Measured Evidence of Thoracic Outlet Syndrome 

September 2001 (Updated July 30, 2008)

Synopsis: Courtesy of a Sorehander, the information below—motion video excerpts from a radiologist—presents the most important development I know of in RSI. With this new info, we propose that computer-related RSI is caused first-and-foremost by Thoracic Outlet Syndrome. We suggest that the greatest generalization among computer users is that the problem starts with circulation and the chain reaction begins at the chest and neck, as a result of the "gargoyle" posture of computer work. Although generalizations are often derided, we think that more good than harm is done by placing attention on this no-longer-hidden weak point in the human anatomy and its relation to fixed-posture, arms-suspended work. Medical literature further emphasizes anatomical anomalies such as muscle arrangement and fibrous bands in this area that can easily explain different susceptibilities among individuals, a frequent source of mystery for sufferers.

UCLA's Dr. Collins Documents the Diagnosis of Thoracic Outlet Syndrome

Through the kindness and concern of a Sorehand member, UCLA University, and UCLA's radiologist, Dr. Collins, we recently received a 52-minute (227MB) video transcription of Dr. Collins' extraordinary and ground-breaking work documenting Thoracic Outlet Syndrome. It is THE most important development we've encountered related to computer-related RSI (and RSI in other jobs involving static posture or overhead work).

The full video shows Magnetic Resonance Angiography (MRA) results being analyzed by Dr. Collins. This page contains about 3 minutes of critical snippets from the video, and some stills. The following annotated figure gives you an idea of the whole picture... clearly showing the difference between one patient's healthy and unhealthy arms.

Healthcare Professionals: The whole 52-minute video is narrated by Dr. Collins, using appropriate medical terminology meaningful primarily to other radiologists, anatomists, or surgeons. In fact the video is useful as a training module to share the technique of performing the anaysis of the MRA, showing extensive manipulations of the various "sections" and surrounding landmark structures. Although less useful to RSI sufferers, this supportive content is meaningful to other healthcare professionals seeking to learn the techniques, and they should contact me to acquire the full video. Perhaps some day I'll post the full file but right now it's just on CD. It will take me a few days or weeks to make a copy and send it.

We've extracted out the most vital segments, the "bottom line" information of concern to RSI sufferers, editing the content down to small snippets that are feasible to download even at modem speeds. These snippets are below.

Dr. Collins

La Machine

The Workstation

Videos

QuickTime Advice

For the Quicktime versions, to really appreciate the content, you must follow these instructions. If you simply click the link, it will be too small to make out the detail.

  1. You must RIGHT-CLICK the link below and

    • If Netscape, click Save Link Target As...

    • If IE, click Save Target As...

  2. Save the file to your system.

  3. Run (double-click?) the file from your system. This will enable you to

  4. As shown in the diagram on the right, use the Movie menu or buttons in the upper right to maximize the size.

 

 

Segment

QuickTime
See above, right-click and download,
so you can zoom in.

AVI

 

 

Viewer Download

Viewer Download

 

Stacked image of blood vessels:

300K +

750K *

 

Front (coronal) view of blood vessels

320K + 

780K * 

 

Most important segment, part 1: uneven scalene muscles

210K

338 *

 

Most important segment, part 2: blocked subclavian artery

500K +

1.3MB *

 

Saggital view (from side of body). This clip is highly edited (reducing the quality) and not as obvious to the layman. It is included to give you just a taste of how detailed Dr. Collins demonstration of the material gets.

1.7MB +

 

 

View with arms overhead. As with the previous clip it is highly edited and not as obvious to the layman.

1.0 MB +

 

 

View of all 4 quadrants and part of Dr. Collins' signoff.

1.0MB +

 

 

+ = Read procedure above or the view won't be large enough to see the point.

* = The AVI's seem to require a decompressor that is not on all systems.

Stills, Transcriptions & Translations

The following sections show a still from each video along with transcription of Dr. Collins' narration and my translation or comments.

Stacked.mov/Stacked.avi:

 

 

Transcription
"... the spinal cord, the irregular veinous drainage of the right arm, here, which is a wee bit different display somewhat gray as compared to high signal white flow. And we can see actually the right cephalic; the axillo-subclavian [artery]...

