hi,

The first thing that strikes me is Cervical spondylosis. You have to tell me if you have any
1)weakness of muscles of your upper limb ( evident from inability to lift weight as you could do earlier).
2)Shooting pain along the arm, when you lift arm (radicular pain).
3)Any tingling sensation or numbness.
4)How was the onset of this problem. Gradual or sudden (following a trauma).

Answers to above questions being 'yes' with a gradual onset is suggestive of Cervical Spondylosis. Also a middle age and above will favour spondylosis. This is a degenerative disease. Depending on severity the management will vary. If mild, spinal and neck excercise, neck collar, etc can be done. Sometimes Shortwave diathermy etc may be of help. If severe surgery is the best option.

Unlike degenerative conditions, there are inflammatory conditions that can cause similar problems this will have associated complaints elsewhere (eg Rheumatoid Arthritis). There several medical treatment options available in these conditions. The Infra red treatment , shortwave diathermy etc will bring good relief of pain and symptoms.

Cervical disc prolapse is another possibility , but if often follows a trauma and is of sudden onset. There will be local tenderness when you press over the cervical vertebra (C6, C7).

Cervical cord compression due to any cause (from outside cord like prolapsed disc or from with in cord like syngomyelia) can also be the cause.

Regarding thoracic outlet syndrome , it may be a remote possibility but since you said it affects both arms , it is very rare to have both arms affected in same manner at the same time. Most often it is only one side that is affected. So you can keep that possibility aside for the last.

How to proceed.

The best person to deal with this problem will be a neurologist. He will make the diagnosis and then decide whether a conservative management or surgery has to be done. he will refer to neurosurgeon if needed.

Investigations should include

1)basic blood investigations ( Blood counts- a high ESR is suggestive of inflammatory causes and further investigations may be needed in that line).
2)X-ray of the neck (in flexion and extension)
3)MRI (most helpful in finding the extend of the problem and also will confirm the diagnosis, also will help to come to diagnosis if no cause was found in other examinations and investigations.)

i hope this was of some help to you. Please do feel free to ask any clarifications that you may have.

Thank you

Dr Santhosh Joseph

Dr. Santhosh MD

You have Thoracic Outlet Syndrome. Usually patients with thoracic outlet syndrome will have bilateral arm parasthesias. Since you have no lower limb symptoms then you can rule out cervical spondylosis. Patients with cervical spondylosis have simultaneous lower extremity paresthesias.

Thoracic outlet syndrome is due to compression and irritation of the brachial plexus and/or subclavian vessels when they pass from their cervical area toward the axillas of both of your arms. http://findlaw.doereport.com/enlargeexhibit.php?ID=1861 This compression of the subclavian blood vessels causes the heaviness in your arms and the pain in the back of your neck which is relieved when you sit down and relax and rub the back of your neck.

The usual site of entrapment is the interscalenic triangle. The syndrome often develops during the 3rd or 4th decade, following external factors such as trauma, weight excess, or incorrect shoulder posture.

Symptoms can include pain in the cervical region and arm, paresthesias (feeling of heaviness in the medial side of both arms predilected) aggravated by overhead positions of the arms, hand intrinsic muscle deficit/atrophy, easy fatiguability, paleness, coldness of hand.

The clinical examination may be normal or show cervical muscle spasm, tenderness of the brachial plexus in the supraclavicular area, radial pulse attenuation and occurence of symptoms upon positional maneuvers, sensory or motor deficit. The diagnosis is based upon clinical evaluation and absence of other relevant pathology. Therefore, the cervical spine and distal peripheral nerves are studied by MRI and EMG. A scalene muscle block is a helpful diagnostic tool that is used with the other clinical data.

The compromise of the neurovascular bundle is usually positional and intermittent which is why when you "sit down and relax and rub the back of your neck the sensation passes within a few minutes". An ultrasound of your subclavian artery with positional maneuvers is useful in confirming the clinical impression of artery compression under specific arm conditions. An arteriogram and/or venogram are only used to evaluate vascular types of thoracic outlet syndrome. The scalene muscle block test will give you temporary relief of your symptoms following an anterior scalene muscle injection with 4 cc of 1% lidocaine. A good response to the block will usually predict improvement following a scalenectomy (surgery).

Your treatment should be conservative unless you have significant motor deficit or subclavian artery compression. Conservative treatment includes reduction of weight and proper breast support (if this is indicated). Medications such as muscle relaxants and tranquilizers or antiinflammatory drugs e.g. Motrin or Advil can help. Your physician will prescribe a 3 to 6 week physical therapy program which includes postural correction, stretching exercises of some muscles and stengthening exercises of others. Most patients improve with physical therapy.

If your symptoms don't respond to conservative medical treatment then you can be helped by thoracic outlet decompressive surgery. Surgical approaches include transaxillary first rib resection or supraclavicular approach. The anterior approach provides a good access to the brachial plexus and subclavian artery which will allow adequate relief from irritation and constriction. Sometimes a posterior subscapular approach is indicated in cases of obesity, a large cervical rib or recurrent thoracic outlet syndrome with residual first rib following transaxillary first rib resection.

I recommend that you be examined and treated in person by a neurosurgeon who is familiar with treating patients who have thoracic outlet syndrome.

Dr. Hanson, MD, PhD