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 Table of Contents  
Year : 2022  |  Volume : 36  |  Issue : 3  |  Page : 159-161

A case report on botox for neurogenic thoracic outlet syndrome – An alternative to surgery

Center for Pain Releif, Hyderabad, Telangana, India

Date of Submission30-Oct-2021
Date of Decision24-Feb-2022
Date of Acceptance01-Mar-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Minal Chandra
Flat 301, Suma Splendor Apartments, Somajiguda, Hyderabad, Telengana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_88_21

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Thoracic outlet syndrome (TOS) remains one of the underdiagnosed conditions due to the unavailability of specific tests. The pain of TOS may mimic shoulder pain and or cervical radicular pain. Understanding the pathology and type of TOS is the key to successful management. Although surgery remains the final permanent solution in a conformed case of TOS, conservative therapies do provide great relief from pain. Botox remains one of the modalities in managing TOS pain by relieving the spasm of the scalene group of muscles and thereby alleviating the compression symptoms.

Keywords: Botox, botulinum toxin type A neurogenic, scalene muscles, thoracic outlet syndrome

How to cite this article:
Chandra M, Dara S, Varma R. A case report on botox for neurogenic thoracic outlet syndrome – An alternative to surgery. Indian J Pain 2022;36:159-61

How to cite this URL:
Chandra M, Dara S, Varma R. A case report on botox for neurogenic thoracic outlet syndrome – An alternative to surgery. Indian J Pain [serial online] 2022 [cited 2022 Dec 7];36:159-61. Available from: https://www.indianjpain.org/text.asp?2022/36/3/159/361632

  Introduction Top

Thoracic obstruction syndrome (TOS) is a complex neurological condition that has various presentations in the form of vascular and neurogenic symptoms of the upper limb. The compression on neurovascular structures at the neck above the first rib leads to this condition. The compression of the neurovascular structures can occur at the interscalene level, costoclavicular space, or retropectoralis minor spaces.[1] Depending on the structures compressed, the TOS can be classified into vascular or neurogenic though 95% of the cases are due to neurogenic claudication.[2],[3] The arterial and venous TOS occur due to compression of the subclavian artery and vein, respectively. The most common cause for arterial TOS is artery narrowing, and the most common cause for venous TOS is thrombosis.

Arterial TOS may produce symptoms such as ischemia of fingers, paresthesia's, pain, pallor, claudication, and decreased temperature of the hands. Venous TOS produces symptoms such as shoulder and arm pain and swelling of the upper limb of the affected side, and in a few cases, cyanosis may be present.[2] Neurogenic claudication is due to compression of the brachial plexus trunks or cords, comprising nerves that come from C5-T1 spinal levels. Neurogenic TOS presents with the clinical picture of nerve irritation or compression and often confused with symptoms of radicular pain due to disc prolapse. Pain, paresthesias, numbness of neck, shoulder, arm, hand. The paresthesia is most often reported in all five fingers but worse in the fourth and fifth digits and medial forearm. Sometimes, pain over the trapezius, neck, occipital headaches, and anterior chest pain may be present. Any movements such as the elevation of the hand or the overhead position of the head can exacerbate the pain.[1],[2]

Multiple treatment options in the form of conservative and surgical modalities are available, and Botox for neurogenic TOS can be one of the effective modalities and effective substitutes to surgery. Botox is a neurotoxin originating from Clostridium botulinum, a Gram-positive anaerobic bacteria. It inhibits calcium-dependent acetylcholine release from presynaptic nerve endings at the neuromuscular endplate.

  Case Report Top

Here, we report an unusual case of neurogenic TOS after taking written informed consent from a 35-year-old male patient who visited our pain clinic with neck pain radiating to the left shoulder and occasionally to the left hand for 3 years. The pain was initially in the anterior aspect of the neck and slowly started to radiate to the left hand with tingling numbness of the fingers. His pain increased while typing, holding any objects, and with sudden movements of the neck. Pain in the posterior aspect of the neck was mild and occasional. There were no motor or sensory deficits and no other signs of any red flags. He consulted his primary orthopedic surgeon for the same and was prescribed pain NSAIDS and muscle relaxants with occasional relief in pain.

After obtaining written and informed consent, intravenous catheter 18 G, routine monitoring for non Invasive blood pressure (NIBP), Heart Rate (HR), SpO2, and electrocardiogram were secured. The patient was put in supine position with the neck slightly rotated to the right. The patient was offered a diagnostic block of anterior and middle scalene muscles under ultrasound guidance with local anesthetic 2% lignocaine. The patient was pain-free for 2 days and so the diagnosis TOS was confirmed and planned for Botox injection for the anterior and middle scalene.

The patient was explained about the procedure along with the pre- and postprocedure precautions. Under all aseptic precautions, with 22-G spinal needle, 25 units of Botox was injected into anterior scalene muscle and 25 U of Botox was injected in middle scalene muscle under ultrasound guidance using a liner probe of frequency 8–12 HTZ. The patient was observed for any changes in vitals in the recovery area for an hour and was discharged after 2 h of the procedure.

