Editor-in-Chief: Alaa Abd-Elsayed, MD, PhD
BACKGROUND: Neurogenic thoracic outlet syndrome (nTOS) makes up 95% of all thoracic outlet cases. Symptoms consist of pain, numbness, dysesthesia, numbness, and weakness of the affected upper extremity. Current treatment options include medical management, physical therapy, steroid injections, and surgical decompression. Even patients who undergo surgical management do not always have complete resolution. These patients tend to develop chronic pain secondary to refractory nTOS. The treatment for refractory nTOS is the same as for the primary disease. Unfortunately, this exposes the patient to more invasive surgeries that may not resolve their symptoms. This case report is about a patient with refractory nTOS and complex regional pain syndrome (CRPS) in the same extremity, treated with a spinal cord stimulator, allowing him to avoid repeat surgery.
CASE REPORT: A middle-aged man presented to the interventional pain clinic with right upper extremity pain. He had a history of bilateral thoracic outlet syndrome and underwent surgical decompression with good resolution on the left, but not the right side. He continued to display nTOS symptoms, but also developed new symptoms of the right anterior chest consistent with CRPS. He opted for conservative therapy without improvement but did not want to undergo another surgery, even though he had been suffering for many years. A temporary spinal cord stimulator (SCS) was placed for a trial period with complete resolution of pain and weakness. A permanent SCS was implanted. The patient continued to have good results leading to improved mood, activity, and overall quality of life.
CONCLUSION: Interestingly, this patient had overlapping symptoms of refractory nTOS and CRPS. A SCS was able to treat both pathologies. This revelation is important, not only because the SCS can treat both pathologies, but also because it has potential to become a great minimally invasive alternative treatment for refractory nTOS. This would allow patients to avoid surgery and the distress that comes with it.
KEY WORDS: Complex regional pain syndrome, spinal cord stimulator, stellate ganglion block, thoracic outlet syndrome