Layman's Translation":
The cloudy gray area is the blood in the vein trying to return to the heart. It should be a distinct white line like the vein on the right. The artery on the left is "high signal," meaning bright white. In fact it is too bright, indicating blood is engorging it because it can't return to the heart easily enough.

Coronal.mov/Coronal.avi:

 

 

Transcription:
"These are the structures that [there is to???] the brachial plexus. Reflection of the diminshed colors you see here, gray and white, represents the decreased veinous return, and as is known, decreased veinous return increases intra-cranial, intra-thoracic, and intra-abdominal pressures and about complaints within the five senses."

Layman's Translation:
These are the blood vessels [and nerves?] that make up the brachial plexus (the complex bundle that intertwines at the point where the arm meets the torso. (They probably form a tight bundle so that the arm can rotate in 3 dimensions, otherwise some would travel different distances and stretch too far.) Blocked blood flow back to the heart increases [blood?] pressure in the head, chest, and stomach, resulting in a surprisingly wide range of problems... not just the hands!

Unevenscal.mov/Unevenscal.avi:

 

 

Transcription:
"...causing asymetry in these anterior scalene muscles as they insert on the first rib... the smaller one on the left, the phrenic nerve here, the larger one on the right, the phrenic nerve here."

Layman's Translation:
...the exaggerated posture, for instance from handling a computer mouse all day, causes the vertical muscles that reach from the top of the neck down to the first rib to get much larger and stronger on one side than another. Dr. Collins points out the phrenic nerve apparently coursing directly under the muscles. [I read in McMinns Color Atlas of Anatomy that the phrenic nerve is the only motor nerve to the diaphragm. Could this explain shortened breathing of computer workers as they concentrate on their work???]

Subclav.mov/Subclav.avi:

 

Transcription:
"Here we have the most important part of the examination. The first rib is identified here as a gray signal intensity sitting on the top of the right lung, as is the one on the left, and the bulbous expansion of the subclavion vein where there is a bicuspid valve. In the subclavion vein, there are three bicuspid valves, one here, one in this region and one j,ust before we enter the axilla. The clavical and the muscle will come down and cause a concave depression even in a supine position, without the arms up."

Layman's Translation:
This video is too subtle for me, and perhaps you, to understand the evidence we're seeing . But to the trained eye, one that has seen other, "normal" bodies, this one shows a ballooning of the main vein returning blood from the arm. Dr. Collins explains something I don't remember every hearing, despite having had a gross anatomy class and disecting cadavers: veins have valves (to prevent backflow presumably because there is very little pressure at points so far from the heart). The collarbone and muscles push down on this area. They push down even more when the arms are raised, but they push down even without the arms raised. One might speculate that the precise location of the valves, relative to the impinging muscles and bones could be a critical differnce between individuals, one that explains why some get RSI and others don't!

Saggital.mov/Saggital.avi:

 

Transcription:
"This is the saggital sequence in three dimensions, and we're rolling from the left side through to the right side. The important thing here is to watch what the clavical does to the structures... in the chest. The clavicle's here with the subclavius muscle. The low signal black here is the artery interrupted. So what you're seeing now is the arrow on the region of the vein. That will open up with the cephalic vein... as the clavicle moves down, forward, in front of the two structures in the chest... the cephalic vein comes in through the hole between the two muscles. Now now we have the clavicle in close proximity to that of the vein, this level right here, and the external jugular here, so we're... potentially with the arms overhead, the clavicle will rotate posterior inferiorly, and compress these two structures on the first rib, decreasing the flow of veinous return, also compressing the inter-scalene triangle??? ... and the vein in close proximity to the anterior scalene muscle and the artery. This is the only place in the human body where a muscle comes down between a vein and an artery... this being the subclavian artery, this being the subclavian vein. This is the rib itself, posteriorly. [Skip ahead in the original video.] Moving along from the left side to the right side. On the right side, notice that the low signal here is much larger than on the left. Again the close proximity to the clavicle... [skip] ...low signl axillo-subclavian vein, indicating [good?] flow, as compared to what we saw on the left side.

