CASE OF THORACIC OUTLET SYNDROME CERVICAL RIBPRESENTED 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 exercise Relieved 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
y Costoclavicular test y Hyperabduction test y 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 ENDSCALENUS 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 testsPlain 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
