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Cervical Rib (Thoracic Outlet Syndrome)

Congenital anomaly where-by an extra cervical rib or post fixed brachial plexus ? an increased angulation of the subclavian artery and first thoracic nerve over the first rib

Incidence:

Cervical ribs occur in 0.4% of the population (70% are bilateral)Only symptomatic in 10% of cases

Clinically:

Although congenital, symptoms rarely develop before the age of 30 years and are more common in womenPain and symptoms usually evident in the distribution of the lower roots of the brachial plexus (C8 & T1)The subclavian artery is rarely compressed but may be narrowed by irritation of its sympathetic supply. Acute angulation may also ? damage of the arterial lining and production of small emboliResults in no general or local neck symptoms usuallyComplain of pain in the ulnar forearm and hand worse after activity and carrying parcelsMay be weakness and clumsiness and excessive sweating , blueness or coldness of the fingers with wasting of the small muscles of the handThe shoulder on the affected side may be lower or both shoulders may sagAn abnormally elevated subclavian artery may be evident above the clavicle Thoracic Outlet Stress test - putting hand behind head ie ER/Abduction/extension of shoulder produces numbness of fingers- positive in 80%The neck and shoulder are fully mobile but traction on the arm and lateral flexion of the neck away from the painful side may exacerbate symptoms and obliterate the radial pulse (Adson's Test)- positive in ~ 20%
ref Glassenberg M " thoracic outlet syndrome" Angiology 32: 180-186, 1981

X-Rays

An occasional well formed rib is seen yet these are less likely to cause significant symptomsElongation of the lateral mass of C7; likely presence of a fibrous band (this sharp fibrous band is more likely to result in symptoms)

Investigations:

EMG not as good as clinical examination in establishing the diagnosisX-Rays demonstrate the abnormality

Differential Diagnosis:

Carpal tunnel syndrome but the sensory and motor changes are not confined to the distribution of the median nerveUlnar tunnel syndrome, again the changes are not confined to the distribution of the ulna nervePancoast syndrome (apical carcinoma of the bronchus) may infiltrate the structures at the root of the neck causing pain numbness and weakness of the hand. Clinically, large lump in the neck and chest X-Ray typical features of malignancyCervical spine lesions eg
disc prolapse or spondylosis where neck movements are limitedTB and mets- X-Rays usually differentiate the cause
Spinal cord lesions such as syringomyelia may cause wasting of the hand but other neurological features suggest diagnosis (dissociated pain and temperature loss)Cuff lesions have painful shoulder and arm movements

Treatment:

Conservative: exercises to improve support of shoulder girdle associated with weight reduction are usually adequateOperation indicated if the above fails in the presence of severe symptoms or there are significant neurological or vascular disturbances then excision of the rib or fibrous band


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