Right Hand Dominant Musician With Right Hand Weakness

Abstract

HPI: EM is a RHD 19yF musician presenting with insidious onset, progressive RH weakness worsening over the last 1-2 years. No trauma. She has difficulty with pincer grasping. Weakness is constant but exacerbated when playing guitar or flute for long periods of time. No numbness, pain, tingling or swelling of the RUE. Denies any fevers, chills, recent URI, polyarthralgia. No family history of neurologic or autoimmune disease. PE: No notable muscle atrophy or TTP in the RUE. Full ROM in neck, shoulder, elbow and wrist. 4/5 strength in pincer grip on right, 5/5 strength in right rotator cuff muscles, tricep, bicep, wrist flexion/extension. +Median nerve weakness, radial and ulnar nerve intact. Normal sensation and RUE reflexes. Positive Adson’s. Negative Spurling, Roos tests., Hoffman, Negative Tinel’s and Phalen’s at the wrist. DDX: Radial neuropathy, Carpal tunnel syndrome, Paget Schroetter Syndrome, Thoracic outlet syndrome, Parsonage-Turner syndrome TEST AND RESULTS: Labs: Within normal limits EMG: Results consistent with a significant True Neurogenic Thoracic Outlet Syndrome on the right. There is also electrodiagnostic evidence of a mild right ulnar mononeuropathy at the ulnar groove. Xray cervical spine: Enlarged transverse processes bilaterally at C7, larger on the right. Partial fusion at C3-4 with 2 mm retrolisthesis of C4 on C5 in extension that reduces with flexion. MRI Brachial plexus: Right cervical rib (at C7), with a hyperintense C8 spinal nerve coursing through this area, as are the medial cord, and visualized proximal ulnar nerve and possibly of the median nerve, likely attributable to mass effect from the cervical rib and/or an accompanying fibrous band. RUE vascular study: negative FINAL WORKING DIAGNOSIS: Neurogenic Thoracic Outlet Syndrome TREATMENT AND OUTCOMES: Initial EMG pointed to neurogenic TOS. Subsequently, patient completed cervical spine xrays and MRI of the brachial plexus, revealing cervical ribs with likely brachial plexus compression. Patient attended physical therapy to focus on posture while playing instruments, stretching of scalene muscles and strengthening scapular stabilizers. Unfortunately, she did not improve with conservative management. She has been seen by orthopedics and vascular surgery and is currently awaiting cervical rib resection surgery.