Laymen's Comments:
This is a view of a vertical cross section of the chest. The patient is facing to the left. This sequence is probably too subtle for the layman, and really only meaningful in motion, showing the relative positions of the blood vessels and bones as the view moves closer to the midline of the body.

Armsup.mov/Armsup.avi:

 

Transcription:
"Now we're seeing the artery and the vein in the same image, the veinj being the axillo-subclavian lower on the right than on the left; the point here being is no matter whether one side is compressed or not is the laxity of the three muscles, the ones mentioned in the articles of which I written much about, the 'sling' muscles: the first fascicle of the serratus, the levator, and the trapezius muscles, the laxity of which will cause the clavicle, the subclavius, and the coracoid process to be depressed. Here you're seeing the coracoid, and attached muscles pushing down on the neurovascular [???]. And likewise [on this side???]. The interesting thing is that this is the image that really shows very nicely the asymetry in the size of the shoulder muscles...the deltoid larger on the right... You can actually see how the vein is being compressed on the first rib, the clavicle and the subclavius compresses the subclavian vein on the first rib far greater than on the right side, point being is that he's compressing more on left than the right, but the point being is that the veinous compression will trigger the complaints.

Laymen's Comments:
Again, a view that really requires a radiologist to step you through each frame showing which subtle gray area represents each structure and showing it in contrast to a healthy specimen.

Quadrants.mov/Quadrants.avi:

"This is the 4-quadrant display that we can control where we can go up to as much as 16 images and annotate but we can't change the quadrants.

This is the coronal image that we started with at the point of the anterior scalenes. This is the transverse sequence that corrolates with approximately 12-22 at the level through the subclavian artery at this level. This is the mid-plane of the cervical spine at the saggital sequence. And this is of course the 2-D stacked image that displays the aorta, pulmonary left and right, and of course the decreased blood flow within this right subclavian vein, this being the facial here, and the spinal plexus, venous plexus here. And we can change that by pushing the button, and go right into this 3-D sequence in the quadrant.

You know it's a proud moment to be able to have equipment like this, but it's not unusual to have equipment like this in every radiology department. It's just [???] the ability to talk anatomy and show anatomy, things we couldn't even do before...[???]."

A Personal Experience

The following story and details were provided by a Sorehand participant. They are published here to demystify the process and make it more accessible in the hope that it will enable more sufferers to avail themselves of the process and solve the RSI puzzle. The information has been edited into roughly chronological order, without being reworded too much, so the flow may not be perfect.

Getting an Appointment

You need a UCLA ID # (to identify you to the Med Center), but that doesn't mean you have to be affiliated with UCLA. You just call a number, and they assign you a number for their computer system.

The phone # to get an ID is: 310-206-6693.

Then you can call the appointment line to schedule: 310-301-6800.

They take Workers Comp (pre-authorized only) and various insurance, but if you plan to self pay, the cost is prohibitive (about $3000 is the last I heard). If you're going to get it, get in the queue immediately - his wait is about 3+ months. Dr. Collins is the only one that does this MRI, and he does at most 2 a day.

The test is very expensive and I had to sue the insurance company that handles my WC claim. It took one year of fighting for it and I won :) They had to pay for my flight, hotel etc. While the test is expensive the reality is UCLA does not receive what they bill. Here is the info on billing:

Dr. Collins's mailing address below is different from the place you actually get the MRI. The exam is performed in the basement of the 200 Medical Plaza at UCLA.

James D. Collins
BL-428
Center for Health Sciences, Univ of Cal
Mail Code 172112
LA, CA 90025

(310) 825-7248

The Examination

"The test is well worth it. It's like a painless look inside without having to cut you open. Incidentally, it has validated TOS in quite a few cases that I know of. Collins's 3D MRI is different than the 3D Neurogram (which is a high-res MRI of the nerves - here, the brachial plexus), which is done by Aaron Filler (in Los Angeles - he is no longer at UCLA, I hear) & a guy at University of Washington. I know some that have had the neurogram, but in those that I know, it ended up detecting cervical compression (which they had cervical fusion for... but they still had TOS and in one case, had TOS surgery).

