ID:15924 Successful Treatment of T4 Syndrome With Thoracic Sympathetic Nerve Block: A Medically Complex Case

Abstract

33-year-old man was referred for 10+ year history of intermittent right sided thoracic back pain, scapular stiffness and muscle spasms, as well as proximal right upper extremity pain. Pain described as spasms, throbbing, shooting, punishing and exhausting that lasts for days and occurs multiple times per week. Pain intensity was 6-8/10 on the numerical pain rating scale (NRS). Exercise exacerbates his symptoms. The patient failed previous conservative treatments and alternative therapies. No improvement with pain medications or previous interventional treatment including thoracic medial branch blocks and prolotherapy. Exam notable for tightness with radiation of the posterior shoulder girdle (between the thoracic spine and medial border of scapula), right biceps and into the first and second digits. Diagnostic testing including radiographs and CT were normal, ruling out musculoskeletal abnormalities. Cervical MRI demonstrated mild degenerative disc disease at C4-7, however thoracic MRI was within normal limits ruling out degenerative or discogenic etiology. EMG nerve conduction study was normal eliminating potential long thoracic nerve syndrome. After thorough evaluation and failing physical therapy costotransverse dysfunction was ruled out. Suspecting T4 syndrome, the patient underwent a diagnostic and therapeutic right T2 thoracic sympathetic block under fluoroscopic guidance.