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Neurogenic PMS Treatment
Treatment for Neurogenic PMS is extremely similar to that of NTOS especially since they often coexist and are treated simultaneously. To read the full description for treatment of NTOS, click here. The main differences in the treatment options between NPMS and NTOS are outlined below, and they mainly apply only when a patient is solely being treated for NPMS.
CONSERVATIVE TREATMENT (NON-SURGICAL)
Activity Modification
Please click here to go to the NTOS treatment page to see an overview of activity modifications. The types of activities that aggravate NTOS tend to also aggravate NPMS.
Medications
Please click here to go to the NTOS treatment page to see a comprehensive overview of the medications which can be helpful.
Physical Therapy (PT)
Please click here to go to the NTOS treatment page to see a comprehensive overview of the PT options and factors that can impact its success particularly since most patients are dealing with NTOS and NPMS at the same time.
PT is one of the mainstays of NPMS treatment. It is often the first course of treatment right after initial diagnosis. PT for NPMS (like NTOS) is much different than PT for other shoulder/arm conditions. Therefore, PT should be with a therapist who has experience with or knowledge of NPMS. This is often very difficult to find as most therapists do not have NPMS experience. However, if the wrong kind of PT is done for NPMS, it can increase symptoms and even cause additional damage to the nerves. For this reason, initial PT is usually attempted for 4-8 weeks with physician follow up and assessment after that time period. If symptoms are worsening and causing significant issues before the end of that time period, it is best to consult with a physician right away. PT for NPMS is usually aimed at the following:
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Upper back muscle rebalancing
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Shoulder blade mobility and mechanics
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Diaphragmatic breathing
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Pec minor muscle relaxation and gentle stretching
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Posture improvement
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Tools to assist with symptoms during activities of daily living i.e. driving, computer work, sleeping
Most TOS specialists have a PT protocol that can be given to the patient’s PT if the PT is not very familiar with NPMS. PT will not necessarily work for everyone with NPMS. It is not uncommon for even the right type of PT to worsen symptoms in NPMS patients including to the point of being intolerable especially in those with longstanding compression. Some TOS experts believe that PT for NPMS is more beneficial after surgical treatment of any coexisting NTOS. Therefore, according to these experts, some patients who have both conditions might not be able to make progress on treating NPMS with PT until the NTOS has been treated.
The success of PT is heavily based on the patient’s view of the situation and whether they feel that the level of relief obtained in comparison to the level of time and effort required to manage the condition is worth it. Each patient’s situation is unique, including which type of therapy helps to manage their condition. Conventional PT is what is most commonly used for treating NPMS. However, some patients find relief in unconventional methods such as Active Release Technique (ART), Feldenkrais, or aquatic therapy.
Botox Injections
Botox is made from botulinum toxin which is the toxin that causes the disease botulism. Used in very small doses, it cannot cause botulism. Most people are familiar with Botox as used for cosmetic purposes to reduce the look of lines and wrinkles on the face. Botox works for that purpose because it temporarily paralyzes muscles into which it is injected. In addition to its cosmetic use, it is also used to treat certain medical conditions. The way it works for treating NPMS is that Botox injected into the pec minor muscle interrupts the muscle spasm and therefore decompresses the nerves resulting in symptom relief. It is not a permanent resolution for NPMS because Botox only stays active for so long and can only be injected every 3 months. Botox injections are usually done by a pain management doctor, interventional radiologist, or physiatrist under ultrasound or other imaging guidance. Following injection, it can take 2-4 weeks for the Botox to kick in and for relief to be felt. Not everyone responds to Botox, so there are some patients who do not get any relief from it. The time range for which the Botox remains active and effective is different for each patient. There are patients who get significant relief only for a few weeks and there are some who get significant relief for 2-3 months and, therefore, get injections repeated every 3 months. Some specialists believe that, although Botox itself is not a permanent fix for NPMS, PT can more easily be done during the time that the Botox is active and thus longer-term relief can be achieved. There are also patients whose bodies can develop an antibody to the Botox the more often injections are done and thus, over time, the Botox becomes less and less effective. Botox is not FDA approved to treat NPMS, so most insurance will not cover the cost of it. It can be quite expensive, so checking with the ordering provider and the patient’s health insurance company is well advised. There is also a Botox savings program that will reimburse patients who qualify.
Other Miscellaneous Treatment Options
Please click here to go to the NTOS treatment page to see a comprehensive overview of the various miscellaneous treatment options.
