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Scheuermann's Disease As a Model

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Scheuermann's Disease As a Model ⅷⅷO RIGINAL C OMMUNICATION SCHEUERMANN’S DISEASE ASAMODEL DISPLAYING THE MECHANISM OF VENOUS OBSTRUCTION IN THORACIC OUTLET SYNDROME AND MIGRAINE PATIENTS: MRI AND MRA James D. Collins, Ernestina H. Saxton, Theodore Q. Miller, Samuel S. Ahn, Hugh Gelabert, and Alfred Carnes Scheuermann’s Disease: An MRI MRA Model Displaying the Mechanism of Venous Obstruc- tion in Thoracic Outlet Syndrome (TOS) and Migraine Patients. Collins JD, Saxton EH, Miller TQ, Ahn SS, Galebert H, Carnes AE Departments of Radiological Sciences Neurology and Vascular Surgery, UCLA Kyphosis of the thoracic spine rotates the scapulae anterior laterally, clavicles and subclavius muscles anteriorly, displaces the manubrium posteriorly, which increases the slope of the first ribs. This increases tension on the anterior scalene muscles and the neurovascular bundles which causes brachial plexopathy (TOS). Scheuermann’s disease (spinal osteochondrosis; juvenile kyphoscoliosis) is a disorder which consists of vertebral wedging, endplate irregularity and narrowing of the intervertebral disk space causing kyphosis of the thoracic spine and may also involve the lumbar space. It occurs at puberty and involves both male and females. Abduction external rotation of the upper extremities (arms overhead) posterior inferiorly rotate the clavicles and the subclavius muscles which enhances tension on the venous drainage and neurovascular supply that diminishes venous return. This triggers complaints of thoracic outlet syndrome (TOS) and migraine headache. Bilateral magnetic resonance imaging (MRI) demonstrates compressing abnormalities of the brachial plexus. Five patients with Scheuermann’s disease were imaged with the 1.5 Tesla magnet (Signa; General Electric Medical Systems, Milwaukee, WI) 3-D reconstruction MRI. T1W and T2W pulse sequences were performed in the coronal, transverse, transverse oblique, sagittal, and coronal abduction external rotation planes using 4 mm slice thickness and 512 ϫ 256 matrix size. Water bags were used to enhance the signal to noise ratio. Magnetic resonance angiography (MRA) 2-D Time Of Flight (TOF) was obtained to evaluate perfusion of the brachial plexus. MRI and MRA captured sites of brachial plexus compression for anatomic display. One patient was selected for this presentation, which dem- onstrates the compression of the brachial plexus and venous obstruction which triggered com- plaints of thoracic outlet syndrome. (J Natl Med Assoc. 2003;95:298–306.) Key words: MRI } MRA } migraine, plexus in the supine position. This feature gave nerves imaging } neuropathy } us an opportunity to image and study the bra- brachial plexus } Scheuermann’s chial plexus1. disease } thoracic outlet syndrome The brachial plexus lies within the fascial planes of the neck and axilla, which is routinely INTRODUCTION displayed on MRI of the thorax and shoulder Magnetic resonance multi-plane imaging al- girdle2. Abnormalities of the brachial plexus lows bilateral display of the thorax and brachial result from problems with the cervico-thoracic © 2003. Departments of Radiology (J.D.C., T.Q.M., A.C.), Neurology Federation of American Societies for Experimental Biology , San Di- (E.H.S), and Vascular Surgery (H.G., S.S.A), University of California at ego, California, April 15–18, 2000. Correspondence should be di- Los Angeles, USA. Presented at the National Medical Association rected to James D. Collins Department of Radiological Sciences, Uni- 104th Annual Scientific Program, Convention and Scientific Assembly, versity of California, Los Angeles, 1083 Le Conte Ave. Los Angeles, Convention center, Las Vegas, Nevada, August 11, 1999 and at the CA 90095–0001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 95, NO. 4, APRIL 2003 298 SCHEUERMANN’S DISEASE segments of the vertebral column, the first rib, clavicle, vascular supply, Manubrium sterni and soft tissues3. In most individuals, the fascial plane spacing between soft tissues and osseous structures is adequate to perform routine func- tions without compromising their neurovascu- lar bundles. Studies by Sunderland in 1945 and Dyke et al in 1984 suggest that pathology in- volving peripheral nerves alters fascial planes4,5. Acute or chronic changes alter adjacent tissues, thereby compromising the vascular supply of the peripheral nerves6. This results in patients presenting with clinical symptoms of thoracic outlet syndrome (TOS): tingling, numbness, pain (face, shoulder, upper and lower extrem- ities, back, and abdomen); visual and auditory changes; syncope and headache (6 FASEB 2002). Knowledge of normal surface and landmark anatomy is important for interpretation of MRI and MRA studies in patients with brachial plexus injury7. The brachial plexus nerve roots pass with the subclavian artery to form a neu- rovascular bundle between the anterior and Figure 1. PA upright chest radiograph displays the forward middle scalene muscles on the first ribs shift of the shoulders with anterior rotated clavicles (C) low over acute sloping first ribs (FR), and the anterior lateral (scalene triangles). The