Why is diagnosing Thoracic Outlet Syndrome so difficult? — Transcript

Full transcript

1. 0:07hey everybody i'm dr scott warden the tos  guy welcome to our next live stream we have
2. 0:12a really special guest today dr art jenkins  was on the faculty at mount sinai new york
3. 0:18neurosurgery he's written dozens of papers basic  science research hundreds of talks and he's here
4. 0:26today to speak about the difficulty in diagnosing  tos thanks art thanks john thanks for having me
5. 0:32it's a pleasure to be here um first thing whenever  you give a talk you got to say hey do i have any
6. 0:38conflict of interest is there anything that would  make me my my words not be valid because i've
7. 0:44got a vested interest in something else and  the answer is no i just do spine surgery um
8. 0:50what is thoracic outlet syndrome it's actually  it's a collection of multiple diagnoses it's no
9. 0:55one diagnosis but it impacts on the neurovascular  bundle the blood vessels and nerves that travel
10. 1:02between the heart and the arm the  thoracic means it's in the chest area
11. 1:08outlet means it's in the area where  structures leave the chest and go out
12. 1:14into the arm and of course syndrome  just means stuff that goes wrong
13. 1:19the anatomy is hard to understand because  it's a very high value real estate area
14. 1:26it spans from the beginning of the brachial  plexus right here the brachial plexus are
15. 1:31the nerves that come out of the spine and go down  into the arm and it goes all the way laterally to
16. 1:37the connection of the clavicle or the collar bone  that goes out to where it meets the shoulder blade
17. 1:46so the entire root of the collarbone from here  to here is the span of the thoracic outlet from
18. 1:52top it goes from the level known as c5 which  is the first nerve that goes out into the arm
19. 1:58all the way to the bottom on the surface  of the ribcage itself or the thoracic wall
20. 2:06it has a whole bunch of different symptoms  it's determined by which structure in that
21. 2:11complex area that's actively being compressed  it can cause pain it can cause tenderness it can
22. 2:17cause numbness tingling weakness in the hand  or in the arm it can cause in extreme cases
23. 2:24atrophy or just a a loss of muscle in the  hands or in the arms but that is a late
24. 2:31finding and you don't want to get to that  point if you can avoid it if it's already
25. 2:35happened it's that's unfortunate but there may  still be some things that can be done for that
26. 2:45these entrapments can be caused by different  things there are compression against one of
27. 2:52these structures between the clavicle or the uh or  your collarbone and the first rib the top of the
28. 2:58rib cage you can also have something called the  pec minor syndrome where your neurovascular bundle
29. 3:06is pinched under the tendon to a minor muscle  that controls the shoulder blade position the
30. 3:13pectoralis minor scalene muscles on top of the  rib itself can pinch nerves or even the artery
31. 3:23if they're either overgrown or if they're there's  some process that causes them to be abnormal
32. 3:30there is a process called a cervical rib it's  a congenital anomaly where you have an extra
33. 3:36rib above the normal ribcage and that can pinch  the nerves coming through in addition there are
34. 3:43fibrous bands that are very hard to see on imaging  but those can cause twisting or pinching of the
35. 3:49nerves trauma to the area can sometimes cause a  fracture or a sprain that is now the dislocation
36. 4:00that's pinching one of the structures going  through there there are certain congenital numbers
37. 4:04where you're just born with weird anatomy and  then there are variants on any one of these that
38. 4:10may be slightly different than the normal flavor  of any of the ones that we've mentioned already
39. 4:19now no one clinical test or radiographic test  is universally reliable or specific there's
40. 4:27no one test that says this is definitely tos  and there's no test that says this is not tos
41. 4:35but you have to look at the entire picture of  what are the symptoms what are the radiographic
42. 4:40findings what are the clinical findings  to determine is it tos or is it not tos
43. 4:47east test east the um the external um the  elevated uh arm stress test is when you lift
44. 4:57your hand up and squeeze the hand while it's  lifted up and that stresses the hand and shows
45. 5:03if you have impaired circulation or impaired nerve  stimulation so that the nerves tire very quickly
46. 5:11electrophysiology which is where they might wire  up your muscles for to determine how well they're
47. 5:16functioning and determine the nerve conduction  is helpful but not always in fact one of the
48. 5:23more most experienced neurologists that i've ever  spoken to treating this says it's not uncommon to
49. 5:29have a completely negative test even when the  patient is having active symptoms so it's not
50. 5:35a precise test nor does it eliminate people  who don't have tos when they think they do
51. 5:42in addition to that there's  all sorts of different types
52. 5:44of imaging there's cat scans there's  mris there's different types of x-rays
