Thoracic Outlet Syndrome Treated With Injecting Botulinum Toxin Into Middle Scalene Muscle and Pectoral Muscle Interfascial Planes: A Case Report

Abstract

Thoracic outlet compression syndrome is a complex syndrome of neurovascular compression at the superior thoracic aperture, thought to occur at 1 of 3 anatomical compartments: the interscalene triangle, the costoclavicular space, and the retropectoralis minor space. Injection into the middle interscalene muscle (ISM) and/or pectoralis muscle plane (PECS I and II) is gaining popularity because it provides significant symptomatic relief. A 44-year-old woman was diagnosed with thoracic outlet compression syndrome, with failed conservative therapy, including physical therapy. She refused surgical intervention. ISM and PECS I and II blocks with botulinum toxin type A were successful. In combination, PECS I/II and ISM injections can provide excellent symptomatic relief.

Localization of nerve entry points and the center of intramuscular nerve‐dense regions in the adult pectoralis major and pectoralis minor and its significance in blocking muscle spasticity

“…For the pectoralis minor muscle, BTX-A injection can also treat outlet syndrome (Rahman et al, 2019). However, the surface location and puncture depth of NEP and CINDR have not been defined.…”

“…Injecting BTX‐A to block the spasticity of the pectoralis major muscle is the most commonly used method to treat hemiplegic shoulder pain (Holmes & Connell, 2019 ). For the pectoralis minor muscle, BTX‐A injection can also treat outlet syndrome (Rahman et al, 2019 ). However, the surface location and puncture depth of NEP and CINDR have not been defined.…”

Thoracic Outlet Syndrome: A Narrative Review

“…Some studies have suggested that BTX-A injections are correlated with significant pain and symptom reduction in 64–69% of TOS patients for up to 3 months [ 70 , 71 , 72 ]. Additionally, numerous case reports have reported sustained symptom reduction in TOS patients with BTX-A injection therapy [ 73 , 74 , 75 ]. However, results from a double-blind, randomized, controlled trial did not find any clinically or statistically significant improvements in pain or symptom reduction in TOS patients [ 63 ].…”

Botulinum toxin for chronic pain: What's on the horizon?

“…Osteoarthritis: knee Beneficial in relieving pain CONTINUED manifestations. 24 Compression can be from a structural variant, such as a cervical rib, or due to soft tissue from the scalene or pectoralis musculature. TOS is difficult to diagnose and treat.…”

“…Decompression surgery is an option if conservative management fails, but it has a high recurrence rate. 24 In an effort to harness the therapeutic value of muscle atrophy, denervation, and relaxation afforded by BoNT, clinicians have injected the agent into the anterior and middle scalenes and the pectoralis minor to provide patients with relief from TOS. 24 This treatment requires advanced imaging with either fluoroscopy or ultrasound guidance for correct placement and knowledge of surrounding anatomy.…”