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