Neurogenic thoracic outlet syndrome: A case report and review of the literature

Abstract

Neurogenic thoracic outlet syndrome (NTOS) is an oft-overlooked and obscure cause of shoulder pain, which regularly presents to the office of shoulder surgeons and pain specialist. With this paper we present an otherwise healthy young female patient with typical NTOS. She first received repeated conservative treatments with 60 units of botulinium toxin injected into the anterior scalene muscle at three-month intervals, which providing excellent results of symptom-free periods. Later a trans-axillary first rib resection provided semi-permanent relief. The patient was followed for 10 years after which time the symptoms reappeared. We review the literature and elaborate on the anatomy, sonoanatomy, etiology and characteristics, symptoms, diagnostic criteria and treatment modalities of NTOS. Patients with NTOS often get operated upon - even if just a diagnostic arthroscopy, and an interscalene or other brachial plexus block may be performed. This might put the patient in jeopardy of permanent nerve injury, and the purpose of this review is to minimize or prevent this.

Keywords: Acute pain; botox; neurogenic thoracic outlet syndrome; shoulder pain; thoracic outlet syndrome.

Figure 1

Deep cervical muscles, (1) Longus capitis muscle, (2) Superior sympathetic ganglion, (3) Rectus capitis muscle, (4) Middle scalene, (5) Longus colli, (6) Posterior scalene muscle, (7) Anterior scalene muscle, (8) Middle sympathetic ganglion, (9) Inferior sympathetic ganglion, (10) Thoracic duct, (11) Phrenic nerve, (12) Suprascapular nerve

Figure 2

Probe position for Figure 3 – probe position 1, probe position for Figure 4 – probe position 2, probe position for Figure 5 – probe position 3

Figure 3

(1) Interscalene probe position at the level of C6 (position 1 in Figure 2) C5 and C6 nerve roots, (2) Carotid artery, (3) Vertebral artery, (4) Thyroid gland, (5) Anterior tubercle of the transverse process of C6, (6) Posterior tubercle of the transverse process of C6, (7) Sternoclydomastoid muscle, (8) Anterior scalene muscle, (9) Middle scalene muscle

Figure 4

Supraclavicular interscalene probe position (position 2 in Figure 2) SA = Subclavian artery

Figure 5

Infraclavicular probe position (position 3 in Figure 2)