Mu receptor agonists are minimally effective in controlling the chronic pain of TOS, producing a generalized numbness, but little amelioration of the more intense symptoms. This is characteristic of neuropathic/neurogenic disorders [16]. Interestingly, nalbuphine, a kappa and sigma agonist, is consistently more effective and has minimal side effects.


Octreotide, a somatostatin analog which quickly down regulates neuropeptide production (SubP, CGRP, VIP, etc.}, is effective during early flare-ups, corroborating the importance of neurogenic peptides in initiating symptoms [17]. Octreotide labeled positron emission tomography is a potential diagnostic method because of its ability to image localized neurogenic inflammation.

Topical nitroglycerin can lessen pain significantly, more so than opiates. This points to the importance of endothelial factors that are nitric oxide mediated as well as the importance of vascular integrity [18].


Substantiating the importance of TNF-alpha, a major cytokine of mast cells, Etanercept, a TNF-alpha blocker, eliminates the diffuse and spreading pain accompanying flare ups (personal communication) [19].

More dramatically, low-dose heparin produces relief, lasting weeks to months. Heparin is a complicated mix of glycose aminoglycans with pleiotropic functions

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