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

Boezaart AP, Haller A, Laduzenski S, Koyyalamudi VB, Ihnatsenka B, Wright T - Int J Shoulder Surg (2010)

Bottom Line: 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.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Division of Acute Pain Medicine and Regional Anesthesia, University of Florida, College of Medicine, Gainesville, Florida, United States of American Society of Anesthesiologists.

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.

No MeSH data available.


Related in: MedlinePlus

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
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Figure 0001: 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

Mentions: The interscalene space: The interscalene space is bounded anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the portion of the clavicle between the insertions of these two muscles [Figure 1]. The anterior scalene muscle arises from the anterior tubercles of the transverse processes of the 3rd to 6th cervical vertebrae (C3-C6), and attaches to the scalene tubercle on the superior aspect of the first rib. The scalene tubercle separates the grooves formed by the subclavian artery laterally and the subclavian vein medially on the superior surface of the first rib. The middle scalene muscle arises from the posterior tubercles of the transverse processes of the 2nd to 7th cervical vertebrae (C2-C7), and inserts onto the posterior aspect of the first rib lateral to the groove of the subclavian artery and medial to the tubercle of the first rib. Enclosed in this triangle are the ventral rami of the 3rd to 5th cervical nerve roots (C3-C5) and the superior, middle, inferior trunks of the brachial plexus, and the subclavian artery. The superior (C5-C6) and middle (C7) trunk of the brachial plexus passes through the upper part of this space. The lower (C8-T1) trunk crosses the inferior part of the interscalene triangle behind the subclavian artery.[1] The subclavian vein passes medial to the anterior scalene muscle and lateral to the costoclavicular ligament. The scalenus minimus muscle, found to be associated with 30-50% of patients with NTOS,[2] originates from the transverse processes of C6 and C7 vertebrae, and inserts into the inner aspect of the first rib and pleura (Sibson’s fascia). Thus, over the top of the first rib, medial to lateral, are present the costoclavicular ligament, subclavian vein, anterior scalene muscle, subclavian artery, brachial plexus, and the middle scalene muscles. Anatomical variations in the scalene triangle have been associated with NTOS[34] [Figure 1].


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

Boezaart AP, Haller A, Laduzenski S, Koyyalamudi VB, Ihnatsenka B, Wright T - Int J Shoulder Surg (2010)

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
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2966747&req=5

Figure 0001: 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
Mentions: The interscalene space: The interscalene space is bounded anteriorly by the anterior scalene muscle, posteriorly by the middle scalene muscle, and inferiorly by the portion of the clavicle between the insertions of these two muscles [Figure 1]. The anterior scalene muscle arises from the anterior tubercles of the transverse processes of the 3rd to 6th cervical vertebrae (C3-C6), and attaches to the scalene tubercle on the superior aspect of the first rib. The scalene tubercle separates the grooves formed by the subclavian artery laterally and the subclavian vein medially on the superior surface of the first rib. The middle scalene muscle arises from the posterior tubercles of the transverse processes of the 2nd to 7th cervical vertebrae (C2-C7), and inserts onto the posterior aspect of the first rib lateral to the groove of the subclavian artery and medial to the tubercle of the first rib. Enclosed in this triangle are the ventral rami of the 3rd to 5th cervical nerve roots (C3-C5) and the superior, middle, inferior trunks of the brachial plexus, and the subclavian artery. The superior (C5-C6) and middle (C7) trunk of the brachial plexus passes through the upper part of this space. The lower (C8-T1) trunk crosses the inferior part of the interscalene triangle behind the subclavian artery.[1] The subclavian vein passes medial to the anterior scalene muscle and lateral to the costoclavicular ligament. The scalenus minimus muscle, found to be associated with 30-50% of patients with NTOS,[2] originates from the transverse processes of C6 and C7 vertebrae, and inserts into the inner aspect of the first rib and pleura (Sibson’s fascia). Thus, over the top of the first rib, medial to lateral, are present the costoclavicular ligament, subclavian vein, anterior scalene muscle, subclavian artery, brachial plexus, and the middle scalene muscles. Anatomical variations in the scalene triangle have been associated with NTOS[34] [Figure 1].

Bottom Line: 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.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Division of Acute Pain Medicine and Regional Anesthesia, University of Florida, College of Medicine, Gainesville, Florida, United States of American Society of Anesthesiologists.

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.

No MeSH data available.


Related in: MedlinePlus