Thoracic Outlet Syndrome Managed With Botulinum Toxin Injection Following Multiple Failed Surgeries

Thoracic outlet syndrome is caused by compression of the neurovascular structures as they pass through the thoracic outlet and may present with pain, weakness, numbness, and paresthesias. Neurogenic thoracic outlet syndrome is the most common subtype and can be difficult to manage in patients with persistent symptoms despite conservative therapy and surgery. We present the case of a female patient in her 20s with post-traumatic neurogenic thoracic outlet syndrome following a motor vehicle accident, who continued to experience persistent pain and neurologic symptoms despite multiple surgical interventions, including first rib resection, scalenectomy, pectoralis minor tenotomy, and brachial plexus neurolysis. After recurrence of symptoms and failure of repeat surgical management, the patient underwent CT-guided botulinum toxin injection into the left pectoralis minor muscle following a successful diagnostic block. On follow-up, she reported approximately 60% improvement in pain, paresthesia, dysesthesia, grip strength, and daily functioning. Clinical improvement began approximately one week after the injection, was sustained for approximately six to seven months, and occurred without procedural complications. This case highlights the potential role of botulinum toxin injection as a minimally invasive therapeutic option in refractory neurogenic thoracic outlet syndrome, even after failed surgical treatment.