Bilateral thoracic outlet syndrome: An uncommon presentation of a rare condition in children
A 13-year-old Caucasian girl, who was otherwise healthy, presented with intermittent swelling, erythema, tingling and numbness of the palmar aspect of her left hand. The nature of the pain was described as dull and shooting. These symptoms lasted for 7-10 days, even though regular analgesics were used.\nOn examination, the patient was found to be in excellent physical condition. Left hand pulses were easily felt. She had a slight functional limitation of her left hand grip due to pain and stiffness. The left hand was slightly cold to touch compared with the right hand. On examination, the patient was found to be in excellent physical condition. A positive Tinel test and elevated arm test was noted in the clinically affected arm. There was no asymmetry of clavicles noted. There was no muscle atrophy identified.\nIn view of these symptoms, neurovascular TOS was considered. X-ray of her cervical spine revealed an anomalous first rib that was fused to the second rib []. Magnetic resonance imaging of her brain, cervical spine and brachial plexus was normal. She also had a nerve conduction study, which interestingly revealed bilateral ulnar sensory and motor conduction abnormalities as well as early bilateral median sensory nerve conduction changes.\nIn view of the neuropathic nature of the intermittent pain, she was started on amitriptyline and gabapentin. This had a variable effect on her pain. Following a surgical opinion, a left-sided supraclavicular approach for exploration was undertaken. During the surgery, there was no apparent bony structure compressing the brachial plexus, nor was there any fibrous band. On moving the arm around, it was evident that the brachial plexus was entirely free. The scalenus anterior itself was impinging on the brachial plexus; hence, she underwent left anterior scalenectomy. She showed good response following the surgery. This was evident from the reduction of her symptoms of pain, swelling and tingling. Postoperative sensory and motor nerve conduction studies in the median and ulnar nerves were normal.