![]() ![]() However, at the 10-year follow up interview, the patient reported a return of symptoms comparable to those experienced before the 10-year pain-free period. The patient was followed up annually for 10 years, and was free of symptoms for the entire period. After this surgery, the symptoms did not return. After the fourth botulinum toxin injection, she was referred to a thoracic surgeon who performed a transaxillary resection of the first rib. The procedure was repeated three more times at approximately 3-month intervals, each time providing the patient with a symptom-free period of 3 months. One hundred units of botulinum toxin were dissolved in 1 mL saline, and 60 units (1 unit/kg) of the toxin were injected into the anterior scalene muscle using the technique described above.įollowing these procedures, the patient was entirely free of symptoms, and actively participated in sports, including swimming and tennis, for 3 months until the symptoms returned. Five milliliters (mL) of 2% ropivacaine injected into the anterior scalene muscle produced immediate relief of the shoulder and periscapular pain, with no signs of brachial plexus blockade. The anterior scalene muscle was identified between these two nerve landmarks by a negative response to neurostimulation set at an output of 2 mA, a frequency of 2 Hz and a pulse width of 0.3 ms. The diagnosis of NTOS was considered, and, with the patient lightly sedated with midazolam, and using nerve stimulation (Stimuplex, B Braun, Bethlehem, PA, USA), the brachial plexus and phrenic nerves were identified by eliciting a biceps muscle motor response for the former and a diaphragm motor response for the latter. The right-sided brachial plexus was very tender upon light palpation compared to the left side, and lateral flexion of the neck aggravated the pain. On examination, the patient was found to be in excellent physical condition, and her neck could be described as slender and “ballerina-like.” Assessment of range of motion in her right shoulder proved negative for signs and symptoms of subacromial or glenohumeral pathology, but the overhead fatigue test (upper arms abducted to 90° and shoulders externally rotated to 90°, while the grip in both hands were squeezed and relaxed) revealed that her right arm developed pain and fatigued, while the left arm did not. The pain was increased by continuous overhead activity, such as swimming and doing her hair, and downward traction, such as carrying heavy objects. ![]() ![]() ![]() The nature of the pain was described as a “lame,” nagging type of pain that increased with exercise, and persisted after cessation of activities. This might put the patient in jeopardy of permanent nerve injury, and the purpose of this review is to minimize or prevent this.Ī 19-year-old, slender, Caucasian female patient, who was otherwise healthy, presented with right-sided periscapular and shoulder pain. Patients with NTOS often get operated upon – even if just a diagnostic arthroscopy, and an interscalene or other brachial plexus block may be performed. We review the literature and elaborate on the anatomy, sonoanatomy, etiology and characteristics, symptoms, diagnostic criteria and treatment modalities of NTOS. The patient was followed for 10 years after which time the symptoms reappeared. Later a trans-axillary first rib resection provided semi-permanent relief. 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. With this paper we present an otherwise healthy young female patient with typical NTOS. 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. ![]()
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