53. 5:49there are even other types of tests that  we can do that we don't usually find useful
54. 5:55now one of the other issues that makes  it so hard to diagnose is there are other
55. 6:00orthopedic and neurologic symptoms syndromes  that overlap with thoracic outlet syndrome
56. 6:07and there are shoulder problems people have  slapped hair or they have a dislocation or they
57. 6:13have some other problem in their shoulder and  it may pinch a nerve but it may not be thoracic
58. 6:18outlet syndrome it's a primary shoulder problem  not a primary thoracic outlet region problem
59. 6:25in addition to that there are problems in the  elbow even sometimes in the wrist with carpal
60. 6:31tunnel syndrome there are other problems  where if you have a rib fracture that can
61. 6:36cause or or mimic thoracic outlet syndrome a  tumor of the rib can also cause similar symptoms
62. 6:44in addition to that neurologic problems  like a pinched nerve in the neck
63. 6:49or a tumor or trauma to the nerves in the  brachial plexus but not necessarily from
64. 6:55thoracic outlet syndrome and then cubital tunnel  a nerve entrapment in the elbow carpal tunnel
65. 7:02nerve entrapment in the in the wrist all of these  can make very similar symptoms to tos so deciding
66. 7:08which one this is it result you know you have  to make sure you eliminate other possibilities
67. 7:14in addition to that either tos is associated  with other conditions or other conditions have
68. 7:21symptoms that are very similar to tos so there  are collagen vascular disorders that often
69. 7:28result in thoracic outlet syndrome symptoms  but it profoundly complicates the management
70. 7:36ehlers-danlos is one in particular that it make  most patients with ehlers-danlos actually are
71. 7:41more likely to have a very complicated course  if you treat them surgically but they frequently
72. 7:48spiral out of physiologic control if they  don't get treatment so it's a difficult
73. 7:54position to be in is having patients you you're  kind of damned if you do and damned if you don't
74. 7:59but you do the best you can to navigate  between the waves and the rocks
75. 8:04in addition there are certain vascular conditions  and uh one of my colleagues in new york is one of
76. 8:09the world's experts on a condition known as may  thurner syndrome and we've found that there are
77. 8:14a number of patients who have a vascular problem  in their pelvis that when we treat that their
78. 8:20thoracic outlet syndrome symptoms just feel  better and so that the relationship between
79. 8:26the vasculature the pelvis and the vasculature  or other anatomic structures in the in the
80. 8:32shoulder region is fascinating and we're still  exploring that um a lot of patients with neck
81. 8:38trauma are more likely to develop thoracic outlet  syndrome prior spinal surgery renaud syndrome
82. 8:44mimics because it causes a vascular problem in  the limb but not in the thoracic outlet other
83. 8:52arthritic conditions either contribute to or  can result in similar symptoms of tos including
84. 8:59ankylosing spondylitis rheumatoid arthritis  and even generic garden variety osteoarthritis
85. 9:08so one of the the next issues is well let's say  you've made a diagnosis of tos what do you do next
86. 9:15and that's part of the complexity and i  think it's one of the things that confuses
87. 9:19a lot of clinicians is there's still no  great uniform understanding of what the best
88. 9:26next step is for every single patient and  we'll get into that in a minute but first
89. 9:32the first line of treatment for tos is always  physical therapy but not all physical therapy
90. 9:37is beneficial for patients with tos and  in some cases can make the symptoms worse
91. 9:43second bracing has been used as an option and one  of the reasons that seems to work we'll get to
92. 9:51in a minute but the the issue is what drives the  pinching is the position of the shoulder blade
93. 9:58and if we can brace and elevate that shoulder  blade so it doesn't pinch as much that can help
94. 10:03alleviate some of the symptoms in addition to  that if you have pinching from one of the muscles
95. 10:09either doing injections or botox botulinum toxin  injections into those muscles may help and they
96. 10:17may um alleviate some of the compression at  least on a temporary basis hydrodissection
97. 10:24is a process where a usually a pain management  doctor will take a needle and inject saline or
98. 10:31something like saline around the nerves to try  to push the soft tissue away from the nerves
99. 10:39it's a tech it's a new and relatively uh novel  technique for for trying to manage the symptoms
100. 10:47i'm not sure it's a long-term treatment but it may  give patients some temporary relief and that that
101. 10:52that's usually better than getting no  relief then finally surgery and surgery
102. 10:58comes in a lot of different shapes and  sizes depending on what the condition is
103. 11:03there's arterial venous and neurogenic each  have different need that needs to be addressed
104. 11:10and then once you have figure out what the  need is what's the underlying source of the
105. 11:15compression or the problem there are different  approaches on how to get there uh and there's
