CERVICAL RIB SYNDROME
Cervical Rib Syndrome
• A cervical rib is a supernumerary (or
extra) rib which arises from the 7th cervical
vertebra.
• Sometimes known as "neck ribs",
• It is a congenital abnormality located above the
normal first rib.
• A cervical rib is estimated to occur in 0.2% to
0.5% of the population.
• May be present on one or both side (Rt/Lt)
Patho-anatomy
• A cervical rib represents a persistent ossification
or delayed 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 the first rib
below.
• The presence of a cervical rib can cause a form
of TOS due to compression of the lower trunk of
the brachial plexus or subclavian artery.
• Cervical rib syndrome is one of the types of TOS.
Other types being
• Scalenus anticus syndrome
• Costoclavicular syndrome
• Hyperabduction syndrome
History
• 1740 Hunauld: first reported
• 1860 Willshire, 1869 Gruber: conception for
diagnosis
• 1861 Coote: first surgical removal of cervical rib
Clinical Features
• Nerve compression:
– Traction & compression: C8, T1 nerve root (lower trunk)
– Pain in neck & shoulder, arm & it is reproducible on suitable
postural position
– Radiating pain, paresthesia & numbness: median & ulnar nerve
dermatome
– Sustained traction on the shoulder by pulling the pts wrist may
reproduce the symptoms.
– Passive elevation of the shoulder girdle may relieve symptoms.
• Arterial compression:
– Pain, claudication, pallor, Raynaud phenomenon
• Venous compression:
– Coolness, venous dilation, edema
– Subclavian vein thromboembolism, peripheral necrosis
Diagnosis
• Physical Tests: Adson test, Allen test, Roos test
Wright’s test etc.
• Myelogram
• Roentgenogram, CT, MRI
• Angiogram, Doppler test
• EMG/NCV
Adson’s Maneuver
• Patient is sitting or standing
• Examiner externally rotates and extends
the patient's arm while palpating the radial
pulse
• Patient then extends and rotates the neck
towards the test arm and takes a deep
breath
• Positive Test: Diminished or absent radial
pulse Implicating Thoracic outlet syndrome
or compression of the subclavian artery by
the scalene muscles
Allen Test
• Patient in sitting or standing with
shoulder in 90° of abduction and
external rotation, and the elbow
in 90° of flexion
• Patient rotates the neck away
from the test arm
• Examiner palpates the radial pulse
• Positive Test
• Diminished or absent radial pulse
indicates TOS.
Roos Test
• sitting or standing with both shoulders in 90°
of abduction and external rotation, and the
elbows in 90° of flexion
• Patient rapidly opens and closes both hands
for 3 minutes.
• Positive Test
• Inability to maintain the test position,
Diminished motor and sensory function in
the upper extremities indicates Thoracic
outlet syndrome, neurovascular compromise
Wright’s Test
(Hyper-abduction Maneuver)
• Patient is seated with arms at the side .
• The radial pulse is palpated
• Step one: Places the patient’s shoulder into abduction and
external rotation to 90 °. The elbow is flexed around 45° . Ask the
patient to take a deep breath and hold. This position is held for 1
minute.
• Step two: Repeat the previous test with the patient’s arm in hyper
abduction (end range of abduction).
• Test the contra lateral side.
• Positive test: change in radial pulse and/or symptom reproduction.
This position compresses the neurovascular bundle as it travels
under the pectoralis minor muscle.
• It has greatest sensitivity for neurogenic and vascular TOS (Hooper
et. al., 2010, Watson et. al, 2009)
Management
• Aims
To restore pain free movts
Correct postural deviation
• Methods:
Advice for Postural correction
Strengthening ex for shoulder girdle msl
Stretching of Scalene muscle & pectoral muscle over
prolonged period of time
Cervical Traction –controversial
Cervical Collar may be used to avoid jerks/jolts.
If fails – removal of cervical ribs by surgery
Surgical Mgt
• If no improvement with conservative T/t.
• Complications:
– Brachial plexus injury
– Subclavian vessels injury
– Phrenic nerve injury
– Perforation of pleura
– Bleeding & hematoma
– Infection
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