Neurology Case Study: Pancoast Tumor or Thoracic Outlet Syndrome

[IamGracey]

Hello. I'm a first year medical student and I'm currently studying a neurologic case. The case is of a 53-year-old, hypertensive, smoker, male who presented with a left shoulder and upper limb pain.

3 months prior, he visited a chiropractor for his chronic low back pain. During the course of treatment, his neck was manipulated. Subsequently, he began experiencing left nagging shoulder and scapular pain which he attributed to the chiro manipulation. This pain became constant and radiated to his left arm and forearm with numbness and tingling of the tips of his fourth and fifth fingers.

Past medical history was unremarkable. He smoked one pack of cigarettes per day for the past 35 years.

Neurologic examination:
He had normal mentation. Cranial nerves were normal, except for slight droopiness of the left eyelid, and a smaller left pupil than the right. Both pupils were reactive to light and accommodation. There was decreased sweat in the left hemiface. Extraocular movements and other cranial nerves were normal. He had normal limb muscle strength except for mild weakness of thumb abduction, finger abduction and flexion. There was also left interossei, thenar and hypothenar atrophy. No fasciculations were detected. Reflexes were equal in the arms and legs at 2+, with no Babinski signs. There was decreased pin prick sensation along the medial aspect of the left forearm, and left 4th and 5th fingers. Normal limb coordination and gait. Supple neck.

My group mates and I have been discussing whether or not we should be considering Pancoast tumor due to his smoking history. However, since the pain in this left upper limb started after the neck manipulation, we're considering Thoracic Outlet Syndrome most likely. We've been thinking that the neck manipulation could have caused the compression of the stellate ganglion which led to ptosis, anhidrosis, and miosis. The lower portion of the brachial plexus must have been affected too causing a bit of sensory and motor problems in some parts of the left upper limb.

If you have thoughts about this case, please feel free to discuss it. Your help will be greatly appreciated. Thank you!

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[typhoonegator]

It sounds like there is some interruption in sympathetic fibers to the face, but at what level? Is there an eponym for such a syndrome? Are there any topical pharmacologic tests that could help you identify which sympathetic nerves in the chain are affected?

We shouldn't help you with your homework, but I think some guidance in this way might be helpful for you.

 

[IamGracey]

It sounds like there is some interruption in sympathetic fibers to the face, but at what level? Is there an eponym for such a syndrome? Are there any topical pharmacologic tests that could help you identify which sympathetic nerves in the chain are affected?

We shouldn't help you with your homework, but I think some guidance in this way might be helpful for you.

Thank you for your response Sir. Unfortunately, the case given to us did not include any tests that could have aided us to identify which sympathetic nerves in the chain were affected. However, looking at the clinical manifestations, we think it's the superior cervical ganglion that has been affected thereby resulting to Horner's syndrome. Thank you again Sir!

 

[neurodoc]

The "droopy" left eyelid and relatively smaller left pupil would indicate Horner's Syndrome, due to a lesion of the sympathetic supply to the left pupil. The lesion can be anywhere from the cervical ciliospinal center of Budge to the iris muscles. The "ptosis" is not due to a 3rd nerve lesion, and is technically called "pseudoptosis." It's due to weakness not of the levator palpebris muscle, but weakness of the intrinsic tarsal muscle (Muller) of the lid itself. The third element of Horner's Syndrome is ipsilateral facial loss of sweating (anhidrosis). A tumor (Pancoast) of the lung apex is one possible cause of Horner's syndrome, and it should always be suspected and ruled out because it is the most serous cause. Another cause is trauma, which is quite common. I've also seen a few cases that were due to problems, like dissection, affecting the carotid sheath. Hope this helps.

 

[IamGracey]

Thank you neurodoc for the help! I'm surprised that the information our group now has matches most of the info. That you have provided. The only difference is that i haven't read about intrinsic tarsal muscle yet but I think it refers to the smooth muscle fibers of the levator palpebrae superioris. I will look into that for sure. Most sources I've read only mentioned that partial ptosis occurred due to the interruption in the sympathetic innervation of the smooth muscle fibers of Levator p.s. while its skeletal muscle fibers are intactly innervated by CNIII
As of now, we're trying to figure out how come the symptoms came out after the neck manipulation. It must have triggered or hit something or perhaps just a coincidence (unlikely though?)

Thank you again neurodoc!

 

[TUGM]

Chiropractic manipulation has been linked to carotid and vertebral artery dissection, so maybe you can do some research on that particular association.