Pain Management in NTOS – Advanced Techniques

Abstract

When thoracic outlet syndrome (TOS) causes chronic neuropathic pain, or in rare cases causes complex regional pain syndrome (CRPS), a wide variety of advanced therapies can be used to treat the chronic, debilitating pain of neurogenic thoracic outlet syndrome (NTOS). Chronic pain treatment algorithms typically begin with less invasive, reversible therapies and those that have few side effects. Thus, physical therapy and non-narcotic medications are used first, often in conjunction with behavioral therapy. These may be followed by more potent analgesics, nerve blocks, neurostimulation, or medication infusions into the spinal fluid by implantable pumps, and finally by neuroablation. Unlike neuroablation, neurostimulation (spinal cord stimulation, peripheral nerve stimulation, deep brain stimulation, and motor cortex stimulation), intrathecal drug delivery, and ketamine infusions spare nerve tissue and can be reversed or discontinued if necessary. Consistent definitions of pain types by the International Association for the Study of Pain (IASP) have allowed indications for these therapies to be refined. Continuing elucidation of the anatomy, physiology, and psychology of pain, as well as recommendations for best practices, have been the focus of study by The North American Neuromodulation Society and the International Neuromodulation Society. A host of technical advances in equipment also support pain practitioners in managing the pain of NTOS more effectively.