I am a workers’ compensation attorney and L&I attorney representing work injury claimants in Washington State. Over the years, I’ve seen a wide variety of work injuries and occupational diseases. As a result, I’ve learned a lot about a wide range of medical diagnoses. I’ve also come to recognize diagnoses that are likely to complicate an L&I claim, potentially resulting in a highly complex workers compensation claim. In my experience, an L&I claim for Thoracic Outlet Syndrome and Cervicobrachial Syndrome are likely to become very convoluted. Thankfully, our office has vast experience handling these conditions and claims.
What is Thoracic Outlet Syndrome?
In order to understand thoracic outlet syndrome, you need to understand some basic facts about human anatomy. The human body has a network of cervical nerve roots that join to connect signals between the brain and the shoulders, and upper extremities or arms. This network is often called the brachial plexus. Injuries to the brachial plexus cause pain, numbness, tingling and even paralysis of the shoulders and arms.
The medical community is still working to fully understand brachial plexus injuries. There seems to be a general consensus that there are at least two primary varieties of thoracic outlet syndrome (TOS) that can result from brachial plexus injuries. These are: (1) Vascular thoracic outlet syndrome; and (2) Neurogenic thoracic outlet syndrome. Vascular TOS occurs as a result of trauma to the arteries or veins around the brachial plexus. Neurogenic TOS occurs when the brachial plexus nerve fibers are compressed.
As far as the Department of Labor and Industries (L&I) is concerned, certain criteria must be met to allow a diagnosis of neurogenic TOS under an L&I claim in Washington State. Those criteria are outlined in the L&I treatment guideline.
L&I treatment guidelines for Thoracic Outlet Syndrome
The L&I medical and treatment guidelines for TOS are complicated. In short, the diagnosing medical provider must produce certain clinical exam findings that are corroborated by an electrodiagnostic study showing that the brachial plexus nerves are being compressed.
Historically, a third kind of TOS called “disputed” TOS was recognized by some. According to the L&I treatment guidelines for TOS, “disputed” TOS occurs when there are positive clinical exam findings of neurogenic TOS, but the electrodiagnostic study is normal and does not confirm impingement of the brachial plexus nerves. In the past, work injury victims with disputed TOS diagnosis were facing challenges in their L&I claims. That’s because the treatment guidelines only include true neurogenic TOS and vascular TOS.
Until recently, if an injured worker was diagnosed with disputed TOS, L&I would issue an order or decision stating that thoracic outlet syndrome is not an accepted condition on the workers compensation claim. Luckily, that’s no longer the case.
What is Cervicobrachial Syndrome?
In February 2019, L&I updated its thoracic outlet syndrome treatment guideline to include cervicobrachial syndrome. According to L&I, the symptoms of cervicobrachial syndrome mimic those of neurogenic TOS but lack the required electrodiagnostic results to diagnose true neurogenic TOS. The symptoms of Cervicobrachial Syndrome include pain and muscle spasm in the cervical or brachial region.
Symptoms may also include neck and headache, and sometimes numbness and tingling in one or both upper extremities. However, cervicobrachial syndrome does not include other common characteristic of TOS such as decreased reflexes, dermatomal sensory loss, specific muscle weakness or atrophy of the upper extremity, and abnormal electrodiagnostic tests that corroborate the presence of objective brachial plexus involvement.
Thoracic Outlet Syndrome and Cervicobrachial Syndrome in a work injury
Thoracic outlet syndrome may develop when workers experience extended periods of time or postures limited to carrying heavy shoulder loads. Workers that their work involves pulling shoulders back and down, or reaching above shoulder level, can also develop thoracic outlet syndrome. This is because those kinds of work activities tend to cause swollen or inflamed mid-back, shoulder and neck muscles and tendons. When swelling occurs around the brachial plexus, it compresses the nerves and blood vessels between the neck and shoulders. And, the result is thoracic outlet syndrome.
L&I claim for jackhammer operators, welders and aircraft assemblers
In the worker’s compensation setting, neurogenic and disputed TOS are more commonly diagnosed than vascular. L&I acknowledges that certain work activities may exacerbate neurogenic TOS. These activities include (but are not limited to) lifting overhead, holding tools or objects above shoulder level, reaching overhead, and carrying heavy weights. Occupations often associated with neurogenic thoracic outlet syndrome include dry wall hangers, plasterers, welders, beauticians, assembly line workers, shelf stockers and dental hygienists.
With respect to cervicobrachial syndrome, the medical community still doesn’t fully understand the types of activities that cause the condition. However, some activities thought to cause cervicobrachial syndrome include sprains and strains involving the cervical or brachial region, shoulder joint dislocation or fracture, rheumatoid arthritis, and degenerative disease (i.e., arthritis).
In my experience, in workers’ compensation claims, common work activities that seem to contribute to the development of cervicobrachial syndrome include prolonged use of vibratory tools such as jackhammers, repetitive heavy and overhead lifting, and working in prolonged and awkward overhead postures. I’ve seen the condition impact laborers, dental hygienists, aircraft assemblers, steel workers and more.
Treatment for Thoracic Outlet Syndrome and Cervicobrachial Syndrome
Going back to L&I claims in Washington State, it is easier to get authorization for thoracic outlet syndrome and cervicobrachial syndrome treatment that follows the L&I treatment guidelines, rather than treatment that falls outside the guidelines. While neurogenic TOS may respond to surgical treatment, L&I favors non-surgical or conservative treatment. That’s because L&I conducted a study of surgical outcomes and the results were bleak.
Surgically, it is not easy to access the brachial plexus region. Also, there’s high risk of damaging other important nerves including the phrenic nerve, which innervates the lungs. Damage to the phrenic nerve during surgery can cause permanent asthma and reduced lung function. Therefore, L&I says surgery should only be considered in severe cases of true neurogenic TOS that do not improve with conservative treatment and interfere with work or daily life activity.
Conservative treatment options for thoracic outlet syndrome and cervicobrachial syndrome are similar. Treatment focuses on reducing inflammation of the affected muscles and tendons, while simultaneously increasing strength, mobility and overall function. In my recent experience, effective treatment involves the use of Botox injections to calm muscle spasm and inflammation and reduce the impact on the brachial plexus. This conservative treatment is authorized under the 2019 amendment to the L&I medical treatment guidelines.
Conclusion and L&I improvements
I’ve worked through many challenging and complex cases involving disputed thoracic outlet syndrome diagnosis. Hence, I was very encouraged by the February 2019 update to the medical treatment guidelines and the inclusion of cervicobrachial syndrome. However, I believe that the administration of workers compensation claims and L&I claims for thoracic outlet syndrome or cervicobrachial syndrome has to improve.
According to the L&I guidelines, people with a work injury claim who are diagnosed accurately and early were far more likely to return to work than workers whose conditions were diagnosed weeks or months later. Unfortunately, in my experience, administrative delays make early diagnosis difficult if not impossible. L&I, Independent Medical Examiners (IMEs), and even some attending providers are quick to relegate injuries to mere sprains and strains. As a result, TOS and cervicobrachial syndrome diagnoses are often delayed, sometimes indefinitely.
I believe that L&I can do a much better job at encouraging and supporting accurate and early diagnoses. This would dramatically improve outcomes in many L&I claims. Unfortunately, in nearly every case of thoracic outlet syndrome or cervicobrachial syndrome that I’ve encountered, the accurate diagnosis has not been made until more than a year following the original injury or onset of symptoms.