Spasticity / Movement Disorders
Swaramsi Katragadda, MD
Resident Physician
Northwestern Medicine Marianjoy Rehabilitation Hospital
Chicago, Illinois, United States
Bryan Lamb, MD
PM&R Attending Physician
Northwestern Medicine Marianjoy Rehabilitation Hospital
Wheaton, Illinois, United States
Swaramsi Katragadda, MD
Marianjoy Rehabilitation Hospital
Wheaton, Illinois, United States
34 year old male with history of right lung carcinoid tumor post resection presents to PM&R clinic with chronic right neck and shoulder pain.
Case Description: The patient complains of multiple year history of right sided neck and shoulder pain. He has a history of carcinoid tumor in the right lung managed through multiple surgeries between 2009-2019: tumor resection, followed by right upper lobe lung resection, followed by right 6th rib removal. He developed medial scapular winging after the final surgery and was diagnosed with long thoracic neuropathy. In addition to scapular winging, he developed neck pain and shoulder pain. By the time of presentation, the pain had persisted for 6 years. History and physical exam were notable for tightness and pulling sensation near the right neck, scapular winging, and tenderness over cervical muscles. He also had occipital headaches associated with right shoulder use. Previous treatments included physical therapy, trigger point injections, and medications: diclofenac, cyclobenzaprine, baclofen. The patient underwent botulinum toxin injections for suspicion of cervical dystonia (CD) and had improvement in pain and headaches.
Discussions: The history of pulling sensation and the association with headaches was suggestive of CD. Therefore, botulinum toxin injections were chosen as both a diagnostic and therapeutic tool. Injections went to the right upper trapezius, levator scapulae, and rhomboid major muscles. The patient reported his neck/shoulder pain and headaches were improved 1 week after injections and lasted 10 weeks. He also noted shoulder flexion weakness which resolved less than 2 weeks after injections. Although the patient suffered weakness briefly, he had greater quality of life and functioning with the reduction in headaches and pain.
Conclusions:
CD is often idiopathic. This case demonstrates a unique development of CD after complex upper thoracic surgeries and long thoracic neuropathy.
