Cervical rib syndrome and its clinical importance

1. Cervical Rib Syndrome
Dr. Prabhu Dayal Sinwar
Assistant Professor

2.  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 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.

7.  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

8.  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

9.  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

10.  Interscalene triangle
 Costoclavicular space
 Sub-coracoid tunnel

14.  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

15.  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

16.  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

17.  Provocative tests
 I. Adson’s test / scalane test
 II. Roos test/ Arm claudication test
 III. Costoclavicular test/ military position
 IV. Wright’s Hyperabduction Test

18.  Sitting position, feel for radial pulse
 Patient extends neck, rotate head towards
testing arm, patient takes a deep breath
 Disappearance 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.

19.  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

20. ROOS TEST

21.  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.

23.  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.

25.  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

26.  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%

27.  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