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Cervical rib
- 1.
- 2. • Although Cervicalribs were described centuries ago by GALEN &VERSALIUS • French anatomist FRANCOIS HUNAUALD made the first scientific description • W.H.WILLSHIRE in 1860 described the association of cervical rib with upper extremeity paraesthesia • R.H.COOTE in 1861 did cervical rib resection
- 3. • A 1939study described incidence rate of cervical rib and anamolous rib at 0.74% and 0.76%. • Anamolous ribs has equal incidence in men and women • Cervical ribs has female:male at 7:3 with no proper explanation for this female preponderance • Both ribs remain higher than the 1st ribs • The only difference is Cervical rib from C7 transverse process and Anamolous rib fromT11 transverse process
- 4. • 30% ofthem are complete rib which fuse to the first rib by a true joint or fibrous attachment • 70% of them are incomplete ribs with no direct attachment but most have tight fascial bands from tip of cervical rib to first rib • This band lies in the scalene triangle narrowing the space compressing nerves specially the lower trunk of brachial plexus • This can sometimes push against subclavian artery causing stenosis with or without post-stenotic dilatation • Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally.
- 5. • 4Varieties ofCervical rib • Complete rib which articulates with manubrium sterni or first rib • Almost Complete rib:Free end expands into bony mass.This variety give rise to visible swelling • True Incomplete rib:Ends into fibrous band which is connected to scalene tubercle of the first rib • Only Fibrous band:Closely applied or incorporated into scalene medius muscle.This anamoly may not be revealed in x-ray
- 7. Pathology • A cervicalrib represents a persistent ossification of the C7 lateral costal element. During early development, this ossified costal element typically becomes re-absorbed. Failure of this process results in a variably elongated transverse process or complete rib that can be anteriorly fused with theT1 first rib below • Vascular symptoms are caused by constriction of lumen of subclavian artery as the artery is lifted by cervical rib. • Constriction is followed by post-stenotic dilatation where clotting occurs in the intima of artery • Mural thrombus may become detached and give rise to emboli • Rarely proximal extension of thrombus may affect vertebral artery and cause cerebrovascular embolic episodes • Neurological symptoms caused by pressure on the first thoracic nerve from below by cervical rib
- 8. CLINICAL FEATURES • Localsymptoms: Lump in the lower part of neck. Tenderness in supraclavicular fossa Lump is bony hard in consistency and fixed If the wrists are dragged down and on palpating both radial pulses the affected radial pulse may be feeble
- 9. Vascular symptoms: • Painis the most important, radiates from neck to upper arm and forearm aggravated by using upper arm and more so if the arm is in upper position during exercise • Relieved by rest. • This pain is the ischemic muscle pain,similar to intermitten claudication pain in leg. • Later similar to rest pain • Numbness is often complained and trophic changes seen if it is associated with vascular symptoms • Affected upper limb is often cold,pale • Raynauds phenomenon can be observed • Systolic bruit may be noted.
- 10. Neurologic symptoms • Painand tingling sensation in the arm and forearm specially in the medial aspect • Wasring of hypothenar eminence in late cases • Hypoaesthesia or anaesthesia supplied byT1 segment • Weakness of the muscles of hand
- 11. SIGNS In Neck: • Lumpin supraclavicular fossa • Lump may be bony hard mass,indicates anterior portion of cervical rib • Lump may be bosselated • Occasionally pulsatile swelling in subclavian triangle indicates elevated subclavian artery • Slight lowering of shoulder girdle due to muscle wasting
- 12. IN LIMB • Anaesthesiaor Paraesthesia in the medial aspect of forearm and hand • Motor changes specially in the small muscles of hand • Loss of muscle tone and power both in thenar and hypothenar • Movements of fingers becomes clumsy and incordinated • Occasionally clawhand can be noticed • Vasomotor symptoms like cyanosis excessive sweating and coldness of fingers
- 13. DIFFERENTIAL DIAGNOSIS • Raynaud”sdisease • MND • Polio • Muscular dystrophy
- 14. Adson maneuver Patientis instructed to take and hold a deep breath and extend his neck fully and then asked to turn his head towards the side being examined. Obliteration or diminuation in the radial pulse suggest compression.
- 15. IMAGING X-rays Cervicalrib Elongated C7 transverse process Hypoplastic 1st rib Callous formation from clavicle or 1st rib fracture Pseudoarthrosis of 1st rib Unable to image soft tissue anomalies and fibromuscular bands – seen only at time of surgery
- 17. Pain control • Musclerelaxants • NSAIDS • Ultrasonography with ionatophorosis • Transcutaneous electric nerve stimulation. (TENS) • Local anesthetic injections.
- 18. Edema control • gloves •Compressive garments • Elevation of limb • Active range of motion exercises • Retrograde massages • Phonophoresis controls pain and edema
- 19. Ergonomics Work posturerelated changes Relative adjustment of chair height so that forearm restscomfortably and without shoulders being elevated or depressed. Avoid carrying heavy weights on effected side Avoid hyperextension of neck and hyperabducting postures
- 20. PHYSICAL THERAPY Is thekey of T.O.S. treatment Its purpose : open the costo-clavicular space fight against physiological shoulders falling attitude Has to be progressive, painless, bilateral Average duration : 3 to 6 months If properly executed : 70 to 90% of good results
- 21. Exercises Involves relaxingshoulder girdle and stretching the scalene and pectoral muscles. Neck : neck side bending exercises neck rotation neck flexion exercises Shoulder : shrugging of shoulders pendulum exercises
- 22. Surgical decompression Symptoms persistsbeyond 2 months of conservative management. Associated vascular compression with poststenotic dialatation. Complete occlusion of a large vessel. P rogression of neurological symptoms. Nerve conduction velocity < 60m/s
- 23. • 1strib resectionand scalenectomy are standard procedures for TOS • 1strib resection is recommended for lower type TOS • Best results and less chance of recurrence with combined 1strib resection and scalenectomy.
- 24. 1st rib resection 1.Transaxillary approach 2. Supraclavicular approach 3. Infraclavicular approach 4. Posterior approach.
- 25. Transaxillary approach (Roos approach) • Transverse Incision at the level of third rib just below the axillary hair line. – Advantages • Limited field of operative dissection • Cosmetically placed incision • Achieve 1strib resection and anterior scalenectomy • Removal of anomalous ligaments and fibrous bands. • Less blood loss, no muscles are divided.
- 26. • Incomplete exposureof entire scalene triangle • Difficulty achieving brachial plexus neurolysis • Limited if vascular reconstruction is needed Disadvantages
- 27. • Supraclavicular approach –Advantages • Wide exposure of all anatomic structures • Permits complete resection of anterior and middle scalenes as well as brachial plexus neurolysis. • Allows resection of cervical ribs and anomalous 1st ribs • Vascular reconstruction is possible
- 28. Infraclavicular approach • ADVANTAGES •Ideal for venous and arterial obstruction. • Venous embolectomy. • Arterial reconstruction. • DISADVANTAGES • Poor view of thoracic outlet. • Poor excision of posterior part of the rib.
- 29. Posterior approach • Advantages •cervical rib can be easily resected. • Sympathetectomy can be done • Disadvantages • Vascular reconstruction can not be performed.
- 30. Thoracoscopic First RibResesction • Three 10mm portal are made -1st anterior 3rdICS -2ndlateral 5th ICS - 3rdlateral wall of 6thICS Endoscopic drill is used to dissesct the rib