Cervical rib syndrome

Cervical rib syndrome and its clinical importance

1. DEPARTMENT OF GENERAL SURGERY Cervical Rib Syndrome Dr. Prabhu Dayal Sinwar Assistant Professor

2. Cervical Rib Syndrome Scalene space, inter-scalene triangle clavicle, first rib, ant. & middle scalene muscles Thoracic outlet syndrome Cervical rib syndrome Scalenus anticus syndrome Costo-clavicular syndrome Hyper abduction syndrome

3. Thoracic Outlet Syndrome Thoracic outlet syndrome results from compression of the subclavian vessels and brachial plexus. Patients may complain of neck and shoulder pain with numbness and tingling in the upper extremity. The ulnar side is typically involved. Using the extremity in an overhead or elevated position is difficult.

4. TOS - Anatomy

5. TOS - Definition Adson first described his maneuver in 1927 Thoracic Outlet Syndrome first coined in 1956 Upper extremity symptoms due to compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle. Etiologies include congenital bony structures, fibromuscular abnormalities, posture, certain movements, trauma

6. TOS - Epidemiology 3 to 80 cases per 1000 Ages 20-40 Women > Men (4:1) Neurogenic TOS (90%) > Venous TOS > Arterial TOS (<1%) Cervical ribs occur in < 1% of population 70% women

7. TOS – Differential Diagnosis Cervical disc disease Cervical facet disease Malignancies ( Pancoast /local tumors, spinal cord tumors) Peripheral nerve entrapments (ulnar or median nerve) Brachial plexitis Rotator cuff injuries Fibromyalgia, muscle spasm Neurologic disorders (MS) Chest pain, angina Vasculitis Vasospastic disorder ( Raynaud’s ) Neuropathic syndromes of upper extremity

8. The 3 sites of compression Interscalene triangle Costoclavicular space Sub-coracoid tunnel

9. Brachial plexus

10. (I). Neurogenic TOS Traction & compression: C8, T1 nerve root(lower trunk) Pain , paresthesia, and weakness in the hand, arm and shoulder ( median & ulnar nerve dermatome) , plus neck pain and occipital headaches. Raynaud’s phenomenon, hand coldness and color changes are also seen frequently in NTOS

11. (II). Venous TOS Swelling of the arm, plus cyanosis is strong evidence of subclavian vein obstruction Pain often present, but may be absent Arm swelling distinguishes VTOS from ATOS and NTOS

12. (III). Arterial TOS Digital ischemia, claudication, pallor, coldness, paresthesia and pain in the hand (but rarely in the shoulder/neck) Symptoms are a result of arterial emboli from a mural thrombus in a subclavian artery aneurysm or from thrombus forming distal to subclavian artery stenosis

13. TOS – Physical Exam Provocative tests I. Adson’s test / scalane test II. Roos test/ Arm claudication test III. Costoclavicular test/ military position IV. Wright’s Hyperabduction Test

14. I. Adson’s test/ scalene test Sitting position, feel for radial pulse Patient extends neck, rotate head towards testing arm, p atient takes a deep breath D isappearance of radial pulse is positive sign. Structures Affected: Compression of the vascular component of the neurovascular bundle (subclavian artery) by one of the following: Spastic or hypertrophied scalenus anterior muscle Cervical rib Mass such as a Pancoast tumor .

15. II. Roos ’ Test/ Arm claudication test Sitting/standing position, shoulders bilaterally abducted to 90 ° and externally rotated, flexes the elbows at 90° Open and close hands 15 times / 3 min. Fatigue, heaviness/weakness in arm, cramping and/or paraesthesia / tingling in hand positive signs

16. ROOS TEST

17. III. Costoclavicular Test/ Military Position Procedure: Patient seated – establish radial pulse. Patient force shoulders posterior and flex chin to chest. Positive Test: Decrease or absence of the radial pulse. Paresthesias or radiculopathy in the upper extremity.

18. Costoclavicular Test

19. IV. Wright’s Hyperabduction Test Procedure: Patient seated – establish radial pulse. Hyperabduct the arm and take the pulse again. Positive Test: Decrease or absence of the radial pulse. Structures Affected: Compression of the axillary artery by a spastic or hypertophied pectoralis minor muscle or a deformed or hypertrophied coracoid process.

20. Wright’s Hyperabduction Test

21. TOS – Diagnostic Testing Neck or chest x-ray Detects cervical rib or elongated C7 transverse process EMG/NCS Normal in large majority of clinically + ve NTOS Most common finding in NTOS is ulnar neuropathy Recent study suggests NCV abnormalities of the sensory medial antebrachial cutaneous nerve are seen in NTOS MRI/CT Venography /venous duplex VTOS Arteriography Only indicated in ATOS

22. TOS – Treatment Conservative Management Massage, hydrotherapy and Physiotherapy Behavioral modification/avoidance of provocative activities Physiotherapy to strengthen muscles of the pectoral girdle and restore normal posture Improvement: 50-90%

23. TOS – Treatment Definitive management Surgical decompression of the neurovascular bundle First rib resection Scalenectomy = Division of scalenus anticus and medius Subclavian artery reconstruction = for large aneurysm and thrombosis

24. THANKS