Abstract
Currently, notalgia paresthetica (NP) is a poorly-understood condition diagnosed on the basis of pruritus, pain, or both, in the area medial to the scapula and lateral to the thoracic spine. It has been proposed that NP is caused by degenerative changes to the T2-T6 vertebrae, genetic disposition, or nerve entrapment of the posterior rami of spinal nerves arising at T2-T6. Despite considerable research, the etiology of NP remains unclear, and a multitude of different treatment modalities have correspondingly met with varying degrees of success. Here we demonstrate that NP can be caused by long thoracic nerve injury leading to serratus anterior dysfunction, and that electrical muscle stimulation (EMS) of the serratus anterior can successfully and conservatively treat NP. In four cases of NP with known injury to the long thoracic nerve we performed transcutaneous EMS to the serratus anterior in an area far lateral to the site of pain and pruritus, resulting in significant and rapid pain relief. These findings are the first to identify long thoracic nerve injury as a cause for notalgia paresthetica and electrical muscle stimulation of the serratus anterior as a possible treatment, and we discuss the implications of these findings on better diagnosing and treating notalgia paresthetica.
Highlights
Notalgia paresthetica (NP) is a poorly-understood condition presenting with pruritus, pain, and paresthesias in an area medial to the scapula and lateral to the thoracic spine
Previous authors have postulated the causes of NP include nerve entrapment of the posterior rami of spinal nerves arising at T2-T6 [3,4,5,6], degenerative changes to the corresponding vertebrae [7], and possible involvement of a hereditary component [8]
Future work We describe a novel and well-defined etiology of long thoracic nerve injury with consequent serratus anterior dysfunction in notalgia paresthetica, and electrical muscle stimulation (EMS) of the serratus anterior as a long-acting and effective treatment conferring the advantage of a once-daily treatment regimen
Summary
Notalgia paresthetica (NP) is a poorly-understood condition presenting with pruritus, pain, and paresthesias in an area medial to the scapula and lateral to the thoracic spine. Traction on these nerves would be expected to refer pain to the area between the scapula and the spine, the region of symptoms in NP This hypothesis would explain 1) the finding of long thoracic nerve and serratus anterior dysfunction in patients presenting with pain medial to the scapula; 2) the finding that the pain was exacerbated by activities with the arm flexed in front of the body, which loads the serratus; 3) the loss of temperature sensation in the area of pain medial to the scapular edge; 4) analgesia medial to the scapula in response to muscle stimulation of the much more lateral serratus; and 5) previous reports of the efficacy of antineuropathic pain medications such as gabapentin [18] and oxcarbazepine [19]. We note that future studies of notalgia paresthetica would benefit immensely from a multidisciplinary approach integrating the expertise of dermatologists, neurologists, orthopedic surgeons, and pain management specialists
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