
Difference between cervical radiculopathy and TOS 20:10
How to approach patients seeking treatment for TOS 24:02
Influence of breathing patterns on TOS 28:41
Activities to promote better posture 32:41
Looking beyond the spine to better diagnose and treat TOS 35:01
Jay and Emily’s health tips 37:40
Links Mentioned in the Episode
Top 5 Non-Disc Causes of Low Back Pain and Sciatica
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Besides cases of lower back pain, another common problem that most people face is neck pain. In severe instances, the pain shoots from the neck to the arm, which can lead to numbness and immobility. One condition that is often difficult to diagnose is the Thoracic Outlet Syndrome (TOS).
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia is joined by Carolina Neurosurgery & Spine Associates’ nurse practitioner Emily Tucker and physical therapist Jay Murugavel in this roundtable discussion on TOS. Drawing from his expertise, Jay dives into what the thoracic outlet is and what causes pain in this particular spinal region. He talks about the various occupational risk factors connected to this condition, including certain sports like baseball and swimming, and working for long periods in awkward positions. You should also look out for things such as predisposing injury and congenital anomalies that can exacerbate
Treatment options such as surgery and physical therapy were also described, which are going to vary depending on the assessment of the patient’s clinical state. The goal is to minimize stiffness in the muscles and promote joint mobility. Breathing patterns also play a huge role in recovery and Jay encourages regular diaphragmatic breathing.
Emily provides valuable insight as well by sharing her personal experience with TOS, from diagnosis to treatment, and how she continues to manage her pain. She highlights the importance of listening to your body and your physicians and being compliant with the treatment plan devised by your medical team.
Key Moments in the Episode
Emily's experience with thoracic outlet syndrome 03:47
Consulting with a specialist 08:40
Course of treatment 11:16
What is the thoracic outlet 13:56
Occupational risk factors 15:11
Anatomical structures that lead to TOS 17:21
Difference between cervical radiculopathy and TOS 20:10
How to approach patients seeking treatment for TOS 24:02
Influence of breathing patterns on TOS 28:41
Activities to promote better posture 32:41
Looking beyond the spine to better diagnose and treat TOS 35:01
Jay and Emily’s health tips 37:40
Links Mentioned in the Episode
Top 5 Non-Disc Causes of Low Back Pain and Sciatica
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01
Welcome, you're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates. Where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia: 00:36
If you've had a chance to listen to any of my recent podcast episodes, I like to cover lists and top fives and top tens as they pertain to back pain and spine care in general. And recently I did a top five lists regarding non-disc related causes of low back pain and sciatica. Today. I want to shift gears and we're going to cover a non-disc related cause of neck pain and breathing pain down the arm. Again, it's not exactly the low back, but spine care in general, pinched nerves in the neck are almost as common as they are in the low back. And today we're going to over a condition called thoracic outlet syndrome, and I'm really delighted to do this in a panel format. I'm going to have two guests that will help us with the discussion today. The first is Emily Tucker and Emily's a nurse practitioner was Carolina Neurosurgery & Spine.
Dr. Sanjiv Lakhia: 01:31
She has been with our group for many years. She has a bachelor of science in nursing from Queens College. And from 2001 to 2003, she has an MSN and Family Nurse Practitioner from University of North Carolina at Chapel Hill. She's also is involved with youth softball. I was talking to her about her coaching and she's very avid about that. And Emily's just a real top notch nurse practitioner that's been helping out patients in the Charlotte community for almost two decades now, both on the surgical and non-surgical side, but for the purposes of today's talk, Emily's gonna almost serve the role as a patient because she has gone through quite a significant experience with thoracic outlet syndrome and graciously has volunteered to share her story.
Dr. Sanjiv Lakhia: 02:17
And then our second guest is my close friend, Jay Murugavel, who's a physical therapist with Carolina Neurosurgery & Spine Associates. Jay is probably one of the best physical therapists that I've known in terms of his knowledge of neuroanatomy, biomechanics and understanding some of these very, very tough conditions.
Dr. Sanjiv Lakhia: 02:37
Jay graduated from the University of Bombay in 1991 with a graduate degree in physical therapy. He's a certified functional manual therapist from the Institute of Fiscal Art in Colorado. He's got extensive educational background in dry needling and myofascial therapy. He understands osteopathic approaches, different manual approaches to spine care, and really I consider to be an expert in neuroanatomy. So my hope for today is to cover this topic, thoracic outlet syndrome from all angles, from a patient side, a clinical side and the rehab side. So Emily and Jay, welcome to the show.
Emily Tucker: 03:15
Thank you for having me.
Jay Murugavel: 03:16
Thank you for having me Dr. Lakhia.
Dr. Sanjiv Lakhia: 03:17
Absolutely. So let's get started. I want to kick that off Emily, you went through, I think it's an understatement to say an ordeal with thoracic outlet syndrome, and I thought your case in particular is quite unique in terms of how it turned out. So I want to open the floor up to you. If you can share your experience with the listeners first about your initial symptoms, what the initial thoughts and diagnoses were and then how you came to a resolution.
Emily Tucker: 03:47
Sure. I'd love to talk about that. Actually, I want to back up just a little bit, because my initial concerns were that I had a problem with my neck and the reason I thought that was because 10 years ago, I had had two different surgeries by Dr. Adamson and I had done incredibly well with both of those surgeries. And when I had the surgeries I presented with both neck and arm pain and I got complete relief of my symptoms immediately after my second surgery. And I had done great with my first surgery as well. They both were at different levels. And when I got complete relief of my neck pain and arm pain in the recovery room in 2010, it was a miracle because I had been plagued with severe neck pain for probably 10 years before that.
Emily Tucker: 04:44
And so, when I had what now was thoracic outlet syndrome, I honestly was blaming it all on my neck. But the thing that was different was I didn't have any neck pain and I just had this relentless arm pain and I'd had it off and on for about five years. And I would always go back to Jay because Jay helped me immensely after my neck surgeries to help me get through the recovery and strengthen my arm because with the surgery, the pain was immediately better, but I still had some residual weakness that took a while to get better.
Emily Tucker: 05:24
So I went back to Jay because Jay was always my peace of mind when I felt discouraged about recurrent arm pain. And he was like, "Okay, we're going to get through this." And I always would. And then in the fall of 2018, I went back to Jay and I said, "You know, Jay, this just feels different. There's something different about what's going on this time that I just can't wrap my head around." But I also went back to Dr. Adamson, he scanned my neck. Dr. Lakhia did a EMG nerve conduction study to make sure that it wasn't coming from my neck and I just still wasn't getting better.
Emily Tucker: 06:06
I also had the privilege of having an injection by Dr. Sumit and I had had injections before and done amazing with those. And again, it just was relentless and not getting better to the point where I would literally have to pack my whole entire arm with ice bags just to drive down the road in the car to go to work. So, one time when I went to Jay, it was actually, I had seen him earlier that week. And then on a Friday night, I emailed Jay and he got back to me, even though it was late. And I had been doing some research about what I was dealing with. And I told Jay, I said, "I think I have thoracic outlet syndrome."
Emily Tucker: 06:50
And I told him, "I think it might not just be the nerve. It might also be a blood vessel problem." Because I was having all this swelling in the front of my neck that I still had no neck pain. And so he emailed me back and said, "I think you're right." So that then proceeded me to get in touch with Dr. Bernard. Who's one of our vascular neurosurgeons and a colleague of mine that I worked very closely with for years. And he emailed me back immediately and said, "Well, dr. Vanderveer treats that condition. Why don't you go and see him?" So I emailed dr. Vanderveer and he very graciously said, "Hey, come see me on Monday. And let's get down to the bottom of what's going on with you."
Dr. Sanjiv Lakhia: 07:38
Before you transitioned into what happened next. Can you pause for a second and for the listeners, can you tell them a little more specifically about where the pain was located? Did it go down a specific distribution in your arm?
