Welcome to the July 2012 edition of Case Studies from the files of the Institute for Nerve Medicine in Santa Monica, California.

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Welcome to the July 2012 edition of Case Studies from the files of the Institute for Nerve Medicine in Santa Monica, California.

In this issue, we focus on a 23-year-old female patient referred by her plastic surgeon for consultation and possible treatment. The patient recently completed surgery for breast augmentation, and shortly thereafter, experienced pain symptoms.

She initially presented to her plastic surgeon with concerns about possible injury. Following general post-operative exams, she was relieved to find that this is likely not the issue. Now that her surgery global period is complete, her plastic surgeon would like to obtain more information about the pain symptoms.

Our case study patient presents with symptoms of neck stiffness and pain as well as headaches and bilateral shoulder pain, upper back pain, stiffness and weakness in her arms, weakness in the hands, phantom chest pains and cold hands. She notes that the symptoms began when she underwent a breast augmentation procedure 15 months ago, and they have progressively gotten worse over the past month.

She has recently received acupuncture, physical therapy, and chiropractic treatment, which gave her some minimal benefit. In the past two months the patient has also been followed by a pain doctor who suggested for the first time that she may have thoracic outlet syndrome.

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compression syndrome of both upper extremities — with the findings more severe on the right than the left.

However, to date she has not undergone a full neurological evaluation. Even more interesting, she has never received a breast exam or mammogram — not even prior to the breast

augmentation procedure.

Because we want to rule out general risk factors and have a comprehensive record file for review, the patient is encouraged to contact her primary care physician for breast examination and possible mammogram prior to her consult with Dr. Aaron G. Filler, medical director of the Institute for Nerve Medicine. The patient brings the results with her to her appointment;

fortunately, they are all negative.

At the appointment with Dr. Filler, she notes her symptoms are usually more severe on the right. She gets numbness into both fifth digits in the hands. She notes hand weakness with grip strength and arm weakness when carrying things. Overall, the symptoms seem to be getting worse. Throughout the various courses of treatment, she has continued to have these upper extremity symptoms and rates her pain at 7 out of 10 with symptoms being largely aggravated whenever she is lifting objects.

Following a specialized neurological exam, it does seem convincing that this is indeed thoracic outlet syndrome. She has a positive Adson's Maneuver. She has tenderness to palpation, and neurologic symptoms with percussion and palpation over the scalene muscles. She has hand symptoms dominated by a fifth-digit numbness and hand-intrinsic symptoms without any evidence of cubital tunnel entrapment.

Trigger point injections, CT guided or Fluroscopy injections would be the insurance-prescribed next step. However, these types of X-ray based injections carry an inherent risk of complication due to lack of soft tissue visualization, so we plan to carry out an Open MR Guided injection procedure.

With her plastic surgeon on hand to view the procedure, the patient is brought to the Open MR Surgical Suite and placed in a supine position. A series of localizing images are obtained.

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anterior and middle scalene muscles (as well as to the area of the distal plexus), these image slices are mapped out onto the skin surface.

X and Y coordinates for the entry point(s) and the target(s) are determined and the trajectory is assessed using the Opti-Guide system.

A titanium interventional device is then introduced and advanced gradually first into the area of the distal plexus. Once a good location is achieved, the introduction of treatment agents is commenced and the device is then withdrawn.

A week following the Open MR Guided procedure, the patient is relieved to find that her pain symptoms have been alleviated for the most part. She does continue to experience infrequent pain symptoms when lifting or carrying objects but she is also continuing to work with a fitness trainer in addition to a physical therapist so that her core muscles become better developed.

The patient expressed great satisfaction with the Open MR procedure, and her plastic surgeon is pleased with the outcome — particularly that it was not related to his procedure, but instead a confirmed diagnosis for thoracic outlet syndrome symptom. And best of all, she responded very well to an injection into the scalene muscles.

Patients who have had implants are especially vulnerable to injection complications, especially if the imaging guidance system is not accurate. In addition to possible puncture of the implant, there is also the possibility of nicking a nearby nerve branch or scraping an adjacent soft tissue.

Only magnetic resonance imaging can provide real time optical guidance of the target location, taking the guess work out of the procedure and minimizing the overall risk to the patient.

To learn more about open MRI guided interventional procedures, please visit www.imagebase

dsurgery.com or

contact our office at 310-314-6410 between 9AM and 5PM, Monday-Friday, to schedule a telephone consult for referral.

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MR Neurography images from this case study are found below; click any image for a larger view

In this view, we see a short segment of thoraco-dorsal nerve irritation.

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In this view, we see the surgeon's finger locating the anterior chest wall pain during the OMR

procedure.

In this view, we see the surgeon's finger locating the thoraco-dorsal nerve for pain during the

OMR procedure.

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