Disclosures: Nicholas E. Peterson, MD: No financial relationships or conflicts of interest

Case Diagnosis: Management of venous thoracic outlet syndrome, with unique vestibular symptoms, by ultrasound guided injections.

Case Description: A 42 year old male with history of upper extremity paresthesia presented with dizziness of 18 months. Reported constant mild dizziness with paroxysmal severe vertigo exacerbated by changes in neck position and upper extremity activities. Reported periodic tinnitus and ocular headaches during severe episodes. No longer driving due to symptoms. He was a boxer with trauma to head, neck and chest. Nerve conduction studies and EMG performed were normal; ultrasound of neck showed decreased flow in right internal jugular and bilateral subclavian veins with thoracic outlet syndrome proactive maneuvers. Patient failed conservative physical therapy with range of motion exercises and release maneuvers.

Setting: Sports spine clinicAssessment/

Results: Patient underwent bilateral lidocaine injections to the sternocleidomastoid and anterior scalene muscles. He had immediate improvement of dizziness and return of symptoms over the next 24 hours. He underwent subsequent Botox injections of these muscles with lasting significant improvement of his symptoms. He returned to driving.

Discussion: Ultrasound guided injections for neurogenic thoracic outlet syndrome (nTOS) is well documented. Venous TOS (vTOS), however, is rare and associated vestibular symptoms are not well documented. We present case series of 10 individuals with vTOS and vestibular symptoms that improved after diagnostic injection of lidocaine with subsequent Botox injections.

Conclusion: TOS is an uncommon cause of upper extremity pain and paresthesia with only approximately 5% venous etiology. Given this rarity additional symptoms specific to venous etiology are less documented. Evaluation of patients with vestibular symptoms can be difficult given non-specific findings. In patients presenting with upper extremity paresthesia and vestibular symptoms, vTOS should be considered with possible referral for diagnostic and therapeutic injections. As physiatrist, we are well trained to handle participate within the interdisciplinary care of this patient population and should advocate and educate for these referrals.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/treatment-of-venous-thoracic-outlet-syndrome-with-unique-vestibular-symptoms-by-ultrasound-guided-injections/