scalene muscles arise rotated coracoid processes (CP), reflecting bilateral round from the cervical segments of the vertebral col- shoulders. The heads of the clavicles (C) are below the fifth umn, insert and, in part, support the curved, posterior ribs (5R). Right and left lung (RL,LL), aorta (A), first flat first ribs. The first ribs slope obliquely at- thoracic vertebra (1T). taching to the manubrium to form most of the thoracic inlet. The slope of the first ribs ease and other disorders of the cervicothoracic changes with respiration, scoliosis, and kypho- spine9,10. The authors have chosen Scheuer- sis of the thoracic spine and affects those struc- mann’s disease as a classic presentation in a tures crossing the first rib, particularly the sub- young patient of brachial plexopathy second- clavian veins7. ary to kyphosis of the thoracic spine and round- Kyphosis of the thoracic spine occurs in ing of the shoulders. Bilateral magnetic reso- Scheuremann’s disease (spinal osteochondro- nance imaging (MRI) and angiography (MRA) sis; adolescent kyphoscoliosis), which is an ab- of the brachial plexus and peripheral nerve normality in the shape and size of the vertebral make it possible to demonstrate the relation- bodies of the thoracic and lumbar spine8. Ver- ship of nerves to their surrounding landmark tebral bodies assume wedge shape deformities anatomy in Scheuremann’s disease patients and disk spaces narrowing which contribute to with TOS. kyphosis of the thoracic spine and abnormal All MRI and MRA sequences were cross-ref- alignment of the shoulder girdle, which alter erenced in order to arrive at an accurate diag- fascial planes (Figs 1,2). nosis. It is not possible to present all of the Thoracic outlet syndrome (brachial plexopa- acquired images; the images selected for this thy) occurs in patients with Scheuremann’s dis- presentation were annotated and best display 299 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 95, NO. 4, APRIL 2003 SCHEUERMANN’S DISEASE transverse, sagittal, and abduction external ro- tation (of the upper extremities) T1-weighted images, and 2D Time Of Flight (TOF) MRA are obtained. If there is clinical evidence of scar- ring, tumor and/or lymphatic obstruction, Fast Spine Echo T2-weighted images are selectively obtained. The parameters for acquiring each sequence have been published1,11,12 CASE HISTORY This was a 21-year-old right handed female with the diagnosis of Scheuermann’s disease. She complained of headache with left upper extremity pain, tingling and numbness radiat- ing into the left forearm, elbow and hand; mild tingling and numbness in the right hand; blurred vision and dots in the visual fields; neck pain radiating down into the coccyx, and ring- ing in ears. Elevating her left arm above shoul- der height and combing her hair aggravated Figure 2. Lateral upright chest radiograph displays kypho- her symptoms. Symptoms began six months sis of the thoracic spine and rounding of the shoulders (X) prior to evaluation by her referring neurolo- with anterior wedging of thoracic vertebrae (7T, 8T). “Pan- gist, and were thought to be the result of pro- cake shaped” heart (H), humerus (Hu), Manubrium (M). longed typing. Physical examination revealed the bent for- the pathologic changes that occur in costocla- ward neck and the “hunched-up” rounding of vicular compression of the brachial plexus. her shoulders, left higher than right, and ky- phosis of the thoracic spine. Swelling and ten- METHODS AND MATERIALS derness were detected over the left supraclavic- Plain chest radiographs (PA and lateral) are ular fossa. Neurological examination revealed obtained and reviewed prior to the MRI. The negative Spurling’s maneuver; negative Lher- procedure is discussed and the patient exam- mitte’s sign and Tinel’s sign over the median ined. Respiratory gating is applied throughout and ulnar nerves at the wrist and elbow. Radial the procedure to minimize motion artifact. pulses were present on abduction external ro- The patient is supine in the body coil, arms tation of the upper extremities. Roos’ test was down to the side and imaging is monitored at positive on the left and negative on the right. the MRI station. Magnetic resonance images Tinel’s sign in the supraclavicular fossa was are obtained on the 1.5 Tesla GE Signa MR negative. scanner (GE Medical Systems, Milwaukee, Wis- The requesting neurologist suspected left consin). A body coil is used and intravenous thoracic outlet syndrome (TOS), with denerva- contrast agents are not administered. A water tion of the left ulnar nerve by SSEP testing, not bag is placed on the right and the left side of demonstrated on the right. Upper extremity the neck to increase signal to noise ratio for electromyogram (EMG) and nerve conduction high resolution imaging. A full field of view (44 velocity study (NCV) indicated no evidence of cm) of the neck and the thorax is used. to left or right cervical or brachial plexopathy; no image both supraclavicular fossae. Contiguous left or right carpal tunnel, Guyon’s, and cubital (4 mm) coronal, transverse (axial), oblique tunnel syndromes, and no peripheral neurop- JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL.
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