106. 11:20a supraclavicular there's an infraclavicular  meaning whether you're going above or below
107. 11:24your collarbone uh there's a transaxillary  where you're going in under the armpit
108. 11:29and then there's also this new technique that i  just recently published for taking out cervical
109. 11:35ribs from the back um of the neck through a tiny  little uh half inch incision so there are a number
110. 11:41of different approaches literally ranging from  the front to the back and so which one is right
111. 11:48once again the answer is it depends so  interpreting the imaging is actually
112. 11:54another reason this is so hard is that these are  very complicated images first of all you got to
113. 12:01know what image to order and the average  clinician just doesn't know what to order
114. 12:07if you really don't know what to order and you  can't get in contact with someone like scott
115. 12:12who's got his own patented system of preparing  and performing these mris that are dedicated just
116. 12:20to thoracic outlet the basic is get a mri of the  chest but important to understand get it with the
117. 12:28arms up and the arms down because most patients  with thoracic outlet syndrome are only symptomatic
118. 12:33when their arms are up so that's where you want to  see what the anatomy looks like but it's good to
119. 12:38compare it to the arms down but there's a whole  and i'm sure uh doctor ward is going to explain
120. 12:44or has explained previously some of the nuances  of his very specific and tailored protocols
121. 12:52which i love looking at and some of them i have  examples of here but you can imagine that when
122. 12:58an mri let's say you've ordered the right mri but  interpreting it requires a whole different level
123. 13:05of expertise that most even neuroradiologists  don't have and i'll tell you that most of these
124. 13:12mris don't come with these colored arrows already  applied these are my annotations that i have made
125. 13:19when i've looked at individual patients films and  you can imagine that sometimes this stuff looks
126. 13:25like you're looking at tea leaves i mean how do  you figure out what's what practice man practice
127. 13:31when you're looking at cat scans they look  at a totally different type of anatomy
128. 13:36they're looking at bone at tissue density whereas  mris are primarily looking at tissue water content
129. 13:43what's the difference it's honestly it's like  night and day but if you put both together you
130. 13:48get the whole picture or at least the majority  of the picture why what's another barrier to the
131. 13:55clinicians being able to make the right diagnosis  knowing how to take a cat scan image like this
132. 14:02and turn it into a 3d model like this one which  will allow you to actually rotate it around in
133. 14:10three dimensions and actually see where the  nerves and the vessels are being pinched
134. 14:16between two structures and most clinicians  either don't have the time or don't have the
135. 14:21inclination or don't have the budget to  buy the 3d modeling software to do this
136. 14:26in addition there are some newer studies where  we're doing dynamic fluoro imaging where we're
137. 14:31actually getting x-rays of the arm up and arm down  to look at what the differences are so the imaging
138. 14:38is not simple interpreting it is not simple and so  understanding what the next step is is not simple
139. 14:47this is a blown up view just because i  think this is really cool to see this and
140. 14:51and so i want to drag you through this here's  the the collar bone up here these are the blood
141. 14:56vessels that are coming through here's a blood  vessel coming through here is a coming between the
142. 15:01the the rib and the clavicle and you  can see it's really getting pinched
143. 15:06here and here and on this side these blood  vessels these veins are actually significantly
144. 15:11larger because the blood is backing up into  the arm when the the vessel is being pinched
145. 15:20so right here i'm backing it up a  little bit and you can actually see
146. 15:27that the rib and the and the collar bone here  are literally scissoring this poor blood vessel
147. 15:35it's no wonder she's very symptomatic
148. 15:39so once you've assuming you've gotten through  the ordering the right imaging interpreting the
149. 15:46imaging correctly now you got to figure out what's  the right treatment well the problem is there are
150. 15:51some tos surgeons out there but all they do is  one surgery they they all everybody gets a first
151. 15:58river section whether that's the right procedure  or not um now granted first resection is probably
152. 16:0590 percent of all tos but it's not a hundred  percent and so if you do a first rib resection on
153. 16:13somebody who's got pectoralis minor syndrome how  are they going to get better if you do a first rib
154. 16:18resection on somebody with a cervical rib how are  they going to get better you really have to make
155. 16:22sure the right diagnosis that made because without  the right diagnosis you can't have the right
156. 16:27treatment and so the other issue is for example  in in venous vtos venous thoracic outlet syndrome
