CASE OF THORACIC

OUTLET SYNDROME
– CERVICAL RIB

PRESENTED AND DISCUSSED BY :

DR PRAVEEN C.R
 Case history
 16 year old girl
 Chief complaints :
 Pain left arm on elevation - 6 months
 Pain – arm ,crampy ,increase with
exercise
 Relieved on lowering the arm
 No h/o bluish discoloration of fingers
 No h/o weakness of arm or hand
 No accentuation of these symptoms with
cold
 No h/o of swelling of the upper limb
 No paraesthesia / numbness in fingers or
hand
On examination
 Bilateral bony supraclavicular mass
suggestive of cervical rib
 Diagnosis -- provocative tests

 Adson test
 Costoclavicular test Decreased
radial
 Hyperabduction test
pulse
 Roos test
Diagnostic imaging
 Plain chest X-Ray
Doppler flowmetry
CT ANGIOGRAM
 Diagnosis :

 Thoracic outlet syndrome with bilateral

cervical Rib with effort related vascular
compromise on left side
 TREATMENT
 Initially conservative treatment tried for 6
weeks
 Meanwhile the relevant investigations were
carried out
 No improvement in symptoms
 Extra periosteal resection of the left cervical
rib by Supraclavicular approach done on
 30 / 05 /05
CRANIAL END

PHRENIC
NERVE
TAPED
 CRANIAL LOWER
TRUNK OF
END BRACHIAL
PLEXUS

SCALENUS
ANTERIOR

SUBCLAVIAN
ARTERY
CERVICAL RIB
POINTED
 POST EXCISION OF
THE CERVICAL RIB

SUBCLAVIAN
ARTERY
DISCUSSION

 Thoracic outlet obstruction

 Obstruction of the subclavian artery or vein and
pressure on the lower trunk of the brachial
plexus
 best recognized being a cervical rib
 The first successful removal of a cervical rib
was undertaken by Coote in 1861.
 predominantly vascular or predominantly
neurological.
 costoclavicular syndrome, scalenus anticus
syndrome, and hyperabduction syndrome
 Etiology:
 I. Anatomic Factors
· Interscalene compression
· Costoclavicular compression
· Subcoracoid compression
 II. Congenital Factors
· Cervical rib
· Rudimentary first rib
· Scalene muscle abnormalities
· Fibrous bands
· Bifid clavicle
· First rib exostosis
· Enlarged C7 transverse process
·
 Etiology( contd)
 III. Traumatic Factors
· Fractured clavicle
· Humeral head dislocation
· Upper thorax crush injury
· Sudden effort of shoulder girdle muscles
· C-spine injuries/cervical spondylosis
 IV. Atherosclerosis
 Epidemiology:

 Variable prevalence: 0.5% to 1% of

population has cervical rib, usually
asymptomatic
 Rare in patients less than 20 years old
 Female>Male, 3.5:1
 Diagnosis of TOS controversial
ANATOMY
CLINICAL PRESENTATION
 women, usually between the ages of 20 and
40.
 CLINICAL PRESENTATION(Contd)

A.Neurogenic
· More frequent than vascular
· Pain and paresthesias- 95%
patients
· True motor weakness in 10%
· Sensory nerve bundles first to be
affected ulnar nerve distribution
· Strenuous physical exercise
preciptates the symptoms,
 Vascular

.·Pain usually diffuse and associated with

weakness and easy fatiguability
· Unilateral Raynaud's phenomonen in
about 7.5% of patients,
· There may be signs of distal
embolization
poststenotic dilation or aneurysm of the
subclavian artery, or true arterial
occlusion
·
Venous obstruction
 uncommon presentation
 thrombosis or intermittent swelling of
the arm.
 sports - surf board riding or butterfly
swimming.
 known as "effort thrombosis" or
"Paget-Schroetter syndrome"
·
Diagnosis

 A. Clinical maneuvers
 B. Radiologic tests
Radiologic tests
 Plain films or CT of cervical spine and chest
 MRI -- assess soft tissue of thoracic outlet
 Venography -- r/o Paget-Schrotter syndrome
 Doppler flowmetry -- assessment of vascular
involvement
 Neurography
 Intravascular ultrosonography
 Arteriography
 MRA
Differential Diagnosis
 herniated cervical disk
 cervical spondylosis
 peripheral neuropathies
 Treatment
 · Physical therapy
 Elevate shoulder
 Rest on arm of chair
 Sling
 Pendulum shoulder exercises
 Strengthening exercises for shoulder girdle muscles
 Trapezius Muscle
 Shoulder shrug with weight
 Serratus anterior
 Bench Press, lifting shoulders from table
 Correct faulty posture
 Avoid positions that exacerbate symptoms
Surgery

 Indications
 muscle wasting
 progressive sensory loss
 unrelenting pain
 worsening vascular impairment
Procedures of choice

 Supraclavicular approach
 Infraclavicular approach
 Posterior approach
 Transaxillary approach
 Intraoperative exploration for congenital bands
of fibrous tissue
Postsurgical recurrence of TOS

 2-30% after rib resection, typically secondary

to significant scarring
 Outcome best in patients with occupations not
requiring labor
 Worst outcomes in obese patients and
patients with other nerve entrapments in
affected arm
 About 1-2% of patients will have persistent or
progressively more severe symptoms after their
operation
· Most have recurrence within 3 months of
operation
· Symptoms, physical examination, and UNCV
findings should be diagnostic before reoperation
· of patients; 7% require a second reoperation
 RECURRENCE
 Pseudorecurrence
 True recurrence
· The posterior thoracoplasty approach provides
the best exposure
· Persistent or recurrent bony remnants should be
excised
· Careful neurolysis of the nerve root and brachial
plexus is performed along with dorsal
sympathectomy
· One series of over 400 patients had
improvement in symptoms in about 80% of
patients; 7% required a second reoperation
Thank you