Emily Tucker: 07:53
It absolutely did it. It was mimicking what we call a neurosurgery as C-7 radiculopathy. And what that means is that was going down the back of my arm and my tricep, and then down the front of my arm and into my index finger and middle finger. But also I couldn't raise up my arm without relentless pain, but also was extremely weak in my tricep and in my hand. And I was very clumsy with my hand. I was dropping things. I was very uncoordinated and that was very difficult and it was only in my left arm. I did not have any symptoms in my right arm.
Dr. Sanjiv Lakhia: 08:33
Wow. So you talked with Dr. Vanderveer and share his thoughts.
Emily Tucker: 08:40
Well, the very first thing he was looking at some scans, he was looking at the recent MRI that I'd had of my neck and we weren't in an exam room yet. And he said, "I want you to do something for me." And he said, "I want you to your arm up." And he had me hold my arm up. And then he pulled my arm down and then pulled it back very similar way of which I would be if I was raising back to say, like brush my hair or something like that. And then he pulled my arm down and he held his hand on my wrist.
Emily Tucker: 09:23
And when he did that, he then gave me this look and he's said, "We've got a problem." And he pointed to the exam room and had me go in there. So we went in the exam room and he looked at me and he said, "You don't have a pulse in your arm." And so I was pretty concerned at that point. He said, "Yeah, when I move your arm that way you have no pulse in your arm." And so he said, "You absolutely have something pinching on a blood vessel in your neck and you have thoracic outlet syndrome." He said, "But we have to figure out where this is being pinched."
Emily Tucker: 10:06
So he further examined me and determined that I was weak in my tricep. I was also weak in my hand. And then, he further examined me and said that he was concerned that I was weak in multiple distributions of my arm. And so he immediately ordered a brachial plexus MRI scan because he wanted to see what was being compressed. But at that point he also said, "We don't have any other option here." He said, "With you not having a pulse on your arm, when you move your arm, we absolutely have to figure out where it's being pinched and then fix it."
Dr. Sanjiv Lakhia: 10:53
Yeah. And that's where I remember you having the discussion with me where you told me he sat down and went through everything that had already been imaged, the CTS and MRIs, and lo and behold discovered the structure that was compressing, what we call neurovascular bundle or nerve artery complex. Is that not correct, what happened?
Emily Tucker: 11:14
Yes, that is correct.
Dr. Sanjiv Lakhia: 11:16
So ultimately for the listeners share with them, what was the resolution here?
Emily Tucker: 11:21
So the resolution was Dr. Vandeveer then on December 13th, 2018, did a surgery where he went in through the front of my neck and made an eight inch incision. And the surgery is called a first rib resection with a brachial plexus exploration. And basically what he had to do for the surgery was go in and remove what was compressing, not only the nerves, but the blood vessels to my arm.
Dr. Sanjiv Lakhia: 11:55
And it's just an amazing story. And I remember when I originally saw you, we were all thinking neck, neck, neck, but then the treatments just weren't lining up with the expected results. And then how are you doing now at this point?
Emily Tucker: 12:10
I'm doing great. I did have to go back and see Jay for a little bit of physical therapy this spring. Like I said, Jay is my go to when I'm having a problem, I will circle back with him because he's helped me so much in the past with everything. And, he helps me to understand what is muscular and what is nerve related. And I think too, when you've had the condition that chronically affect your body, when you're under stress immediately, that part of your body tends to act up.
Emily Tucker: 12:44
When I was trying to homeschool my kids and keep working through the pandemic and everything that we're going through. And a lot more screen time with the kids, with the homeschool and everything. My arm flared up a little bit. And I got in with Jay and had to get back on track with doing my exercises. But overall I could not be more happy about how I'm doing. I'm doing everything that I want to do. Everything that I love to do. Being a mother, coaching my girls in softball and picked up a new sport this season, been wake surfing and our family's having a great time doing that. And, looking back a year and a half ago, I never would have been able to do that had I known what was going on.
Dr. Sanjiv Lakhia: 13:34
Yeah. That's an amazing story. I really appreciate you opening up and sharing your story so others can benefit. We covered a lot there. And I want to break that down a little bit with Jay transitioning more about thoracic outlet in general. Jay, can you go ahead and just educate listeners? Let's start very simple here. What is the thoracic outlet?
Jay Murugavel: 13:56
Thoracic outlet is the area around the neck. It starts about the clavicle and it also covers the arm. It's a part where the nerve root and the blood vessels and the vein pass through to enter the shoulder and arm. It's a situation where people have trouble with tightness around these structures. What we call extrinsic factors, where the people's occupational demands are positioned, which they are using their arm to throw a baseball repeatedly and cumulatively causes internal changes in the arteries and veins.
Jay Murugavel: 14:39
And also most importantly, the nerve which causes inflammation and causes problem of tingling, numbness, pain, and weakness. And when there are associated with vascular changes, patients have changes associated with decreased circulation and also hands feeling cold and sometimes getting very cyanotic.
Dr. Sanjiv Lakhia: 15:01
Yeah. So cyanotic blue fingers?
Jay Murugavel: 15:04
Yes.
Dr. Sanjiv Lakhia: 15:05
Now you mentioned some occupational risk factors. What are you saying was an occupational risk factor for Emily?
Jay Murugavel: 15:11
Let me talk about it in general. And then I come to Emily.
Dr. Sanjiv Lakhia: 15:15
Yeah.
Jay Murugavel: 15:16
So occupational risk factors where people have to work for long hours in awkward positions where their head is forward and their shoulders are rounded and upper back hunched over as in thoracic kyphosis. It creates tightness and contracture of some of the neck muscles and weakness of the deeper intrinsic neck muscles. So also working with their arm, overhead position or reaching about 90 degrees causes all of these vascular changes.
Jay Murugavel: 15:46
So in case of a baseball pitcher, pitching 90 miles hour pitches or 80 miles hour pitcher where his arm is swung sideways and maximally rotated to throw pitches at high velocity repeatedly can cause these changes. And in Emily's situation, I think her occupational demands of doing a lot of surgeries and working in that awkward position. Her posture was good but when she worked for long hours, I am not there with her, but I think what she tells me was that she had to stoop over and bend over and reach in a forward bend position that caused a lot of the problems, could be.
Dr. Sanjiv Lakhia: 16:25
You agree with that, Emily?
Emily Tucker: 16:27
I do. And another thing I think that stems back to this is, when I was 20 years old, I had a bad whiplash injury. And so it's hard to know looking back, cause that was a long time ago, but a whiplash injury can certainly bring this condition on.
Dr. Sanjiv Lakhia: 16:47
Yeah. So you were set up, your cervical spine had already gone through some challenges to begin with. Jay for the average listener who doesn't have a medical background, can you review some of the important anatomical structures that can lead to thoracic outlet syndrome or another way to think about this is thoracic outlet syndrome is a compression phenomenon where you're getting a compression of nerves or blood vessels. So what are some of the major suspects here that we have to be on the lookout for?
Jay Murugavel: 17:21
A very good point Dr. Lakhia. And I also want to interject a little bit earlier, that many cases of thoracic outlet syndrome, especially in athletes and younger adults, there's always a predisposing injury possible. There are some congenital anomalies like a cervical drip, but also people who had a clavicle fracture, automobile union of clavicle fracture or previous neck injuries can be a good factor.
Jay Murugavel: 17:46
And moving forward, talking about what the anatomical structures that are involved in the thoracic outlet syndrome, definitely the first rib, which lies underneath the clavicle and the muscles attaching to the first rib are your scalene, anterior scalene and then middle scalene are significantly involved. The common site is where these muscles lay in close proximity. They are attached to the sites of the neck and in between them comes the brachial, lower part of the brachial plexus, and also the blood vessels coming through it.
Jay Murugavel: 18:21
So in terms of athletes who do a lot of heavy lifting training and swimmers, especially these muscles can be hypertrophied or become significantly thick and compromising the space through which the nerves and blood vessels comes through are in many patients population, I think there was also a situation where they have spasm of these muscles or irritation of the nerve ending, causes spasm of these muscles and vice versa because of the spasm of the muscles, the muscles in turn compressing on the nerve causing this kind of situation.