157. 16:37one of the problems is that the chronic trauma to  the vein results in internal bands that develop
158. 16:44that promote more clotting so many patients with  venous tos may present with a clot in there in
159. 16:50a major blood vessel that it can be cleared but  if it the the injury's been going on long enough
160. 16:57that clot can recur unless appropriate measures  are taken to prevent the clot from coming back
161. 17:03and the longer it goes on the less  effective any of those treatments are
162. 17:07arterial tos actually one of the major mechanisms  of injury is you damage the artery so badly you
163. 17:15form an aneurysm and so if you don't resect  the aneurysm and reconstruct the artery wall
164. 17:22you're not treating the underlying problem  you're actually throwing clots into the arm
165. 17:28so on top of the whole issue of identifying  the individual components one of my
166. 17:35new current hypotheses is that all of this  is being caused not because the clavicle
167. 17:41the the collar bone is in the wrong place but that  the collarbone is in the wrong place because the
168. 17:47scapula the shoulder blade itself is not supported  properly because of damage to one or more muscles
169. 17:53in that area and that bigger picture issue is  not adequately being addressed because if you
170. 17:59if you fix the to take the rib out for example  and take the compression off the shoulder blades
171. 18:04just going to fall a little further until it  starts to pinch it again against the second rib
172. 18:11so we need to start addressing the big picture  items as well as the little picture items
173. 18:18one of the other barriers to getting the right  diagnosis is a lot of clinicians have kind of
174. 18:23given up on tos there are some some very good  outcomes and a lot of papers that report 94 95
175. 18:32successful outcomes from surgery for up to five  years but a lot of clinicians have been practicing
176. 18:38for more than five years and they noticed that  after more than 5 10 15 years a lot of these
177. 18:44patients symptoms come back well i think they're  coming back because we aren't addressing the
178. 18:48scapula problem and so this the shoulder blade  just falls until it starts pinching against the
179. 18:54second rib as well as the chronic injury to the  artery or the vein leading to further downstream
180. 19:01you know subsequent problems and so it's not  without reason that many clinicians think oh well
181. 19:06in the long term these patients ultimately don't  do as well as we would like so why bother even
182. 19:11making the diagnosis in fact i know some thoracic  surgeons who have essentially stopped doing
183. 19:18thoracic outlet uh syndrome surgery because of  the long-term lack of efficacy and so i think
184. 19:27that you're doing a disservice at least for the  short-term benefits that you can get from this
185. 19:32but i also think the focus has to be on  coming up with both a short-term treatment
186. 19:36and a long-term treatment and  so we've got some work to do
187. 19:42plus also another reason i think not fair to  the patient but there are a lot of patients
188. 19:47with in the workers compensation system and  there are a lot of clinicians who think that
189. 19:52a lot of the workers comp patients they're just  out to get out of work and that's just not fair
190. 19:57to the patients who want to get back to work  and just are being treated like they don't
191. 20:06so why are the long-term outcomes not as  good well i've already kind of addressed this
192. 20:09if all you have is a hammer everything  starts to look like a nail um if the the
193. 20:16the recanalization if the if you get the clot out  and then it develops clot again well we got to
194. 20:24find a better way of preventing that clot and  then we need to come up with other treatments
195. 20:29for some of the underlying conditions especially  ehlers-danlos um which will treat the underlying
196. 20:37genetic deficiencies that lead to  developing tos in the first place
197. 20:45this is kind of one of my central practice  philosophies seeing is believing but
198. 20:53believing is necessary for seeing if you don't  believe in a diagnosis you're never ever going
199. 20:59to make it and so if you don't believe in a  diagnosis you're never going to look for it
200. 21:03on the films that you order you're just going to  blow right by it and that's true of a number of
201. 21:08other what i would call the minor or the orphan  conditions and tos has kind of become an orphan
202. 21:13condition in america today so most clinicians they  diagnose what they're used to seeing regularly and
203. 21:19often skip over the things that are a little  bit rarer what we call in medicine the zebras
204. 21:24instead of the the horses there's an old saying in  medicine when you hear hoof beats think horses not
205. 21:31zebras but if you live in africa you should think  zebras not horses so it really depends on what you
206. 21:38expect to see but also kind of keep in the back  of your mind there may be more than one type of
207. 21:43hoofed animal that's running around another issue  is there's this com this term called disputed tos