  Discussion Top

In our patient, single shot of 50 U of botulin injection was injected into anterior and middle scalene in equal divided units which provided good pain relief at 1, 3, 6, and 9 months. Patient's NRS scores were 5/10 at 1-month follow-up, 3/10 at 3-month follow-up, and 3/10 at 6-month follow-up. At 9-month follow-up, the patient complained of mild occasional discomfort with NRS score of 3/10. The patient was able to resume his full-time office job and reported about the improved quality of life. Botox is a neurotoxin originating from Clostridium botulinum, a Gram-positive anaerobic bacteria. It inhibits calcium-dependent acetylcholine release from presynaptic nerve endings at the neuromuscular endplate leading to chemodenervation of the injected muscle. Neurogenic TOS comprises 95% of the cases. The anterior and middle scale pathology such as any trauma leading to spasm and then scarring of these muscles becomes a potential source to compress the brachial plexus presenting with TOS. The interscalene triangle is frequently implicated in neurogenic TOS which is formed between the anterior and middle scalene muscles. Any injury in the neck or the presence of congenital abnormalities such as a cervical rib or band compresses the interscalene space. As scarring and spasm develop in the scalene, the muscles posttrauma, compress the brachial plexus leading to symptoms such as pain and paresthesia in the upper extremity.[2],[3] Treatment for neurogenic can be classified into conservative and surgical management. The surgical management implies splenectomy surgeries. The nonsurgical techniques such as injections of local anesthetic agents, steroids, and botulinum toxin type A (BTX-A) into the scalene group of muscles aim at decreasing the interscalene pressure. The use of scalene muscle injections with local anesthetics is very short-lived and as such will only provide adjunctive support to one's clinical diagnosis and possible prognosis regarding the reversibility of symptoms. BTX-A injections have demonstrated an ability to result in more sustained improvement in symptoms.[4],[5]

Botox injections have antinociceptive effect by weakening the freeing the compression on brachial plexus trunks and cords by relaxing the scalene muscles. Jordan et al.[6] injected 100 units of Botox in equal divided does in the anterior and middle scalene muscles and trapezius. 64% of the study group had greater than 50% reduction of symptoms with mean duration of 88 pain free days. Torrianni et al.[3] reported a study of 41 individuals of NTOS being treated with Botox injections in the scalene muscles showing 69% success. Danielson et al.[7]

demonstrated that BTX-A injections under ultrasound guidance could be used to treat arterial TOS. In this case report, they injected a 28-year-old male with subclavian artery compression on Doppler ultrasound, with 15 units of BTX-A into his anterior scalene muscle. Three weeks following injection, the patient was found to have a clinical improvement in subclavian artery blood flow as demonstrated by Doppler ultrasound. The beneficial effects of anterior scalene muscle injection with BTX-A, in this case, could possibly be attributable to diminished compression and irritation of the adjacent brachial plexus nerves.

Christo et al.[5] examined the effectiveness of injecting 20 units of BTX-A into the anterior scalene muscles under CT guidance in the treatment of NTOS in 27 patients who had failed physical therapy concluding that BTX-A injection into the anterior scalene muscle may offer an effective and minimally invasive treatment for NTOS. Among all the conservative treatment options available, Botox does offer better and more sustained results as compared to others and the major advantage is the absence of any major complications.

  Conclusion Top

NTOS remains one of the medical conditions which are still underdiagnosed, thereby leading to increased suffering to the patient. This condition should be differentiated from other conditions which mimic it. The condition needs to be evaluated and treated accordingly. The conservative management offers good pain relief, and Botox can be considered an equally efficacious treatment alternative to surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome. Toxins (Basel) 2012;4:1223-35.  Back to cited text no. 1
Sanders RJ, Hammond SL, Rao NM. Thoracicoutlet syndrome: Review. Neurologist 2008;14:365-73.  Back to cited text no. 2
Torriani M, Gupta R, Donahue D. Botulinum toxin injection in neurogenic thoracic outlet syndrome: Results and experience using an ultrasound-guided approach. Skeletal Radiol 2010;39:973-380.  Back to cited text no. 3
Braun RM, Sahadevan DC, Feinstein J. Confirmatory needle placement technique for scalene muscle block in the diagnosis of thoracic outlet syndrome. Tech Hand Up Extrem Surg 2006;10:173-6.  Back to cited text no. 4
Christo PJ, Christo DK, Carinci AJ, Freischlag JA. Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome. Pain Med 2010;11:504-11.  Back to cited text no. 5
Jordan SE, Ahn SS, Freischlag JA, Gelabert HA, Machleder HI. Selective botulinum chemodenervation of the scalene muscles for treatment of neurogenic thoracic outlet syndrome. Ann Vasc Surg 2000;14:365-9.  Back to cited text no. 6
Danielson K, Odderson IR. Botulinum toxin type A improves blood flow in vascular thoracic outlet syndrome. Am J Phys Med Rehabil 2008;87:956-9.  Back to cited text no. 7


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