Dr. Sanjiv Lakhia: 18:57
Yeah. So just another way to say that, the strap muscles of the neck attach somewhat to that first rib and when these muscles get tight or contract or compressed over time, I think it can elevate that first rib. And for lack of better term, pinched the lower part of the brachial plexus, which is the big group of nerves to go through there. And honestly, I feel like when I've looked at this topic before that we should be calling it the thoracic inlet and not that the thoracic outlet based upon how the structures dive into that area and go down your arm. But that's kind of semantics, I guess.
Dr. Sanjiv Lakhia: 19:36
As a physical therapist, so Emily touched on something I think that's important that if you're out there listening and struggling with pain going down your arm and you can't find a cause, I, myself, I remember seeing her and doing the nerve test and my initial thought was that it could be a cervical radiculopathy or a pinched nerve in her neck, so I missed it at first. So as a physical therapist, what are your suggestions for patients and even clinicians who are listing on how to decipher between a pinched nerve in the neck, cervical radiculopathy versus a thoracic outlet syndrome?
Jay Murugavel: 20:10
That's always a challenge because many times the C-7 radiculopathy mimics the symptoms of thoracic outlet syndrome. And the diagnosis is very difficult unless you have a provocation test of the vascular structures that can, if it is significantly positive, then you can prove it's a thoracic outlet syndrome. And in many situations, some of these tests have a false positive. That means that it's just as positive, but patients are not having thoracic outlet syndrome situations.
Jay Murugavel: 20:42
So the common tests that I use in clinically for both radiculopathy and thoracic outlet syndrome is putting the nerves and the tension, the upper limb neural tension test, where we integrated manner put the brachial plexus and then the peripheral nerve under tension, and then compared to the other arm and many times that's positive and also tapping along the brachial plexus approximately around the neck.
Jay Murugavel: 21:07
Usually we produce the symptoms and invariably many of these people have an elevated first rib as you alluded to earlier. So it's a comprehensive evaluation and putting all the small pieces together we'll come to a conclusion, but still it's a very challenging diagnosis to make. And many times the nerve conduction studies and all of those are negative.
Dr. Sanjiv Lakhia: 21:28
That is correct. That was a situation for Emily. You can at times see some changes on the EMG and nerve conduction involving the lower trunk of the plexus, but it doesn't always show up. Now, Emily, your resolution essentially, you had the rib removed, correct?
Emily Tucker: 21:46
I did. I actually had two. I had the full rib removed at my extra cervical rib that was found, but also I believe about three quarters of the first rib was also removed. And the reason that happened was Dr. Vanderveer said later that there was a bone spur coming off of that area. And he said that it was extremely narrowed and there's actually two different approaches that can be done for this type of surgery. One where you can go in through the armpit, which is the transactseal, but he does it from the front. And I think for me, had it not been done that way, I may not have had such a positive outcome because that bone spur was actually not identified on the MRI scan of the brachial plexus, but was found interoperatively.
Emily Tucker: 22:46
He said that that was the main reason why I had so much weakness in my arm was because I had the C-7 radicular pain, but I had a C-8 weakness. And that was the component that he could not explain by my imaging studies. And so intraoperatively found this extra bone spur, so had to take off additional bone and it was extremely tight in there and they had to retract significantly on the nerve during the surgery, but ultimately the outcome was great.
Dr. Sanjiv Lakhia: 23:22
Yeah, that's fantastic. And fortunately, I would say majority of patients who have thoracic outlet syndrome never get to that point and can find improvement and resolution even mostly through physical therapy interventions. So Jay, I want to transition back to your input here. If you have a patient that you're evaluating and you've put them through your nerve tension tests, and you've looked at their circulation and concluded that they have, let's say a neurogenic thoracic outlet syndrome or a nerve related syndrome, what is your mental model for approaching these patients on how to get them better?
Jay Murugavel: 24:02
Generally, it depends on what stage of inflammation the patients are coming in. Sometimes patients might have had symptoms for six to eight months and they have gone through several places for therapy and other medical management, their conditioners as a plateaued, it's not improved, but they still have and there are a lot of things they cannot function. I would probably treat them very differently than somebody presents with acute symptoms where their nerve retention is significant. They are not able to function. They have to keep the arm by the side, even sleeping is disturbed.
Jay Murugavel: 24:36
We try to assess them based on the clinical presentation they present with. I usually follow a guideline of reading the severity of the symptoms and irritability of the nerve and also the nature of the dysfunction. So if clinically they're present with a lot of pain dominant symptoms, I try to manage the pain first by teaching them postures or positions that will elevate their symptoms. And also from their history, they'll give me details of what activity, unknown to them, they may be doing things to keep on aggravating the pain so that they're repeatedly performing the same moment that provokes their symptoms, unless they avoid or minimize or stop, they will be inflaming their nerve tissue significantly.
Jay Murugavel: 25:29
So in a baseball pitcher, it could be stopping from playing. In an industrial worker who has to do a lot of overhead activities, telling them to avoid doing those, and also trying to teach them about good posture so that we are trying to minimize their initial symptoms and moving forward, I also try to work with them about educating them about the condition they're in and what activities they need to do. I do use a lot of manual therapy to treat that first rib and also the sternal area where it attaches treating the scalene with manual therapy or dry needling, and also treating the whole upper thoracic ring as one unit trying to normalize the range of motion.
Jay Murugavel: 26:15
So if the extrinsic factors are causing them more compression, tightness, stiffness in the muscles. So we are trying to minimize the stiffness and tightness in the muscles, improve the joint mobility. So the container through which the nerve passes will have more mobility and stay relaxed. So our job at the initial stage is to manage pain and gently start them with exercises. Most of the chronic situation due to postural dysfunctions patients tend to have lower trapezius weakness. So we also work on strengthening the lower trapezius muscles and also piece them stretching exercises for the scalene and upper trapezius.
Dr. Sanjiv Lakhia: 26:56
That's pretty comprehensive. Emily, are you still committed to, or having to go through these types of home exercises on a routine basis or a maintenance basis?
Emily Tucker: 27:09
Yes. And I would say sometimes I'm more diligent than others. I went through extensive physical therapy after my surgery. I had some nerve pain, quite a bit of nerve pain afterwards due to the retraction on the nerve afterwards. So Jay was great about working with me through the pain and teaching me some different things and then rebuilding the strength in my arm. I'm an avid swimmer. I love the water. It's good therapy for me, but I know too that swimming can aggravate this condition. So I definitely had to do some modified approaches with my swimming. I do a lot of backstroke where I just use my legs and not my arms. But also when I went back in to see Jay this past spring, re-engaged a lot of the exercises and I probably do my physical therapy exercises about five days a week. And on the other days, I try and be pretty active with other things.
Dr. Sanjiv Lakhia: 28:09
Plus you're in the 95th percentile of compliance, Emily, so you should feel really good.
Emily Tucker: 28:13
Well, I try, because I tell my patients, like you brush your hair and brush your teeth, you got to do your PT exercises. So I am a huge proponent and advocate of physical therapy.
Dr. Sanjiv Lakhia: 28:24
Jay, one of the things I wanted to ask you about your graciously sent me a presentation you put together on this topic, you mentioned in your presentation, the potential influence of breathing patterns on thoracic outlet syndrome. Can you elaborate a little bit on that?
Jay Murugavel: 28:41
I think breathing is very, very important. And if I may also add on what Emily said, I think that getting the patient to agree with the plan, because Emily at that point had a little pain like she was mentioning and she went along and she was 100% cooperative and she did all her exercise very diligently. And initially she had a little bit of pain, but she put up with the pain for the greater good at the end. And I would have to say that she worked really hard in a rehab and she became very strong and I think she is a lot stronger than how she is even compared to before surgery. Thank you, Emily.
