cervical rib
Post on 07-Apr-2015
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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
exerciseRelieved 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 Hyperabduction test Roos test
Decreased radial pulse
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 END
SCALENUS ANTERIOR
LOWER TRUNK OF BRACHIAL PLEXUS
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
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