208. 21:53and it's i i take it as a pejorative term  disputed means you don't really believe in
209. 21:58it there are people who dispute that it's really  tos and the and the the definition of disputed tos
210. 22:04is it's thoracic outlet syndrome without hard emg  findings we've already mentioned that you can have
211. 22:11tos and not have emg findings but for some  people they use that as their threshold as
212. 22:17saying well if you don't have emg findings i'm  not going to make the diagnosis well making the
213. 22:23diagnosis shouldn't be dependent upon one single  test if the rest of the tests all support it
214. 22:30so i i actually don't call it disputed  tos i just call it emg negative tos
215. 22:36it's really early tos because you  typically start to see emg findings
216. 22:41at the point where you start to get nerve  damage that's so bad that the muscles are dying
217. 22:48so where do we go from here the first thing  is for the clinicians out there and for people
218. 22:55who are seeing a clinician make sure that  you or your doctor takes the time to listen
219. 23:00to what's going on and it's very hard in today's  data-driven and finance-driven medical environment
220. 23:08where hmos obamacare medicare reimburses poorly  per hour per minute spent with the patient so they
221. 23:15want to get through the list quickly so stopping  and listening is almost a bit of a lost art
222. 23:21um all these algorithm-driven treatments in  electronic medical records that basically
223. 23:28take the top five diagnoses for a given set of  symptoms and expect you to make one of those five
224. 23:33diagnoses well what if tos is number six and it  doesn't pop up on your list of the the most five
225. 23:39syndromes to test for it requires a detailed  physical examination you have to test for
226. 23:45tenderness in multiple places you have to do an  east test you might want to do a rights test there
227. 23:49are a number of different tests that we can do  to try to identify where the pain is coming from
228. 23:55and the first issue is you need to believe the  patient has the pain and then you need to believe
229. 24:00you can find the cause of the pain and ultimately  this just comes down to the concept of treat the
230. 24:06patient treat the patient that's in front of you  before you start thinking about the next patient
231. 24:12we need to get better research to validate a lot  of the things that we're talking about here even
232. 24:18better because a lot of the naysayers out there  in medicine will say well there isn't great class
233. 24:251 evidence to describe what you're saying and the  answer is well i guess we've got to get together
234. 24:30and the the tos treating physicians need to band  together more and come up with large databases
235. 24:38pooling all their patients to have class one  data do prospective studies instead of just
236. 24:44looking back on you know a dozen two dozen three  dozen patients you've operated on really do joint
237. 24:50multi-center prospective studies  where we all follow the same rules
238. 24:54there's better we need better modeling of the  underlying conditions in coming up with computer
239. 24:59models physical models and other and a better  mathematical model concept of what's going on
240. 25:06will help us to then develop even better  treatments that are more effective and
241. 25:11less invasive so that's where we're at i  want to thank you guys for your attention
242. 25:18um and uh if there's any questions out there now  is a great time to send them in all right that was
243. 25:25really great to listen to that uh it hits a whole  lot of points that are challenging for clinicians
244. 25:32and patients alike uh if i could start you with a  question from me first you brought up disputed tos
245. 25:39how many patients come to you that you find  have tos that have been told by other doctors
246. 25:45that the diagnosis is disputed i just had one  last week where i had a i won't say it was a a
247. 25:54heated discussion but it was certainly um  one-sided with the patient's neurologist and he
248. 26:01flat out said she doesn't she has at most disputed  tos i think she's primarily got fibromyalgia um
249. 26:09and fibromyalgia is i think it's 90 over diagnosed  i think there is an entity of fibromyalgia out
250. 26:16there but i think more often than not fibromyalgia  is the bucket that people put patients into when
251. 26:21they can't figure out or haven't taken the time to  figure out what the real diagnosis is um you know
252. 26:27for example 10 of fibromyalgia patients have been  found to have chiari malformations which cause
253. 26:32almost the exact same symptoms that we ascribe to  fibromyalgia how do the patients respond when you
254. 26:41tell them that in fact the diagnosis is not  disputed they're just different stages of it
255. 26:46right i mean most of them are internally grateful  that somebody's actually listening to them
256. 26:53i'm going to read you a couple questions we  have from our viewers first one is hi i've
257. 26:58seen multiple physicians in the area that i live i  think i have tos but none of the physicians i have