Jay Murugavel: 29:18
Moving forward to the breathing exercise, I think it's a very important component. As I said earlier on most of these patients that I see present with forward head rounded shoulders and increased thoracic kyphosis and the scalene have also accessory muscles of breathing and respiration. So what I try to emphasize is on diaphragmatic breathing and we spend a lot of time trying to work on educating them on diaphragmatic breathing on a regular basis.
Jay Murugavel: 29:48
We also work on the lower coastal rib area to release those tightness in those areas. So that they'll have a proper diaphragm excursion. And also teaching them the difference between normal diaphragmatic breathing and upper thoracic epical breathing and how to differentiate between the two. So we emphasize a lot on diaphragmatic breathing to minimize their symptoms.
Dr. Sanjiv Lakhia: 30:14
Diaphragmatic breathing would involve, if you take a deep breath and you have your hands on your lower abdominal area?
Jay Murugavel: 30:20
Yes, you are at a good point. So I have actually have the patient cup their hand and place it on the lower abdomen and try to have them breath into their hand. Also emphasizing on the lower lateral costal breathing so that they are using lower ribs to expand laterally in sideways direction and not just fill air in their stomach. And we try to differentiate that to have a proper diaphragmatic breathing.
Dr. Sanjiv Lakhia: 30:48
Excellent. Well, I think that's a very good summary from different angles of this condition. My experience has been, I typically think about thoracic outlet syndrome when I have patients for which the cervical spine workup is negative and they have persistent what we call parasthesias or numbness and tingling down the arm into the hands sometimes even into the middle finger, ring finger, distribution area. And, we touched on earlier, the biggest element that in retrospect for me should have had me thinking about this for Emily are the occupational hazards or occupational risk factors.
Dr. Sanjiv Lakhia: 31:29
So I'm highly suspicious now when I see dental hygienists or dentists or people who are on their computers, their devices long periods of time, and you see the rounded shoulder posture, tightness in the chest muscles. I think this whole workplace syndrome now where everything's at our frontal plane for us is creating a wide variety of problems, thoracic outlet syndrome, carpal tunnel syndrome, or neuropathies. I think you can find the root to a lot of this and just how we go about our day to day life. Would you agree with that, Jay?
Jay Murugavel: 32:03
Absolutely.
Dr. Sanjiv Lakhia: 32:04
What do you think would be ... Emily mentioned swimming, which is very interesting. I know the concern there would be the repetitive overhead motion with freestyle swimming stroke. What do you think would be an ideal exercise? If someone says, "Hey, look, I have an occupation that puts me in that compromised position, but I don't have any symptoms now. And I want to prevent it from happening." Would you say swimming or yoga or Pilates? What's a good activity that you can get started with to make sure you have good posture and decreased tension in your neck and shoulders?
Jay Murugavel: 32:41
I think a lot of the swimmers who develop thoracic outlet syndrome is because of the number of the hours they put into swimming. Sometimes it could be a combination of fatigue and for technique. So I try to have them minimize the combination of breathing through the mouth and turning their head to rotate them freestyle. I try to have them use a snorkel. Some patients are eager to adapt that temporarily to alleviate the symptoms. And then they work with the swim coach to clean their technique.
Jay Murugavel: 33:13
So that's one modification and Emily's modification was adopting backstroke. So that's another options. And when they come to therapy, we also work with them on trying to loosen the scalene and working on the upper thoracic extension and release the tightness from the pec minor and pectoralis muscles that also allows them to have a better freedom of range of motion so that they have a swim with the good form. As you alluded, other forms of independent gym exercises like Pilates and yoga are good. I can't think of any specific type of yoga that would be counter productive to this.
Dr. Sanjiv Lakhia: 33:52
So the movement is in general, really good with some slight modifications that you suggested. Okay, well, I just want to [crosstalk 00:34:00]. Yeah, go ahead.
Emily Tucker: 34:01
One thing that I have found to be extremely helpful for me, because a lot of my life is forward with kids and softball and assisting with surgery and computers is the foam roll. And that's something that's used a lot in physical therapy. So many days when I get home from work or after exercise, I'll go lay on the foam roll and do some different exercises to help keep my shoulders back. And that I think for me has been extremely effective.
Dr. Sanjiv Lakhia: 34:33
That's a great point. I have one at home as well. Use it routinely. I've worked with Jay. He would tell you are, I probably don't use it enough. But that's a very inexpensive tool that a lot of people could adopt and use it for the better. Well, I want to just open the floor for any last comments that you guys have. Emily, anything else you want to share from a hybrid clinician patient perspective on your experience dealing with thoracic outlet syndrome?
Emily Tucker: 35:01
Well, I think it's important that when we're dealing with the spine, that we also look outside the box of the spine, because I think when we see patients day in and day out for neck and back issues, we also have to think about some other conditions that can mimic those. I think that's where physical therapy plays such a huge role in what we do, because we can do different images of the spine and different nerve tests, but also with the different techniques that are used in therapy, a lot of patients can get better with therapy. And, before I was diagnosed with thoracic outlet syndrome, I saw Jay for five years off and on just to keep my arm at bay.
Emily Tucker: 35:49
And looking back at that, I probably had the neurogenic component of thoracic outlet for that time. I spent countless nights not sleeping because of the nerve pain in my arm, but I think what pushed me over the edge was when the vascular structures became compressed. And that's when my body said enough was enough. And I think it's super important that we listen to our body, that we listened to our healthcare professionals. We listened to our physical therapists and we have to answer each piece of the puzzle as it comes and not give up on if a scan looks normal, it doesn't mean that nothing is wrong.
Dr. Sanjiv Lakhia: 36:33
That's a great bit of advice. I know many times you can have a patient come in or I've seen someone and I tell them your scan is normal, but that doesn't mean everything is fine. And I want people to understand that it doesn't necessarily mean we think nothing's wrong with the individual. So, you really pushed and advocated for your health. And it's such a blessing that you got to see Dr. Vanderveer as well. And he's able to take care of the problems for you. Jay, any last thoughts you want to share from your perspective on the condition?
Jay Murugavel: 37:06
I think you covered very well. Dr. Lakhia and Emily I think narrated her experience and the her hard work in getting better. I think we all got it covered. Thank you [crosstalk 00:37:17].
Dr. Sanjiv Lakhia: 37:17
Fantastic. Yeah. Before we leave, I always like to ask my interviewees to share maybe one or two health tips that they've adopted into their daily lives that the listeners could consider or at least learn from. I've always shared that I do a fair amount of meditation and exercise. Jay what's your one or two go-to's to keep yourself healthy?
Jay Murugavel: 37:40
I try to do regular yoga and also incorporate my family into doing a little bit of yoga conditioning classes and try to all eat healthy together because unless you incorporate your community, the success is not going to be as good. So I try to incorporate my daughters and my wife in to all the physical activities we do together.
Dr. Sanjiv Lakhia: 38:03
That's a great tip. It's never been brought up, but there's actually good research that we are healthier when we involve a community versus trying to do it on our own. So thanks for sharing that. Emily, how about from your side? I know you're really into nutrition and exercise and what's your go to?
Emily Tucker: 38:23
Well, my go to is definitely nutrition and exercise. And I think the two go hand-in-hand, if I don't eat healthy, then I don't want to exercise. And when I first started having the arm pain again, five years ago, I really adopted more of a clean eating and healthy lifestyle through eating more of an antiinflammatory based diet. And I think that has been huge for my body. I've been an athlete my entire life. And so, I have always exercised, but I think it's important too, especially as we age that we exercise in the right way.
Emily Tucker: 39:02
So when I had started swimming after my neck surgeries, I was hoping to not do as much wear and tear with running. So I thought swimming would be the best way to go through with that. So I think it's just important to control what we can control. And I think in our life, I couldn't control the fact that I had an extra rib in my neck, but I can control the fact that I can try and eat healthy and exercise. And so I think for me, it's more of a mindset of what I can control, is what I put in my body and how I move my body in a healthy way to stay as healthy as I can be.
