Description

A 56-year-old right-handed lifelong recreational baseball pitcher with no significant past medical history presented for evaluation of 1 year of right arm pain, finger tingling, heaviness, and brain fog. Previous evaluations by neurology and neurosurgery revealed a mild sensory polyneuropathy and degenerative changes seen at the C5 to C6 level on MRI and the absence of a cervical rib (Fig 1, Fig 2, Fig 3). He completed a course of physical therapy (PT) with mild improvement, though he noted full return of symptoms. He also concomitantly saw rheumatology where he had autoimmune laboratory work done that was unrevealing. Given continued symptoms, his primary care physician referred him to Sports Medicine for further evaluation. In clinic, the patient reported sudden onset pain and numbness going down his right arm with “loss of power” and associated “brain fog,” which he described as feeling sluggish with low energy, forgetfulness, and having difficulty concentrating. There was no preceding trauma. He reported his pitch count had decreased to where he could only throw 30 pitches before his symptoms became unbearable.

Fig 1: Multilevel facet degenerative changes, reduced disk height at C3 to C4 and C5 to C6. Absence of a cervical rib.

Fig 2: T2 sequence. Degeneration of disk and loss of height at the C5 to C6 level. Diffuse narrowing of thecal sac consistent with spinal stenosis.

Fig 3: T2 sequence. Degeneration of disk and loss of height at the C5 to C6 level. Diffuse narrowing of thecal sac consistent with spinal stenosis.

Physical examination revealed a well appearing man in no acute distress, resting comfortably on the examination table. Examination of the right and left shoulders revealed no redness, warmth, swelling, or tenderness to palpation. No prominent venous collaterals were observed on the shoulder or chest. Bilateral shoulder range of motion revealed full-active flexion, extension, abduction and adduction, and internal and external rotation. Strength was 5/5 in bilateral upper extremities throughout. Bilateral Adson tests were negative. Spurling compression tests were negative bilaterally. Neer test, empty can, and shoulder drop tests were negative. Scapular assistance test was negative bilaterally. Roo test was positive on the right side.

Given the patient’s history and physical examination, the differential included TOS (vascular vs neurogenic), cervical radiculopathy (C5-C6 stenosis) secondary to degenerative cervical disk disease, peripheral nerve entrapment (suprascapular, axillary, long thoracic nerve, and radial nerve), brachial plexopathy (Parsonage-Turner syndrome), inflammatory/autoimmune neuropathy, mononeuritis simplex/multiplex, superior labrum anterior to posterior lesion, and a biceps tendon tear.

An electromyography revealed a moderately reduced amplitude with borderline slow conduction velocities of the right radial nerve. Needle examination of the deltoid, biceps, and triceps and right paraspinals muscles (C5/C6, L5/S1) were normal. Results were consistent with a mild sensory axonal polyneuropathy with no evidence for right cervical radiculopathies. MRI of the brain and neck failed to reveal any neurological explanation for the patient’s brain fog. MRI revealed no evidence of intracranial hemorrhage or fluid collections and no areas of ischemia.

Vascular duplex ultrasound guidance of the upper-extremity veins revealed decreased color Doppler signal and flow within the distal right subclavian vein, with rouleaux flow, with the patient’s arm at 90°. Upper-extremity arterial duplex ultrasound guidance and functional maneuvers showed evidence of TOS involving the right upper extremity at 180° and military position with head to the right and left (Fig 4). The right wrist-brachial index also demonstrated compression. No evidence of TOS involving the left upper extremity was observed. The final working diagnosis was right-sided venous and neurogenic TOS.

Fig 4: Continuous wave Doppler via photoplethysmography of the bilateral upper extremities with the arms in multiple positions. Evidence of dynamic right arterial obstruction with provocative movements.

The patient was referred to vascular surgery who performed a scalene block with improvement of pain for 2 to 3 days, further confirming the likelihood of TOS. The patient went on to have a first rib resection. Two weeks postoperatively, the patient reported his brain fog resolved, and his arm felt much better. Three months postoperatively, the patient reports continued substantial improvement in right arm symptoms and brain fog, and he has returned to his previous level of pitching performance. A 12-month postoperative follow-up revealed no return of symptoms.