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.

Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome

“…Nerve injury is a major risk in any surgical intervention aimed at treating TOS. 3 Peripheral nerve injury was rare in our analysis, occurring at a frequency of 1% or less across both cohorts. There was no statistically significant difference in nerve injury rate with or without FRR or across any of the specific procedural cohorts.…”

Evaluation of Complications after Surgical Treatment of Thoracic Outlet Syndrome

“…Prior to the operation, patients should be monitored for diseases such as carpal tunnel syndrome, cubital tunnel syndrome, cervical disc, and tendinitis of the rotator cuff that can occur with or without TOS. If first-rib resection is to be performed, it is important to find the best operative approach with relatively few complications [ 9 ]. The experience of the surgical team is an important factor affecting surgical outcomes; therefore, the same experienced team performed the operations, and no chronological differences existed between the deployments of the two techniques.…”

“…A transaxillary approach for such a resection was introduced by Roos [ 8 ] in 1966. A TOS operation should be well thought-out, and an accurate diagnosis should be made before considering decompression surgery to be the final solution [ 9 ]. Complications of TOS surgery include the recurrence of symptoms, brachial plexus, phrenic nerve, long thoracic nerve, complete or transient paralysis, subclavian artery and vein injuries, axillary artery thrombosis, hemothorax, pneumothorax, chylothorax, permanent damage to the brachial plexus, severe sequelae such as causalgia and weak ness of the hand muscles, sensory deficits, autonomic dysfunction, and at times even death [ 10 – 12 ].…”

Cross-sectional Imaging Anatomy and Pathologic Conditions Affecting Thoracic Nerves

“…Depending on the level being targeted, rates of postoperative Horner syndrome range from 0.7% to 3% (27). In patients undergoing thoracic outlet decompression for neurogenic or vascular thoracic outlet syndrome, approximately 1% of patients will develop at least temporary Horner syndrome, especially when surgery is from a supraclavicular approach with resection of the first rib and middle scalene muscle (28,29).…”