Dr. Sanjiv Lakhia: 39:44
That's music to my ears, Emily. I love it. That is, control what's in front of you and not really focused on things that are out of our control, over your stress and eat well. And I think you hope for the best after that so. Guys, I really appreciate your time today. I think we took a very complex topic and put a real personal spin on it and broke down the rehabilitative approach, hopefully in a way that if there's someone listening today with similar symptoms could understand it and also provide them with a little hope that if you're out there and you're struggling with a condition like thoracic outlet syndrome, don't give up, talk to your clinicians, if you're local come see us at Carolina Neurosurgery & Spine and keep pushing, find a very knowledgeable physical therapist and take Emily's lesson. Don't give up on your health. There's light at the end of the tunnel. So Emily and Jay, thank you for your time today.
Jay Murugavel: 40:35
Thank you, Dr. Lakhia.
Emily Tucker: 40:35
Thank you, Dr. Lakhia.
Jay Murugavel: 40:37
Thank you, Emily.
Emily Tucker: 40:38
Thank you, Jay.
Outro: 40:42
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome, you're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates. Where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia: 00:36
If you've had a chance to listen to any of my recent podcast episodes, I like to cover lists and top fives and top tens as they pertain to back pain and spine care in general. And recently I did a top five lists regarding non-disc related causes of low back pain and sciatica. Today. I want to shift gears and we're going to cover a non-disc related cause of neck pain and breathing pain down the arm. Again, it's not exactly the low back, but spine care in general, pinched nerves in the neck are almost as common as they are in the low back. And today we're going to over a condition called thoracic outlet syndrome, and I'm really delighted to do this in a panel format. I'm going to have two guests that will help us with the discussion today. The first is Emily Tucker and Emily's a nurse practitioner was Carolina Neurosurgery & Spine.
Dr. Sanjiv Lakhia: 01:31
She has been with our group for many years. She has a bachelor of science in nursing from Queens College. And from 2001 to 2003, she has an MSN and Family Nurse Practitioner from University of North Carolina at Chapel Hill. She's also is involved with youth softball. I was talking to her about her coaching and she's very avid about that. And Emily's just a real top notch nurse practitioner that's been helping out patients in the Charlotte community for almost two decades now, both on the surgical and non-surgical side, but for the purposes of today's talk, Emily's gonna almost serve the role as a patient because she has gone through quite a significant experience with thoracic outlet syndrome and graciously has volunteered to share her story.
Dr. Sanjiv Lakhia: 02:17
And then our second guest is my close friend, Jay Murugavel, who's a physical therapist with Carolina Neurosurgery & Spine Associates. Jay is probably one of the best physical therapists that I've known in terms of his knowledge of neuroanatomy, biomechanics and understanding some of these very, very tough conditions.
Dr. Sanjiv Lakhia: 02:37
Jay graduated from the University of Bombay in 1991 with a graduate degree in physical therapy. He's a certified functional manual therapist from the Institute of Fiscal Art in Colorado. He's got extensive educational background in dry needling and myofascial therapy. He understands osteopathic approaches, different manual approaches to spine care, and really I consider to be an expert in neuroanatomy. So my hope for today is to cover this topic, thoracic outlet syndrome from all angles, from a patient side, a clinical side and the rehab side. So Emily and Jay, welcome to the show.
Emily Tucker: 03:15
Thank you for having me.
Jay Murugavel: 03:16
Thank you for having me Dr. Lakhia.
Dr. Sanjiv Lakhia: 03:17
Absolutely. So let's get started. I want to kick that off Emily, you went through, I think it's an understatement to say an ordeal with thoracic outlet syndrome, and I thought your case in particular is quite unique in terms of how it turned out. So I want to open the floor up to you. If you can share your experience with the listeners first about your initial symptoms, what the initial thoughts and diagnoses were and then how you came to a resolution.
Emily Tucker: 03:47
Sure. I'd love to talk about that. Actually, I want to back up just a little bit, because my initial concerns were that I had a problem with my neck and the reason I thought that was because 10 years ago, I had had two different surgeries by Dr. Adamson and I had done incredibly well with both of those surgeries. And when I had the surgeries I presented with both neck and arm pain and I got complete relief of my symptoms immediately after my second surgery. And I had done great with my first surgery as well. They both were at different levels. And when I got complete relief of my neck pain and arm pain in the recovery room in 2010, it was a miracle because I had been plagued with severe neck pain for probably 10 years before that.
Emily Tucker: 04:44
And so, when I had what now was thoracic outlet syndrome, I honestly was blaming it all on my neck. But the thing that was different was I didn't have any neck pain and I just had this relentless arm pain and I'd had it off and on for about five years. And I would always go back to Jay because Jay helped me immensely after my neck surgeries to help me get through the recovery and strengthen my arm because with the surgery, the pain was immediately better, but I still had some residual weakness that took a while to get better.
Emily Tucker: 05:24
So I went back to Jay because Jay was always my peace of mind when I felt discouraged about recurrent arm pain. And he was like, "Okay, we're going to get through this." And I always would. And then in the fall of 2018, I went back to Jay and I said, "You know, Jay, this just feels different. There's something different about what's going on this time that I just can't wrap my head around." But I also went back to Dr. Adamson, he scanned my neck. Dr. Lakhia did a EMG nerve conduction study to make sure that it wasn't coming from my neck and I just still wasn't getting better.
Emily Tucker: 06:06
I also had the privilege of having an injection by Dr. Sumit and I had had injections before and done amazing with those. And again, it just was relentless and not getting better to the point where I would literally have to pack my whole entire arm with ice bags just to drive down the road in the car to go to work. So, one time when I went to Jay, it was actually, I had seen him earlier that week. And then on a Friday night, I emailed Jay and he got back to me, even though it was late. And I had been doing some research about what I was dealing with. And I told Jay, I said, "I think I have thoracic outlet syndrome."
Emily Tucker: 06:50
And I told him, "I think it might not just be the nerve. It might also be a blood vessel problem." Because I was having all this swelling in the front of my neck that I still had no neck pain. And so he emailed me back and said, "I think you're right." So that then proceeded me to get in touch with Dr. Bernard. Who's one of our vascular neurosurgeons and a colleague of mine that I worked very closely with for years. And he emailed me back immediately and said, "Well, dr. Vanderveer treats that condition. Why don't you go and see him?" So I emailed dr. Vanderveer and he very graciously said, "Hey, come see me on Monday. And let's get down to the bottom of what's going on with you."
Dr. Sanjiv Lakhia: 07:38
Before you transitioned into what happened next. Can you pause for a second and for the listeners, can you tell them a little more specifically about where the pain was located? Did it go down a specific distribution in your arm?
Emily Tucker: 07:53
It absolutely did it. It was mimicking what we call a neurosurgery as C-7 radiculopathy. And what that means is that was going down the back of my arm and my tricep, and then down the front of my arm and into my index finger and middle finger. But also I couldn't raise up my arm without relentless pain, but also was extremely weak in my tricep and in my hand. And I was very clumsy with my hand. I was dropping things. I was very uncoordinated and that was very difficult and it was only in my left arm. I did not have any symptoms in my right arm.
Dr. Sanjiv Lakhia: 08:33
Wow. So you talked with Dr. Vanderveer and share his thoughts.
Emily Tucker: 08:40
Well, the very first thing he was looking at some scans, he was looking at the recent MRI that I'd had of my neck and we weren't in an exam room yet. And he said, "I want you to do something for me." And he said, "I want you to your arm up." And he had me hold my arm up. And then he pulled my arm down and then pulled it back very similar way of which I would be if I was raising back to say, like brush my hair or something like that. And then he pulled my arm down and he held his hand on my wrist.
