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the base of the neck and the axilla1 3 Our discussion is here limited to the rare neurogenic form of thoracic outlet syndrome, which, in essence, is a lower trunk plexopathy Most individuals who are affected are women with a prominent C7 transverse process or true cervical rib that can be appreciated on plain lms of the cervical spine (Fig 21 13) These cases are often associated with a sharp brous band extending from the tip of the elongated C7 transverse process or cervical rib to the rst thoracic rib This band usually cannot be visualized on imaging studies, including MRI scans The proximal aspect of the lower trunk becomes angulated or stretched as it passes over this brous band Because the T1 bers lie below the C8 bers, these are usually distorted and thus are more likely to be damaged Thus, individuals who are affected present with muscle atrophy and weakness that is often greater in the thenar muscles, which have more T1 innervation than the hypothenar muscles, which have more C8 innervation In addition, patients complain of numbness, paresthesia, and pain along the medial aspects of the arm, forearm, and hand Electrodiagnostic studies demonstrate that the median CMAP and medial antebrachial cutaneous SNAP amplitudes are reduced to a greater extent than the ulnar SNAP and CMAP because the former studies assess (ie, studies that primarily assess T1 bers while ulnar studies that primarily assess C8 bers 2,59,92 95 Neurogenic thoracic outlet syndrome is typically treated by surgical resection of the taut band

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Neoplasms involving the brachial plexus may be primary nerve tumors, local cancers expanding into the plexus (eg, Pancoast lung tumor or lymphoma), and metastatic tumors96,97 Primary brachial plexus tumors are less common than the secondary tumors and include schwannomas, neurinomas, and neuro bromas25,43,98 100 These primary tumors may present as mass lesions in the supraclavicular fossa region or axilla Pain and paresthesias are early symptoms, while motor and sensory losses occur later as the tumor may initially distort the nerve bers but do not result in conduction block, demyelination, or axon loss right away Schwannomas are commonly benign and well encapsulated, affect the proximal segments of the plexus, and may be surgically removed with minimal damage to the nearby nerve bers98,100,101 However, malignant schwannomas do rarely occur102 Neuro bromas are the most common form of peripheral nerve tumor and are typically benign However, when seen in the context of neuro bromatosis, these are often multiple and affect a larger portion of the brachial plexus98 Additionally, neuro bromas interdigitate more with nerve bers within the nerve fascicle and are more commonly associated with neurological de cits than schwannomas Further, it

The term thoracic outlet syndrome has been ascribed to a group of disorders attributed to compromise of blood vessels or nerves at any of several points between

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Figure 21 13 Neurogenic thoracic outlet syndrome Atrophy of the right thenar eminence and rst dorsal interosseus muscles are evident (A) Plain cervical spine lms demonstrate small cervical ribs (arrows) bilaterally on AP (B) view and oblique view (C) (Photo courtesy of Steven A Greenberg MD Reproduced with permission from Greenberg SA, Amato AA EMG Pearls Philadelphia: Hanley & Belfus, 2004, Fig 1A and B, p 46 and Fig 3, p 50)

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