Abnormal Anatomical Etiology and the Resultant Bilateral Thoracic Outlet Syndrome: An Exploration Case Report

Abstract

HISTORY: 32-year-old healthy female presented to the vascular surgeon for right arm pain (pn) and a hand tremor. She was a mesomorph with forward head posture and was a volleyball athlete and triathlete. PHYSICAL EXAMINATION: Patient reported years of pn and disfunction with no mechanism of injury. Symptoms began as stabbing pn 8/10 along right ulnar and radial nerves. Pn increased when the arms were unsupported. Right hand tremor increased with ADLs, and arm above 100 degrees. Feeling of heaviness and tingling in the arms impaired sleep and decreased effective grasping of objects causing patient to often drop things. Left arm pn 6/10 in trapezius, radiated to the forearm. Trapezius felt as if it needed to be stretched, but stretching increased pn 7/10. Pn was felt in the jaw and teeth 5/10 and the ear had a “cloudy” sensation. Patient had three root canals yet the facial pn persisted. DIFFERENTIAL DIAGNOSIS: Paget-Schroetter syndrome Rotator Cuff injury Multiple Sclerosis TEST AND RESULTS: MRA right shoulder: -Labrum tear, infraspinatus atrophy, rotator cuff tear. Suprascapular nerve laceration with maximal involvement of infraspinatus MRI c-spine: -Minor arthrosis, slightly desiccated discs with no bulging at C5-C6 X-ray c-spine: -No cervical ribs or narrow facets MRI brain: -No multiple sclerosis Electromyography: -Infraspinatus atrophy Special Tests - Adson, Allen, Military Brace: -Absent bilateral pulse DASH score: -Significant ADL impairment Lidocaine muscle block, scalenes and right pec minor: -Patient reported 50% decrease in pn MRI bilateral brachial plexus: -Post-surgical edema, asymmetrically large right jugular vein, pec minor and subclavian muscle atrophy with scarring at SC joint. Brachial plexus matted in scalene compartment; left side normal FINAL/WORKING DIAGNOSIS: Bilateral TOS with right pec minor impingement TREATMENT AND OUTCOMES: 1. Sx 1: Subtotal resection of subclavius, scalenes, resection of scalene minimus, division of pec minor, brachial plexus neurolysis, and subclavian artery lysis 2. Sx 2: Subtotal resection of subclavius, scalenes, brachial plexus neurolysis, and subclavian artery lysis 3. Sx 3: Scalenectomy of right scalenes and scar tissue removal 4. Paralyzed right diaphragm from surgery complication 5. Patient reports 75% improvement on right, 90% improvement on left.