Emily Tucker: 09:23
And when he did that, he then gave me this look and he's said, "We've got a problem." And he pointed to the exam room and had me go in there. So we went in the exam room and he looked at me and he said, "You don't have a pulse in your arm." And so I was pretty concerned at that point. He said, "Yeah, when I move your arm that way you have no pulse in your arm." And so he said, "You absolutely have something pinching on a blood vessel in your neck and you have thoracic outlet syndrome." He said, "But we have to figure out where this is being pinched."
Emily Tucker: 10:06
So he further examined me and determined that I was weak in my tricep. I was also weak in my hand. And then, he further examined me and said that he was concerned that I was weak in multiple distributions of my arm. And so he immediately ordered a brachial plexus MRI scan because he wanted to see what was being compressed. But at that point he also said, "We don't have any other option here." He said, "With you not having a pulse on your arm, when you move your arm, we absolutely have to figure out where it's being pinched and then fix it."
Dr. Sanjiv Lakhia: 10:53
Yeah. And that's where I remember you having the discussion with me where you told me he sat down and went through everything that had already been imaged, the CTS and MRIs, and lo and behold discovered the structure that was compressing, what we call neurovascular bundle or nerve artery complex. Is that not correct, what happened?
Emily Tucker: 11:14
Yes, that is correct.
Dr. Sanjiv Lakhia: 11:16
So ultimately for the listeners share with them, what was the resolution here?
Emily Tucker: 11:21
So the resolution was Dr. Vandeveer then on December 13th, 2018, did a surgery where he went in through the front of my neck and made an eight inch incision. And the surgery is called a first rib resection with a brachial plexus exploration. And basically what he had to do for the surgery was go in and remove what was compressing, not only the nerves, but the blood vessels to my arm.
Dr. Sanjiv Lakhia: 11:55
And it's just an amazing story. And I remember when I originally saw you, we were all thinking neck, neck, neck, but then the treatments just weren't lining up with the expected results. And then how are you doing now at this point?
Emily Tucker: 12:10
I'm doing great. I did have to go back and see Jay for a little bit of physical therapy this spring. Like I said, Jay is my go to when I'm having a problem, I will circle back with him because he's helped me so much in the past with everything. And, he helps me to understand what is muscular and what is nerve related. And I think too, when you've had the condition that chronically affect your body, when you're under stress immediately, that part of your body tends to act up.
Emily Tucker: 12:44
When I was trying to homeschool my kids and keep working through the pandemic and everything that we're going through. And a lot more screen time with the kids, with the homeschool and everything. My arm flared up a little bit. And I got in with Jay and had to get back on track with doing my exercises. But overall I could not be more happy about how I'm doing. I'm doing everything that I want to do. Everything that I love to do. Being a mother, coaching my girls in softball and picked up a new sport this season, been wake surfing and our family's having a great time doing that. And, looking back a year and a half ago, I never would have been able to do that had I known what was going on.
Dr. Sanjiv Lakhia: 13:34
Yeah. That's an amazing story. I really appreciate you opening up and sharing your story so others can benefit. We covered a lot there. And I want to break that down a little bit with Jay transitioning more about thoracic outlet in general. Jay, can you go ahead and just educate listeners? Let's start very simple here. What is the thoracic outlet?
Jay Murugavel: 13:56
Thoracic outlet is the area around the neck. It starts about the clavicle and it also covers the arm. It's a part where the nerve root and the blood vessels and the vein pass through to enter the shoulder and arm. It's a situation where people have trouble with tightness around these structures. What we call extrinsic factors, where the people's occupational demands are positioned, which they are using their arm to throw a baseball repeatedly and cumulatively causes internal changes in the arteries and veins.
Jay Murugavel: 14:39
And also most importantly, the nerve which causes inflammation and causes problem of tingling, numbness, pain, and weakness. And when there are associated with vascular changes, patients have changes associated with decreased circulation and also hands feeling cold and sometimes getting very cyanotic.
Dr. Sanjiv Lakhia: 15:01
Yeah. So cyanotic blue fingers?
Jay Murugavel: 15:04
Yes.
Dr. Sanjiv Lakhia: 15:05
Now you mentioned some occupational risk factors. What are you saying was an occupational risk factor for Emily?
Jay Murugavel: 15:11
Let me talk about it in general. And then I come to Emily.
Dr. Sanjiv Lakhia: 15:15
Yeah.
Jay Murugavel: 15:16
So occupational risk factors where people have to work for long hours in awkward positions where their head is forward and their shoulders are rounded and upper back hunched over as in thoracic kyphosis. It creates tightness and contracture of some of the neck muscles and weakness of the deeper intrinsic neck muscles. So also working with their arm, overhead position or reaching about 90 degrees causes all of these vascular changes.
Jay Murugavel: 15:46
So in case of a baseball pitcher, pitching 90 miles hour pitches or 80 miles hour pitcher where his arm is swung sideways and maximally rotated to throw pitches at high velocity repeatedly can cause these changes. And in Emily's situation, I think her occupational demands of doing a lot of surgeries and working in that awkward position. Her posture was good but when she worked for long hours, I am not there with her, but I think what she tells me was that she had to stoop over and bend over and reach in a forward bend position that caused a lot of the problems, could be.
Dr. Sanjiv Lakhia: 16:25
You agree with that, Emily?
Emily Tucker: 16:27
I do. And another thing I think that stems back to this is, when I was 20 years old, I had a bad whiplash injury. And so it's hard to know looking back, cause that was a long time ago, but a whiplash injury can certainly bring this condition on.
Dr. Sanjiv Lakhia: 16:47
Yeah. So you were set up, your cervical spine had already gone through some challenges to begin with. Jay for the average listener who doesn't have a medical background, can you review some of the important anatomical structures that can lead to thoracic outlet syndrome or another way to think about this is thoracic outlet syndrome is a compression phenomenon where you're getting a compression of nerves or blood vessels. So what are some of the major suspects here that we have to be on the lookout for?
Jay Murugavel: 17:21
A very good point Dr. Lakhia. And I also want to interject a little bit earlier, that many cases of thoracic outlet syndrome, especially in athletes and younger adults, there's always a predisposing injury possible. There are some congenital anomalies like a cervical drip, but also people who had a clavicle fracture, automobile union of clavicle fracture or previous neck injuries can be a good factor.
Jay Murugavel: 17:46
And moving forward, talking about what the anatomical structures that are involved in the thoracic outlet syndrome, definitely the first rib, which lies underneath the clavicle and the muscles attaching to the first rib are your scalene, anterior scalene and then middle scalene are significantly involved. The common site is where these muscles lay in close proximity. They are attached to the sites of the neck and in between them comes the brachial, lower part of the brachial plexus, and also the blood vessels coming through it.
Jay Murugavel: 18:21
So in terms of athletes who do a lot of heavy lifting training and swimmers, especially these muscles can be hypertrophied or become significantly thick and compromising the space through which the nerves and blood vessels comes through are in many patients population, I think there was also a situation where they have spasm of these muscles or irritation of the nerve ending, causes spasm of these muscles and vice versa because of the spasm of the muscles, the muscles in turn compressing on the nerve causing this kind of situation.
Dr. Sanjiv Lakhia: 18:57
Yeah. So just another way to say that, the strap muscles of the neck attach somewhat to that first rib and when these muscles get tight or contract or compressed over time, I think it can elevate that first rib. And for lack of better term, pinched the lower part of the brachial plexus, which is the big group of nerves to go through there. And honestly, I feel like when I've looked at this topic before that we should be calling it the thoracic inlet and not that the thoracic outlet based upon how the structures dive into that area and go down your arm. But that's kind of semantics, I guess.
Dr. Sanjiv Lakhia: 19:36
As a physical therapist, so Emily touched on something I think that's important that if you're out there listening and struggling with pain going down your arm and you can't find a cause, I, myself, I remember seeing her and doing the nerve test and my initial thought was that it could be a cervical radiculopathy or a pinched nerve in her neck, so I missed it at first. So as a physical therapist, what are your suggestions for patients and even clinicians who are listing on how to decipher between a pinched nerve in the neck, cervical radiculopathy versus a thoracic outlet syndrome?