258. 27:04seen agreed do doctors like yourself do telehealth  consults and this is from gina in phoenix
259. 27:11um hi gina yes as a matter of fact i've been  doing telehealth for about 10 15 years now
260. 27:19and then it this it's actually blown up  in the time of covid um if you go to my
261. 27:23website jenkinsneurospine.com um there's a  process for registering to do a telehealth
262. 27:31process in fact we actually have an initially a  free consult with one of my one of my treating
263. 27:38clinicians who will do a first pass  and he's great everybody loves him
264. 27:44dr wood so if you wanted to go to my website  that's a great place to uh to start on the
265. 27:50process and we'll give you our two cents as  best we can after if if dr wood goes through
266. 27:57your stuff and thinks that it's worth having  a second-tier consult with me we can arrange
267. 28:02for that too the next question says how can i find  a doctor that does hydro dissection for tos i live
268. 28:11in san francisco well san francisco is a huge  medical community and um i would bet that there
269. 28:19are any one of a number of uh places that you  could look online and and uh just i would google
270. 28:26pain management and hydro dissection and see who  who is doing it and you can contact me through my
271. 28:34website i can help find local docs here too next  question says i had first rib resection surgery
272. 28:42for neurogenic tos 11 months ago i have cervical  ribs that are still there because my surgeon did
273. 28:49transaxillary approach i have muscle atrophy in my  thumb will it just get worse the arm still aches
274. 28:58um i think the answer is yes we know that  typically if you haven't treated um all of the
275. 29:05issues that are leading to neurologic  dysfunction um it often will get worse
276. 29:12but it probably got a little bit better because  you probably had more than one compression issue
277. 29:17at the time and so they did the one they knew how  to do i would certainly recommend you go online
278. 29:24to my website as well and we'd be happy to do uh  you know the the uh get that first level consult
279. 29:31get in the door um and see if you're a candidate  for my minimally invasive cervical ribs section
280. 29:38and what you've implied from your lengthy  discussion is how many variants the rftos and
281. 29:44implied is many different kinds of treatment it's  not a one-stop shop right correct so we both know
282. 29:53some surgeons who just say i don't need imaging i  know what the disease is yeah going in there and
283. 29:58taking everything yeah is there i mean haven't we  evolved beyond that in surgery in a more dedicated
284. 30:05detailed surgery over the past few  decades i think the answer there
285. 30:09is it depends on what you consider a successful  outcome rate my goal is 100 of my patients do
286. 30:17well with the surgery that i do for them  if you accept a 90 successful outcome rate
287. 30:25then you're accepting the fact that you're doing  the wrong operation in 10 percent of your patients
288. 30:30um and so if all you want to do is you follow one  of two or three different tests you you may miss
289. 30:42the the variance if you don't do the thorough  like the 12 point inspection right you got it
290. 30:47you can't just do a three-point inspection you got  to make sure you do the full 12-point inspection
291. 30:53we have another question from ben  who is a tos patient that i know
292. 30:57uh young man he said i just want to say i've had  the same experience with a neurologist who did an
293. 31:03emg and said i was negative for neurogenic  tos i had it diagnosed later fortunately
294. 31:10glad you are spreading  awareness thank you very much
295. 31:13yeah i gotta say as a spine surgeon and i do emgs  on almost every single one of my surgeries if you
296. 31:21don't have weakness already your emgs are going to  be negative so if you just have pain if you have
297. 31:26numbness if you have other physical findings or if  you have temporary weakness that goes away because
298. 31:32you're weak when your arm is up but but gets  strong again when your arm is down okay that's
299. 31:38called you know differential strength testing and  that's also considered a variant of these tests
300. 31:43if your pain is not if your weakness is not  persistent throughout if you're not 24 7 week it's
301. 31:49going to be negative on the mgs i don't consider  atrophy i don't consider permanent weakness to be
302. 31:56one of the diagnostic criteria of tos  and that's why i think that disputed tos
303. 32:03it's it's an oxymoron it's a  contradiction it's it makes no sense
304. 32:09i think uh for our viewers ace of willborn at  the cleveland clinic who was a widely respected
305. 32:14neurologist was the one who came up with this  classification and i would point out and i'm sure
306. 32:20i would agree with me that in any other entrapment  neuropathy doctors try to treat it first of all
307. 32:26to diagnose it secondarily treat it before you get  this muscle involvement because muscle involvement
308. 32:33usually means it's permanent damage so what ace of  woolworn did in my eyes is he took early and late