SURGICAL TREATMENT
In contrast to NTOS, in a patient who appears to be dealing solely with NPMS, surgery might more readily be offered given that the surgery for it is relatively minor compared to surgery for NTOS. However, it is still being performed in an area of the body where vital vessels and nerves are packed in tightly, so it is not a surgery without risk. With a surgeon who is not experienced in TOS surgery, damage to vital vessels and to nerves that serve the arm and hand can occur and can be devastating. Therefore, of the surgeons available to a patient, it is recommended to choose the surgeon who has the highest level of TOS experience possible. There are very few dedicated TOS centers in the United States and even fewer throughout the rest of the world. Because of this, many patients must travel to other states or other countries for experienced care. However, choosing a highly experienced TOS surgeon gives the patient the highest chance for a successful outcome and the lowest chance for serious complications. Under these circumstances, TOS surgery can be very safe and successful. For help finding a TOS surgeon, click here.
What does surgery for NPMS entail?
In general terms, NPMS surgery is often referred to as subcoracoid decompression surgery as it involves altering anatomical structures and removing scar tissue in order to decompress the nerves. NPMS surgery typically includes:
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Release of the pec minor muscle known as Pec Minor Tenotomy
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Removal of scar tissue from around the nerves known as Brachial Plexus Neurolysis
Most TOS experts will perform NPMS surgery at the same time as NTOS surgery. For a comprehensive overview of what NTOS surgery entails, please click here. Other experts prefer to perform NTOS surgery first and wait to see if NPMS surgery is needed later down the road. However, in a patient who is believed to have NPMS without NTOS, the surgery can be performed as a standalone procedure. In this case, it is almost always outpatient surgery. Below is a detailed description of each surgical component:
Release of the pec minor muscle known as Pec Minor Tenotomy the pec minor muscle heads fuse into a tendon where it attaches to the front of the shoulder blade at the coracoid process. To release the pec minor muscle, the tendon is cut all the way through so that it is no longer attached to the front of the shoulder. Some surgeons will also remove a small portion of the muscle after releasing it. Otherwise, the majority of the muscle remains but retracts downward and will reattach to the chest wall.
Removal of scar tissue from around the nerves known as Brachial Plexus Neurolysis removing scar tissue in this area is different from removing it during NTOS surgery as the actual nerve roots are not being dealt with. After releasing the pec minor muscle, most TOS experts will remove any scar tissue seen around the brachial plexus nerves which are in the vicinity of the pec minor area.
As with any surgery, the decision to have surgery and which components should be included in said surgery should be made based on advice given by the patient’s surgeon as to what is best for their specific clinical situation.
NPMS Surgery Recovery
Because NPMS surgery is often performed at the same time as NTOS surgery, please click here to go to the NTOS treatment page to see a comprehensive overview of NTOS surgery recovery.
In general, recovery from NPMS surgery as an isolated procedure is much easier and much more predictable than NTOS surgery. Although, as with any surgery, it is different for each patient, and it still involves the brachial plexus nerves which can be challenging during recovery.
As with NTOS surgery, following NPMS decompression surgery, the nerves will be decompressed, but this does not mean that they are healed. They still need to heal from the damage sustained from the compression and from any manipulation or scar tissue removal done during surgery. Occasionally, patients will experience pain and symptoms that are temporarily worse than before surgery which is normal. Below is a list of potential expectations following NPMS surgery keeping in mind that every recovery is different and not everyone will experience the things listed.
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can include original symptoms the patient had pre-op in addition to new symptoms caused by the surgery
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some will have pre-op symptoms that are temporarily worse than before surgery
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some will have new symptoms that can be felt in the shoulder, arm, or hand
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new symptoms from surgery can include numbness, tingling, pain, burning, skin hypersensitivity, itching, stinging, electrical zaps, cold sensations, hot sensations, skin color and temperature changes, or muscle twitching, although these are not as common as they are after NTOS surgery
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Most return to work within 1-2 weeks
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Most do not have any restrictions or activity limitations
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Most are fully healed in 3-4 weeks
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PT is not usually needed
Return of Symptoms (Recurrent TOS)
Sometimes a patient will experience initial relief and then have symptoms return. The three most likely causes for a recurrence of symptoms are:
Complete decompression not achieved during surgery this would occur if some of the pec minor muscle was left attached to the coracoid process and not completely released.
Reattachment near the nerves following pec minor release surgery, the remaining muscle retracts downward and will eventually reattach to the chest wall lower down and out of the range of the nerves. Rarely, the muscle remnant reattaches to the chest wall in a location that is too close to the nerves and can compress them again.
Scar tissue formation around the nerves this is most likely to occur within the first 1-2 years post op. It can occur from the patient overusing the nerves too much too soon while they are still healing. It can also form if a secondary injury occurs such as a fall or a car accident or any injury to the chest, shoulder, or arm. The injury can reignite the healing process within the surgical field and an overgrowth of scar tissue can occur. It can also form in those patients who have a genetic predisposition to make a lot of scar tissue.
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