Jay Murugavel: 20:10
That's always a challenge because many times the C-7 radiculopathy mimics the symptoms of thoracic outlet syndrome. And the diagnosis is very difficult unless you have a provocation test of the vascular structures that can, if it is significantly positive, then you can prove it's a thoracic outlet syndrome. And in many situations, some of these tests have a false positive. That means that it's just as positive, but patients are not having thoracic outlet syndrome situations.
Jay Murugavel: 20:42
So the common tests that I use in clinically for both radiculopathy and thoracic outlet syndrome is putting the nerves and the tension, the upper limb neural tension test, where we integrated manner put the brachial plexus and then the peripheral nerve under tension, and then compared to the other arm and many times that's positive and also tapping along the brachial plexus approximately around the neck.
Jay Murugavel: 21:07
Usually we produce the symptoms and invariably many of these people have an elevated first rib as you alluded to earlier. So it's a comprehensive evaluation and putting all the small pieces together we'll come to a conclusion, but still it's a very challenging diagnosis to make. And many times the nerve conduction studies and all of those are negative.
Dr. Sanjiv Lakhia: 21:28
That is correct. That was a situation for Emily. You can at times see some changes on the EMG and nerve conduction involving the lower trunk of the plexus, but it doesn't always show up. Now, Emily, your resolution essentially, you had the rib removed, correct?
Emily Tucker: 21:46
I did. I actually had two. I had the full rib removed at my extra cervical rib that was found, but also I believe about three quarters of the first rib was also removed. And the reason that happened was Dr. Vanderveer said later that there was a bone spur coming off of that area. And he said that it was extremely narrowed and there's actually two different approaches that can be done for this type of surgery. One where you can go in through the armpit, which is the transactseal, but he does it from the front. And I think for me, had it not been done that way, I may not have had such a positive outcome because that bone spur was actually not identified on the MRI scan of the brachial plexus, but was found interoperatively.
Emily Tucker: 22:46
He said that that was the main reason why I had so much weakness in my arm was because I had the C-7 radicular pain, but I had a C-8 weakness. And that was the component that he could not explain by my imaging studies. And so intraoperatively found this extra bone spur, so had to take off additional bone and it was extremely tight in there and they had to retract significantly on the nerve during the surgery, but ultimately the outcome was great.
Dr. Sanjiv Lakhia: 23:22
Yeah, that's fantastic. And fortunately, I would say majority of patients who have thoracic outlet syndrome never get to that point and can find improvement and resolution even mostly through physical therapy interventions. So Jay, I want to transition back to your input here. If you have a patient that you're evaluating and you've put them through your nerve tension tests, and you've looked at their circulation and concluded that they have, let's say a neurogenic thoracic outlet syndrome or a nerve related syndrome, what is your mental model for approaching these patients on how to get them better?
Jay Murugavel: 24:02
Generally, it depends on what stage of inflammation the patients are coming in. Sometimes patients might have had symptoms for six to eight months and they have gone through several places for therapy and other medical management, their conditioners as a plateaued, it's not improved, but they still have and there are a lot of things they cannot function. I would probably treat them very differently than somebody presents with acute symptoms where their nerve retention is significant. They are not able to function. They have to keep the arm by the side, even sleeping is disturbed.
Jay Murugavel: 24:36
We try to assess them based on the clinical presentation they present with. I usually follow a guideline of reading the severity of the symptoms and irritability of the nerve and also the nature of the dysfunction. So if clinically they're present with a lot of pain dominant symptoms, I try to manage the pain first by teaching them postures or positions that will elevate their symptoms. And also from their history, they'll give me details of what activity, unknown to them, they may be doing things to keep on aggravating the pain so that they're repeatedly performing the same moment that provokes their symptoms, unless they avoid or minimize or stop, they will be inflaming their nerve tissue significantly.
Jay Murugavel: 25:29
So in a baseball pitcher, it could be stopping from playing. In an industrial worker who has to do a lot of overhead activities, telling them to avoid doing those, and also trying to teach them about good posture so that we are trying to minimize their initial symptoms and moving forward, I also try to work with them about educating them about the condition they're in and what activities they need to do. I do use a lot of manual therapy to treat that first rib and also the sternal area where it attaches treating the scalene with manual therapy or dry needling, and also treating the whole upper thoracic ring as one unit trying to normalize the range of motion.
Jay Murugavel: 26:15
So if the extrinsic factors are causing them more compression, tightness, stiffness in the muscles. So we are trying to minimize the stiffness and tightness in the muscles, improve the joint mobility. So the container through which the nerve passes will have more mobility and stay relaxed. So our job at the initial stage is to manage pain and gently start them with exercises. Most of the chronic situation due to postural dysfunctions patients tend to have lower trapezius weakness. So we also work on strengthening the lower trapezius muscles and also piece them stretching exercises for the scalene and upper trapezius.
Dr. Sanjiv Lakhia: 26:56
That's pretty comprehensive. Emily, are you still committed to, or having to go through these types of home exercises on a routine basis or a maintenance basis?
Emily Tucker: 27:09
Yes. And I would say sometimes I'm more diligent than others. I went through extensive physical therapy after my surgery. I had some nerve pain, quite a bit of nerve pain afterwards due to the retraction on the nerve afterwards. So Jay was great about working with me through the pain and teaching me some different things and then rebuilding the strength in my arm. I'm an avid swimmer. I love the water. It's good therapy for me, but I know too that swimming can aggravate this condition. So I definitely had to do some modified approaches with my swimming. I do a lot of backstroke where I just use my legs and not my arms. But also when I went back in to see Jay this past spring, re-engaged a lot of the exercises and I probably do my physical therapy exercises about five days a week. And on the other days, I try and be pretty active with other things.
Dr. Sanjiv Lakhia: 28:09
Plus you're in the 95th percentile of compliance, Emily, so you should feel really good.
Emily Tucker: 28:13
Well, I try, because I tell my patients, like you brush your hair and brush your teeth, you got to do your PT exercises. So I am a huge proponent and advocate of physical therapy.
Dr. Sanjiv Lakhia: 28:24
Jay, one of the things I wanted to ask you about your graciously sent me a presentation you put together on this topic, you mentioned in your presentation, the potential influence of breathing patterns on thoracic outlet syndrome. Can you elaborate a little bit on that?
Jay Murugavel: 28:41
I think breathing is very, very important. And if I may also add on what Emily said, I think that getting the patient to agree with the plan, because Emily at that point had a little pain like she was mentioning and she went along and she was 100% cooperative and she did all her exercise very diligently. And initially she had a little bit of pain, but she put up with the pain for the greater good at the end. And I would have to say that she worked really hard in a rehab and she became very strong and I think she is a lot stronger than how she is even compared to before surgery. Thank you, Emily.
Jay Murugavel: 29:18
Moving forward to the breathing exercise, I think it's a very important component. As I said earlier on most of these patients that I see present with forward head rounded shoulders and increased thoracic kyphosis and the scalene have also accessory muscles of breathing and respiration. So what I try to emphasize is on diaphragmatic breathing and we spend a lot of time trying to work on educating them on diaphragmatic breathing on a regular basis.
Jay Murugavel: 29:48
We also work on the lower coastal rib area to release those tightness in those areas. So that they'll have a proper diaphragm excursion. And also teaching them the difference between normal diaphragmatic breathing and upper thoracic epical breathing and how to differentiate between the two. So we emphasize a lot on diaphragmatic breathing to minimize their symptoms.
Dr. Sanjiv Lakhia: 30:14
Diaphragmatic breathing would involve, if you take a deep breath and you have your hands on your lower abdominal area?
Jay Murugavel: 30:20
Yes, you are at a good point. So I have actually have the patient cup their hand and place it on the lower abdomen and try to have them breath into their hand. Also emphasizing on the lower lateral costal breathing so that they are using lower ribs to expand laterally in sideways direction and not just fill air in their stomach. And we try to differentiate that to have a proper diaphragmatic breathing.