The experience I had at UCLA with Dr. Collins was fabulous! As far as I know, Collins is the only one in the country to do this MRI. He's been doing it for at least 10 years now (maybe 15). Dr. Collins starts with a chest xray to rule-out any osseous abnormalities and then moves on to perform the MRI/MRA (Magnetic Resonance Imaging/Magnetic Resonance Angiography). The procedure lasts about 90 minutes. No intravenous dyes are needed-thus it is non-invasive and less risky.

By using the MRI/MRA Dr. Collins is able to reconstruct in 3-D the nerves and vascular system in relationship to their surrounding landmark anatomy. This information is further analyzed by looking at several different planes (coronal, transverse sagittal etc..) Dr. Collins also evaluated me with my arms overhead, which triggers symptoms, to look at the compression of the neurovascular bundle. The last scan he took was with my clavicle support brace and a small roll of bubble wrap inserted in the brace between my scapula. (This is something we have been experimenting with at my Doctors office).

It takes about 1 1/2 to 2 hours to do the scans (several, with one being in a "provocative" position of arms overhead for 7 minutes). If you are claustrophobic, they pull you out between scans. You can't listen to music (messes up scan), and I think Dr. Collins recommends against sedation. The MRI machine takes a series of scans, and the software interpolates between them to get an effective 3D model (which Dr. Collins can then "slice" up at different angles and resolutions to get a bunch of 2D pictures to have a look at things from different angles). At least that is my understanding. Oh yes, and do NOT belly breathe (diaphragmatic breathing) in the machine. There is a sensor on your chest that times some of the scans with your breathing rate (and relies on your chest moving).

Results

Afterward, Dr. Collins allots about 1 1/2 hours to show you the slides and talk you through what he found. He's a great guy, and he's extremely knowledgeable. The most important part of the MRI/MRA is to have a radiologist that REALLY understands anatomy and physiology and understands that as you compress one part of the body it can result in pressure changes thoughout any part of the body. Our circulatory system is a closed system.

The series of scans is like taking your body (pretty much your torso between your diaphragm to your chin, including shoulders, but not arms - maybe cuts off at the upper arm), and slicing it various ways like a loaf of bread. He can see the blood vessels, nerves/fat/scar tissue (I believe, comes out the same "color" on the scan), muscles, and bones. He pays particular attention to the thoracic outlet - costoclavicular space, scalene triangle, AND axillary area (pec minor/armpit area). He can also see things like pancoast tumors, etc. They also take an X-ray to check for cervical ribs & elongated C-7. The guy is an anatomy whiz.

So what did this test tell me?

  1. My subclavian arteryand nerves are being compressed between the clavicle and first rib with poor venous return.

  2. My external jugular is backing up with blood causing a dilatation. My internal jugular is narrow and the sternocleidomastoid is causing a compression (This is why I was blacking out and why I have bad headaches)

  3. My heart, liver, spleen, spine are all normal. I do not have cervical compression which can cause similar symptoms. No tumors any where!

  4. My left scalene muscles are larger than the right due to something in my habits or overcompensation for my small rhomboid muscles.

  5. With the brace on the subclavian vein looks more open, my spine is more straight-it helps keep my chin back and there is a positive attitude change in my Pec Minor & Major, trapezius etc.

Bottom line is that I have a small frame and my working conditions placed stress on my framework and caused structural changes to my body. I have without a doubt TOS. What do I do with this information? I am a surgical candidate but I know my doctor and I want to try everything we can first. The information can help my PT direct her therapy.

----- End -------

For More on Therapy...

That's the end of the personal experience. But let me address the topic of treatment, since it can be hard to find good info on resolving TOS. My co-author/therapist Suparna uses a combination of physical therapy techiques to create space in the thoracic outlet and free up the muscles. She pushes, pulls, and manipulates around the collarbone and does strengthening and posture exercises along with ergonomic corrections. And you can find excellent information at http://www.whiplash101.com/thoracic_outlet_syndrome.htm This web article doesn't get down to the details of therapy, but it provides a lot of insight into the whole subject of diagnosis and treatment. I'll end with the following bullet points from that article, summarizing the goals of treatment:

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