Presented at the 2013 AAPM Annual Meeting « Back

Little Girl Lost: An Unusual Case of Neurogenic Thoracic Outlet Syndrome

Anastacia Munro, MD, amunro@anest.ufl.edu¹, Trusha Govindji, MD², Andre P. Boezaart, MD PhD², Devon Cole, MD¹, (1) Shands Hospital at University of Florida, Gainesville, Florida, (2) University of Florida, Gainesville, Florida

Introduction: A case of a 15 yo female softball player whose symptoms began 7 weeks prior during a game with a "pop," followed by excruciating pain in right shoulder with a 10cm round erythematous patch, change in temperature and severe allodynia. Infectious, immunologic, orthopedic and dermatologic etiologies were r/o after an extensive work-up at an outside facility. Materials and Methods: Upper extremity US; MRIs and CTs of neck, brachial plexus and shoulder and an extensive laboratory work-up were negative. 3D CT with contrast through an interscalene nerve catheter demonstrated limited spread of dye laterally along the brachial plexus beyond the 1st rib and clavicle with hypertrophy of scalene muscles. She was treated with 20U of Botox injection into the anterior scalene and a continuous cervical paravertebral block (CCPVB), which resulted in complete resolution of symptoms for 2 months. After her pain returned patient underwent repeat treatment with 80U of Botox and ambulatory CCPVB, which was removed after 7 days. Results: Pt achieved complete resolution of all symptoms along with full range of motion of affected extremity. Conclusions: Considering patient’s unusual presentation the DDx included atypical CRPS, atypical neurogenic thoracic outlet syndrome – or both. It remains unclear if she achieved pain resolution secondary to a Botox-induced relief of brachial plexopathy from scalene muscle hypertrophy, regional analgesia from the CCPVC or sympathetic blockade of stellate ganglion due to spread from the CCPVB. Should symptoms return we will treat with RCPVC without Botox in an attempt to delineate the etiology of her symptoms.

Funding: None