309. 32:39stage tos late stage would have muscle atrophy  and positive emgs and he would say wait until we
310. 32:46get to the late stage before you diagnose it to my  eye that seems to connem patients to a lifetime of
311. 32:55disability what are your thoughts about that  actually i think it's it's a little bit of um
312. 33:04it's it's actually it's very myopic it's  basically saying if you don't have a finding
313. 33:10in the thing that i do i do emgs therefore if  you don't have an emg abnormality it's not real
314. 33:17that's just that misses like the entire rest  of medical school of listen to your patient
315. 33:22examine your patient and understand that  transient nerve compression doesn't lead to
316. 33:28emg com findings permanent nerve compression  leads to permanent nerve findings it's also
317. 33:35honestly a little bit of a warning that maybe you  shouldn't step outside your field of expertise
318. 33:40well yeah you know but they think that they they  they're so used to seeing what they see that it's
319. 33:46a um it's a self-confirmation bias they think  that if it's not positive on emg it isn't real
320. 33:52and that's not the definition then the the patient  that just asked the question had that experience
321. 34:01and he um i think he he felt badly that the  person who did the emg said it couldn't be tos
322. 34:07just couldn't be sure fortunately ben was very  proactive and a smart guy and he went out and
323. 34:12found the answers himself otherwise he could  have been searching down 10 other diagnoses
324. 34:16instead of the good diagnosis he has now  let me read you another question from terry
325. 34:23i think a part of that answer is patience i refuse  to allow our local vascular surgeon to touch me
326. 34:29because he only knows of the rib removal once  we have a bit more clarity i'll be sharing so
327. 34:36this is another patient i know as well and um i  think we we're bringing up two things there are
328. 34:42docs who don't know other specialties who don't  know other bases of knowledge so as you said
329. 34:47they could be myopic and say without my test  can't be positive but then they're also the
330. 34:53docs who at least when they recognize tus they'll  only treat it one way now you said before that
331. 35:00a significant proportion of these patients  don't need a rib resection could you expand
332. 35:05on that a little um i i think it's it's about  three to five percent of patients have um
333. 35:12we'll have a pec minor syndrome either isolated  or in conjunction so you might do a river section
334. 35:18but if you don't also release the pec minor  tendon you're not going to get as good as if you
335. 35:23just do one or if you do both the cervical ribs  and i saw there was a question on there also about
336. 35:29the cervical rib approach um you know if you  have a cervical rib and you don't release the
337. 35:35issues about that that are related to  that which includes additional fiber spans
338. 35:39it includes compression on on the vessel as well  as on the nerve at the at c8 which is hand um
339. 35:46and so if you don't treat that you're not  going to be in the process of getting better
340. 35:53and it will likely continue to get worse and  cervical ribs also make up like three to five
341. 35:58percent of the uh of the cases so granted uh the  remaining ones are either uh compression from the
342. 36:05scalene muscles um which attach to the first rib  or compression between the the um the clavicle
343. 36:14and the first rib um which therefore is involves  the first rib so if you take out the first rib
344. 36:20you take and you take it all the way back to  the scalene muscles you'll release the scalene
345. 36:25muscles so you'll get both the entities with the  same operation so that's why a lot of people will
346. 36:31do well with one operation as long as the one  operation is done right and if you take a lot of
347. 36:36things out if you take everything out you're more  likely to have complications so i i don't advocate
348. 36:43that um so i saw there's a question just about  the cervical rib operation um it's actually it's
349. 36:50a half inch incision on the back the way i do it  is day surgery and i just i basically i sneak in
350. 36:58um at a very very particular angle it's different  than what other people do and i was able to figure
351. 37:05this out with a lot of 3d modeling that we did  with virtual fly-throughs and things like that
352. 37:11and the answer is i just come down on  the outside of the spine and i follow
353. 37:16the cervical rib around and just drill it out  and disconnect it from the fibrous attachments
354. 37:21that it may have all the way to the front and  that releases um any compression that there was
355. 37:27on the either the the vein or the um or the  usually it's the eighth nerve but it could
356. 37:33also get the seventh nerve um in that area uh  so it's uh it's a beautiful operation it takes
357. 37:40about an hour hour and a half to do out it's  an outpatient procedure a half inch incision
358. 37:46and um but it's not you know it's  published but it's not widely practiced
359. 37:55and then one thing i'd like to reinforce which  you talked about all of these tests that we have