Dr. Sanjiv Lakhia: 30:48
Excellent. Well, I think that's a very good summary from different angles of this condition. My experience has been, I typically think about thoracic outlet syndrome when I have patients for which the cervical spine workup is negative and they have persistent what we call parasthesias or numbness and tingling down the arm into the hands sometimes even into the middle finger, ring finger, distribution area. And, we touched on earlier, the biggest element that in retrospect for me should have had me thinking about this for Emily are the occupational hazards or occupational risk factors.
Dr. Sanjiv Lakhia: 31:29
So I'm highly suspicious now when I see dental hygienists or dentists or people who are on their computers, their devices long periods of time, and you see the rounded shoulder posture, tightness in the chest muscles. I think this whole workplace syndrome now where everything's at our frontal plane for us is creating a wide variety of problems, thoracic outlet syndrome, carpal tunnel syndrome, or neuropathies. I think you can find the root to a lot of this and just how we go about our day to day life. Would you agree with that, Jay?
Jay Murugavel: 32:03
Absolutely.
Dr. Sanjiv Lakhia: 32:04
What do you think would be ... Emily mentioned swimming, which is very interesting. I know the concern there would be the repetitive overhead motion with freestyle swimming stroke. What do you think would be an ideal exercise? If someone says, "Hey, look, I have an occupation that puts me in that compromised position, but I don't have any symptoms now. And I want to prevent it from happening." Would you say swimming or yoga or Pilates? What's a good activity that you can get started with to make sure you have good posture and decreased tension in your neck and shoulders?
Jay Murugavel: 32:41
I think a lot of the swimmers who develop thoracic outlet syndrome is because of the number of the hours they put into swimming. Sometimes it could be a combination of fatigue and for technique. So I try to have them minimize the combination of breathing through the mouth and turning their head to rotate them freestyle. I try to have them use a snorkel. Some patients are eager to adapt that temporarily to alleviate the symptoms. And then they work with the swim coach to clean their technique.
Jay Murugavel: 33:13
So that's one modification and Emily's modification was adopting backstroke. So that's another options. And when they come to therapy, we also work with them on trying to loosen the scalene and working on the upper thoracic extension and release the tightness from the pec minor and pectoralis muscles that also allows them to have a better freedom of range of motion so that they have a swim with the good form. As you alluded, other forms of independent gym exercises like Pilates and yoga are good. I can't think of any specific type of yoga that would be counter productive to this.
Dr. Sanjiv Lakhia: 33:52
So the movement is in general, really good with some slight modifications that you suggested. Okay, well, I just want to [crosstalk 00:34:00]. Yeah, go ahead.
Emily Tucker: 34:01
One thing that I have found to be extremely helpful for me, because a lot of my life is forward with kids and softball and assisting with surgery and computers is the foam roll. And that's something that's used a lot in physical therapy. So many days when I get home from work or after exercise, I'll go lay on the foam roll and do some different exercises to help keep my shoulders back. And that I think for me has been extremely effective.
Dr. Sanjiv Lakhia: 34:33
That's a great point. I have one at home as well. Use it routinely. I've worked with Jay. He would tell you are, I probably don't use it enough. But that's a very inexpensive tool that a lot of people could adopt and use it for the better. Well, I want to just open the floor for any last comments that you guys have. Emily, anything else you want to share from a hybrid clinician patient perspective on your experience dealing with thoracic outlet syndrome?
Emily Tucker: 35:01
Well, I think it's important that when we're dealing with the spine, that we also look outside the box of the spine, because I think when we see patients day in and day out for neck and back issues, we also have to think about some other conditions that can mimic those. I think that's where physical therapy plays such a huge role in what we do, because we can do different images of the spine and different nerve tests, but also with the different techniques that are used in therapy, a lot of patients can get better with therapy. And, before I was diagnosed with thoracic outlet syndrome, I saw Jay for five years off and on just to keep my arm at bay.
Emily Tucker: 35:49
And looking back at that, I probably had the neurogenic component of thoracic outlet for that time. I spent countless nights not sleeping because of the nerve pain in my arm, but I think what pushed me over the edge was when the vascular structures became compressed. And that's when my body said enough was enough. And I think it's super important that we listen to our body, that we listened to our healthcare professionals. We listened to our physical therapists and we have to answer each piece of the puzzle as it comes and not give up on if a scan looks normal, it doesn't mean that nothing is wrong.
Dr. Sanjiv Lakhia: 36:33
That's a great bit of advice. I know many times you can have a patient come in or I've seen someone and I tell them your scan is normal, but that doesn't mean everything is fine. And I want people to understand that it doesn't necessarily mean we think nothing's wrong with the individual. So, you really pushed and advocated for your health. And it's such a blessing that you got to see Dr. Vanderveer as well. And he's able to take care of the problems for you. Jay, any last thoughts you want to share from your perspective on the condition?
Jay Murugavel: 37:06
I think you covered very well. Dr. Lakhia and Emily I think narrated her experience and the her hard work in getting better. I think we all got it covered. Thank you [crosstalk 00:37:17].
Dr. Sanjiv Lakhia: 37:17
Fantastic. Yeah. Before we leave, I always like to ask my interviewees to share maybe one or two health tips that they've adopted into their daily lives that the listeners could consider or at least learn from. I've always shared that I do a fair amount of meditation and exercise. Jay what's your one or two go-to's to keep yourself healthy?
Jay Murugavel: 37:40
I try to do regular yoga and also incorporate my family into doing a little bit of yoga conditioning classes and try to all eat healthy together because unless you incorporate your community, the success is not going to be as good. So I try to incorporate my daughters and my wife in to all the physical activities we do together.
Dr. Sanjiv Lakhia: 38:03
That's a great tip. It's never been brought up, but there's actually good research that we are healthier when we involve a community versus trying to do it on our own. So thanks for sharing that. Emily, how about from your side? I know you're really into nutrition and exercise and what's your go to?
Emily Tucker: 38:23
Well, my go to is definitely nutrition and exercise. And I think the two go hand-in-hand, if I don't eat healthy, then I don't want to exercise. And when I first started having the arm pain again, five years ago, I really adopted more of a clean eating and healthy lifestyle through eating more of an antiinflammatory based diet. And I think that has been huge for my body. I've been an athlete my entire life. And so, I have always exercised, but I think it's important too, especially as we age that we exercise in the right way.
Emily Tucker: 39:02
So when I had started swimming after my neck surgeries, I was hoping to not do as much wear and tear with running. So I thought swimming would be the best way to go through with that. So I think it's just important to control what we can control. And I think in our life, I couldn't control the fact that I had an extra rib in my neck, but I can control the fact that I can try and eat healthy and exercise. And so I think for me, it's more of a mindset of what I can control, is what I put in my body and how I move my body in a healthy way to stay as healthy as I can be.
Dr. Sanjiv Lakhia: 39:44
That's music to my ears, Emily. I love it. That is, control what's in front of you and not really focused on things that are out of our control, over your stress and eat well. And I think you hope for the best after that so. Guys, I really appreciate your time today. I think we took a very complex topic and put a real personal spin on it and broke down the rehabilitative approach, hopefully in a way that if there's someone listening today with similar symptoms could understand it and also provide them with a little hope that if you're out there and you're struggling with a condition like thoracic outlet syndrome, don't give up, talk to your clinicians, if you're local come see us at Carolina Neurosurgery & Spine and keep pushing, find a very knowledgeable physical therapist and take Emily's lesson. Don't give up on your health. There's light at the end of the tunnel. So Emily and Jay, thank you for your time today.
Jay Murugavel: 40:35
Thank you, Dr. Lakhia.
Emily Tucker: 40:35
Thank you, Dr. Lakhia.
Jay Murugavel: 40:37
Thank you, Emily.
Emily Tucker: 40:38
Thank you, Jay.
Outro: 40:42
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.