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Pain Management in Neurogenic Thoracic Outlet Syndrome – Pharmacologic Strategies

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Thoracic Outlet Syndrome

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Abstract

The diagnosis and management of thoracic outlet syndrome (TOS) is challenging and controversial. The symptoms seen in TOS patients depend on which structures are affected in the thoracic outlet. The most common form of TOS is the neurogenic TOS (NTOS), which frequently can cause neuropathic pain (NP). Treatment strategies for NTOS patients include minimally invasive therapies, muscle relaxants, anti-inflammatories and analgesics, trigger point injections or surgery. Treatment for NP will also include medications that target peripheral and central nerves or different cytokines affecting the sensitivity of sensory neurons to painful stimuli. The pharmacological treatment is challenging and patients often need to be treated with more than just one medication. Antidepressants, ­alpha-2-delta calcium-channel ligands, and topical lidocaine are considered as first-line treatments for NP in recent evidence-based recommendations. Tricyclic antidepressants (TCA) are established to be efficacious for several different types of NP and the antidepressant effect may be beneficial, because depression is a common concomitant disease in patients with chronic pain. Selective serotonin reuptake inhibitors are better tolerated than TCA’s, they are superior to placebo, but show only a weak ­analgetic effect. Anticonvulsants are a further important group. Carbamazepine, a sodium-channel blocker, has shown efficacy in the treatment of some forms of NP. Gabapentin is approved by the U.S. Food and Drug Administration for the treatment of postherpetic neuralgia (PHN). The pain relieving effects of pregabalin have been demonstrated in ­randomized controlled trials. Lidocaine patches are used as supplemental therapy. The benefits of opioids have been proven in RCT’s in central and peripheral NP. Pharmacological treatment of NP associated with TOS is challenging. Combination therapy appears useful and pain relief in NP patients is often achieved at the expense of unwanted systemic side effects. Clinical trials looking at pharmacological treatment of NP in patients with NTOS are lacking.

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Author information

Authors and Affiliations

  1. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Center for Pain Medicine, Boston, MA, 02114, USA

    Marta J. Rozanski MD, Christopher Gilligan BA, MPhil, MD, MBA & James P. Rathmell MD

Authors
  1. Marta J. Rozanski MD
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  2. Christopher Gilligan BA, MPhil, MD, MBA
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  3. James P. Rathmell MD
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Corresponding author

Correspondence to James P. Rathmell MD .

Editor information

Editors and Affiliations

  1. , Division of Vascular Surgery, University of South Florida, Tampa General Circle, STC 7016 2, Tampa, 33606, Florida, USA

    Karl A. Illig

  2. Barnes-Jewish Hospital, Department of Surgery, Washington University, Queeny Tower Campus Box, St. Louis, 63110, Missouri, USA

    Robert W. Thompson

  3. , Department of Surgery, John Hopkins Medical Institutions, Rutland Avenue - Ross 759 729, Baltimore, 21205, Maryland, USA

    Julie Ann Freischlag

  4. , Department of Thoracic Surgery, Blake 15, Massachusetts General Hospital, Fruit Street 55, Boston, 02114, Massachusetts, USA

    Dean M. Donahue

  5. Neurological Associates of West LA, Wilshire Blvd, Suite 790 2811, Santa Monica, 90403, California, USA

    Sheldon E. Jordan

  6. , Graduate Program in Physical Therapy, UCSF/SFSU, Balmoral Street 2429, Union City, 94587, California, USA

    Peter I. Edgelow

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© 2013 Springer-Verlag London

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Rozanski, M.J., Gilligan, C., Rathmell, J.P. (2013). Pain Management in Neurogenic Thoracic Outlet Syndrome – Pharmacologic Strategies. In: Illig, K., Thompson, R., Freischlag, J., Donahue, D., Jordan, S., Edgelow, P. (eds) Thoracic Outlet Syndrome. Springer, London. https://doi.org/10.1007/978-1-4471-4366-6_35

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  • DOI: https://doi.org/10.1007/978-1-4471-4366-6_35

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  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-4365-9

  • Online ISBN: 978-1-4471-4366-6

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