Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 22 - Neurological and Neuromuscular Disorder Medical Treatment Guidelines › Subchapter B - Thoracic Outlet Syndrome › Section I-2221 - Initial Diagnostic Procedures

Current through Register Vol. 50, No. 6, June 20, 2024
A. The OWCA recommends the following
					 diagnostic procedures be considered, at least initially, the responsibility of
					 the workers' compensation carrier to ensure that an accurate diagnosis and
					 treatment plan can be established. Standard procedures that should be utilized
					 when initially diagnosing a work-related TOS complaint are listed below.
1. History taking and physical examination
					 (Hx and PE) are generally accepted, well-established and widely used procedures
					 which establish the basis for diagnosis, and dictate all other diagnostic and
					 therapeutic procedures. When findings of clinical evaluations and those of
					 other diagnostic procedures are not complementing each other, the objective
					 clinical findings should have preference. Neurogenic TOS will be described
					 separately from vascular TOS, although some general symptoms may occasionally
					 overlap. Vascular TOS usually requires emergent treatment as described in the
					 surgical Section. Treatment for non-specific neurogenic TOS begins with jobsite
					 alteration and therapy as described in Section F. and rarely requires surgical
					 intervention. True neurogenic TOS may require early surgical intervention if
					 there is significant weakness with corresponding EMG/NCV changes. The medical
					 records should reasonably document the following.
a. History Taking. A careful history
					 documenting exacerbating activities and positions which relieve symptoms is
					 essential. Timing of the onset of symptoms is important. TOS has been
					 associated with trauma and motor vehicle accidents. Avocational pursuits should
					 also be specifically documented.
i. Symptoms
					 Common to Neurogenic TOS. Neurological symptoms are usually intermittent in
					 non-specific TOS. If symptoms are constant, consider other diagnoses such as
					 true TOS or other brachial plexus injuries. Neck pain is often the first
					 symptom with complaints within the first few days of injury. Occipital
					 headaches may also occur early. Some patients experience coldness or color
					 changes in the hands. Neurogenic symptoms include the following:
(a). forearm (frequently medial), or proximal
					 upper extremity pain;
(b). numbness
					 and paresthesia in arm, hand and fingers:
(i).
					 fourth and fifth digits: most common pattern;
(ii). all five fingers: next most common
					 pattern;
(iii). first, second and
					 third digits: symptoms may occur, but one must rule out carpal tunnel
					 syndrome;
(c). upper
					 extremity weakness: arm and/or hand; "dropping things" may be a common
					 complaint;
(d). exacerbating
					 factor: arm elevation. Common complaints are trouble combing hair, putting on
					 clothing, driving a car, or carrying objects with shoulder straps such as back
					 packs; disturbed sleep, etc.
(i). Symptoms
					 Common to Vascular TOS
[a]. Pain, coldness,
					 pallor, digital ischemia and claudication in the forearm are signs of arterial
					 compromise which is most frequently chronic and due to subclavian aneurysm or
					 stenosis.
[b]. Swollen, cyanotic,
					 and sometimes painful arm is indicative of a venous obstruction requiring
					 immediate attention.