Introduction

Thoracic Outlet Syndrome (TOS) refers to a

collection of subjective symptoms and

clinical findings caused by compression of

the neurovascular bundle as it passes

through the thoracic outlet. Patients with

persistent or worsening symptoms despite

conservative management may be surgical

candidates. We report a case of a patient

with post-traumatic neurogenic thoracic

outlet syndrome with persistent pain

following multiple surgeries and neurolysis

but had significant pain relief following a

left pectoralis minor botulinum toxin

injection.

 

Discussion

Initial management of TOS includes physical therapy, pharmacologic agents,

and injections (anesthetic, steroid, or botulinum toxin).

Patients with persistent symptoms are candidates for thoracic outlet

decompression.

Due to recurrence and surgical complications, the benefit of surgical

intervention remains questionable.

Our patient failed multiple surgeries but had significant relief with a botulinum

toxin injection.

This highlights the potential of botulinum toxin for refractory TOS.

More research is needed to identify long-term treatment options.

 

Results

Our patient is a 28-year-old female with left-sided post-traumatic

neurogenic thoracic outlet syndrome following a whiplash injury. She

reported left shoulder, arm, and finger pain with weakness, numbness, and

tingling, unrelieved by physical therapy or oral medications. She

underwent left first rib resection, brachial plexus neurolysis, scalenectomy,

and pectoralis minor tenotomy with initial relief, but symptoms returned

after another motor vehicle accident. Diagnosed with recurrent pectoralis

minor syndrome, she had resection of the left pectoralis minor and repeat

neurolysis, but symptoms persisted. At our pain clinic, she presented with

pain, weakness, allodynia, and hyperalgesia of the left arm, chest wall, and

hand. A left pectoralis minor botulinum toxin injection provided 40%

symptom improvement, enabling physical therapy and daily activities.