From the Guidelines
The workup for costoclavicular syndrome should begin with a thorough clinical evaluation, including a detailed history and physical examination, followed by imaging studies such as plain radiographs, CT scans, and MRI to evaluate the thoracic outlet and assess for neurovascular compression. The clinical evaluation should focus on symptoms of neurovascular compression in the thoracic outlet, and provocative maneuvers such as the Adson test, Wright test, and Roos test should be performed to reproduce symptoms 1.
Imaging studies are essential in the workup for costoclavicular syndrome, and the choice of imaging modality depends on the suspected type of thoracic outlet syndrome (TOS) 1. For example, CT scans with IV contrast can help evaluate the space sizes and demonstrate anatomical narrowing that could cause neurovascular compression, while MRI can provide detailed images of the brachial plexus and cervical spine, and dynamic evaluation of neurovascular bundles in the costoclavicular, interscalene, and pectoralis minor spaces.
Some key points to consider in the workup for costoclavicular syndrome include:
- Identifying bony abnormalities such as cervical ribs or clavicular deformities using plain radiographs
- Evaluating arterial or venous compression using vascular studies such as duplex ultrasound, CT angiography, or MR angiography
- Assessing neurogenic involvement using electrodiagnostic studies such as nerve conduction studies and electromyography
- Considering specialized tests such as scalene muscle blocks to temporarily relieve symptoms and confirm the diagnosis
- Ordering laboratory tests to rule out other conditions that may mimic costoclavicular syndrome
Overall, a comprehensive approach that includes a thorough clinical evaluation, imaging studies, and specialized tests is necessary to differentiate costoclavicular syndrome from other conditions with similar presentations and guide appropriate management decisions 1.
From the Research
Diagnostic Approach
The workup for costoclavicular syndrome involves a combination of clinical evaluation and diagnostic tests.
- A careful and detailed medical history and physical examination are essential for proper identification of the syndrome 2.
- Electromyography, nerve conduction studies, and imaging of the cervical spine and the chest can provide helpful information regarding diagnosis 2.
- MR imaging can be used to assess the dynamic modifications of the thoracic outlet and detect vasculonervous compressions in symptomatic patients 3.
- Quantitative measurements of the microcirculation of the fingertip can be examined with the shoulders and head in various positions to provide quantitative information relative to the costoclavicular syndrome 4.
Provocative Tests
Provocative tests, such as the Wright position, can be used to induce nerve compression in the costoclavicular space and aid in diagnosis 5.
- The Wright position has been shown to increase nerve contact pressure and artery contact pressure in the costoclavicular space 5.
- Other provocative positions, such as the depressed position, alternative Eden position, and throwing position, can also be used to assess neurovascular bundle compression in the costoclavicular space 5.
Imaging Studies
Imaging studies, such as MR imaging, can be used to evaluate the thoracic outlet and detect any anatomical abnormalities that may be contributing to the syndrome 3.
- MR imaging can provide measurements of the costoclavicular distance, distance between the inferior border of the subclavius muscle and the anterior chest wall, and maximum thickness of the subclavius muscle 3.
- These measurements can be compared between asymptomatic volunteers and symptomatic patients to identify any significant differences 3.