Cervical Rib Syndrome

- A Case Report -

Sung Soo Kim, M.D.

Hyeong Cheol Ryu, M.D.

Department of Orthopaedic Surgery, School of Medicine, Dong-A University, Busan, Korea.

Case Report• F/16• C/C: Pain on both lateral neck esp. when raising arms• D: 2 years (1 year ago, symptoms

aggravated especially on left side and radiating pain to elbow)

• P/H: N-C

Case Report• P/Ex:

– Palpable bony prominence on both lateral neck(esp. Lt.)

– Tenderness(+/++)– Radiating pain on arm(+/++)– Lt. 4th & 5th fingers: sensory decreased & tingling sensation– Adson test(-/+)– LOM on neck: mild– Thrill(-/-), muscle atrophy(-/-), DTR(NL/NL)

• EMG/NCV: WNL

Roentgenograph

3-dimensional CT

Treatment

• Rt.: conservative Tx.• Lt.: surgery

– Supraclavicular approach– Release of ant. scalene muscle– Removal of 7th cervical rib

Operative Findings

Postop Roentgenograph

Postop Care

• POD 2: intermittent shoulder exercise start• Adson test at POD 2: Lt.(-)• Sx.: radiating pain & tingling sensation -> improved• Cx.: none

Cervical Rib Syndrome

• Scalene space, interscalene triangle– clavicle, first rib, ant. & middle scalene mu

scles• Thoracic outlet syndrome

– Cervical rib syndrome– Scalenus anticus syndrome– Costoclavicular syndrome– Hyperabduction syndrome

Cervical Rib Syndrome

• 1740 Hunauld; first reported• 1860 Willshire, 1869 Gruber; conception for diagnosis• 1861 Coote; first surgical removal of cervical rib

Cervical Rib Syndrome• Sx.

– Nerve compression Sx.(MC)• Traction & compression: C8, T1 nerve root(lower trunk)• Pain on neck & shoulder• Radiating pain, paresthesia & numbness: median & ulnar

nerve dermatome– Arterial compression Sx.

• Pain, claudication, pallor, Raynaud phenomenon• Peripheral embolism

– Venous compression Sx.• Coolness, duskiness, venous dilation, edema• Subclavian vein thromboembolism, peripheral necrosis

Costoclavicular Syndrome

Cervical Rib Syndrome

• Dx.– Adson test, Wright test and hyperabduction tes

t etc.(But positive to normal person)– Roentgenogram, CT, MRI– Angiogram, Doppler test– Myelogram– EMG/NCV

Cervical Rib Syndrome

• Davis & King– Symptom developed third & fourth decade

• Delayed ossification of cervical rib• Delayed developmental completion• Descending shoulder girdle(esp. scalenus anticus

syndrome: middle aged female)

Cervical Rib Syndrome

• Tx.– Conservative Tx.

• Postural correction• Physical therapy: sternoclavicular joint & acromi

oclavicular joint exercise, scalene muscle & pectoral muscle stretching

-> costoclavicular space widening• Shoulder muscle strengthening & home exercis

e program

Cervical Rib Syndrome

• Tx.– Surgical Tx.: no improve to conservative Tx.

• Supraclavicular approach• Supraclavicular & post. parascapular approach• Transaxillary approach(Ant. Scalene muscle, middle scalene muscle, cervic

al rib, first rib & part of clavicle)

Cervical Rib Syndrome

• Cx.– Brachial plexus injury– Subclavian vessels injury– Phrenic nerve injury– Perforation of pleura– Bleeding & hematoma– Infection

Thank you for your attention