360. 38:00are challenging imaging tests because that's  my field are challenging to produce and to read
361. 38:07and i i have found it incredibly valuable  for the patients that i interact with art
362. 38:12to be able to work with someone like you because  the combination of the clinical team a doc
363. 38:19whether it's a neurologist with a surgeon  along with physical therapists or other
364. 38:24parallel healthcare workers along with a  radiologist i think that has tremendous power i
365. 38:29uh if this were low-hanging fruit we would have  had one specialist dedicated to it but as you
366. 38:34know in some cities it's vascular surgeons some  cities it's neurologists would you care to comment
367. 38:40on that value of a team helping patients with i  couldn't agree more i mean i think that it takes
368. 38:46a village to take care of patients um and you have  to have a team of people that you can work with
369. 38:52um you can talk you that i if i've got a question  about a particular patient maybe i i call you up
370. 38:59and i say hey i need a variation i mean we  need to do it a little bit off the normal menu
371. 39:04because this patient has slightly different  symptoms than normal we've got to image them
372. 39:07in a slightly different position and when  you have people who understand the anatomy
373. 39:12and they're imaging and can help tailor  the treatment to the individual patient
374. 39:17then you can really help a larger swath of  people but i also think that the key is you
375. 39:23got to find people who are bridge builders  not damn breakers um and that so for example
376. 39:30i do my surgeries with vascular surgeons so we're  actually working there's a vascular surgeon on one
377. 39:36side neurosurgeon on the other doing the operation  together um and then that allows us to communicate
378. 39:41we share patience we share information we share  insight they teach me i teach them and that
379. 39:48spreads knowledge instead of keeping knowledge  in the silo where you're doing the same thing
380. 39:52over and over and nobody's telling you that maybe  there's a better way or maybe some of the things
381. 39:58you're doing aren't working also for example if  i ask you are why do you need to get this piece
382. 40:03of information why does this make a difference  you know i have to challenge myself when you
383. 40:09say to me scott i don't get this right i have to  learn something i have to figure it out right no
384. 40:15pushing each other is is a much better place than  getting complacent and doing the same thing over
385. 40:19and over and thinking everything is just fine  as shown by your new minimally evasive approach
386. 40:25something that wouldn't happen if you did  the same thing for 20 years right awesome
387. 40:30i'm going to let you make any closing comments  you want to make is a great talk to listen to
388. 40:35we also heard we have another talk coming up
389. 40:39i'm talking to our moderator here because we  have another talk coming up and i am going to
390. 40:43find it and let people know when that is bear  with me for a second as i look at my calendar
391. 40:52february 16th 2021 the limitations of standard  physical therapy with thoracic outlet syndrome
392. 40:57looks interesting i mean that's as a surgeon  we don't always get the insight on the uh
393. 41:02on the physical therapy nuances and that's uh  that's something i think not only patients but
394. 41:07clinicians need to know more about too excellent  all right do you have any closing comments
395. 41:14i i would just say for clinicians out there who  are who are observing listen to your patient
396. 41:21learn what you don't know because it's not what  you don't know that gets you in trouble in life
397. 41:27it's what you know that ain't so and so you've  got to keep an open mind you've got to believe
398. 41:33in your patience and you got to believe  in the diagnosis before you can see it
399. 41:37um and as the for the patients out there you  know you hear it before you'll hear it again
400. 41:42you got to be your own advocate if you don't feel  people are listening to you and if you don't feel
401. 41:48if the doctor can't explain to you in a way  that makes sense to you what's going on and
402. 41:54what the treatment plan is going to be and why  the treatment plan is going to be the way it is
403. 42:00find somebody else i mean it is what it is um i i  hate to say it um but by the definition of average
404. 42:10half of all doctors of every specialty  are below average half are above average
405. 42:16and half are below average and  average is right down the middle so
406. 42:2050 are above average 50 or below average if you  wind up with somebody who's in the below average
407. 42:26in a particular field find  somebody who is above average
408. 42:32words of wisdom advocate for yourself find good  specialists and listen to your patients thanks
409. 42:39to all of our viewers we really appreciate you  attending go visit the website for our next talk
410. 42:46go see neuro what's your neural spine  jenkinsneurospine.com neurospine.com
411. 42:54all right all right thank you very much thanks  for having me this has been a real pleasure