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CERVICAL RIB SYNDROMES

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Cervical Rib refers to an abnormal protrussion in the cervical region which can either be due to abnormal
enlargement of the transverse process of C7 vertebra or a small rib or fibrous band running from the 7th cervical
vertebra to the first true rib or to the sternum but usually it is present posteriorly upto a short distance.

It is usually diagnosed in middle age group persons though is

present since birth. The cause is that by middle age, the
shoulders start drooping which causes the cervical rib to get
depressed and hence compressing the nerve root of the
concerned region. This rib is usually asymptomatic but it may
give rise to neurological symptoms if it exerts pressure on the
subclavian artery or the brachial plexus like-

• paraesthesia of hand
• hypothenar wasting
• atonia in the muscles of the shoulder girdle.

A cervical rib is a supernumerary (extra) rib which arises from

the seventh cervical vertebra. It is a congenital abnormality
located above the normal first rib. A cervical rib is present in
only about 1 in 200 (0.5%) of people; in even rarer cases, an
individual may have not one but two cervical ribs. The presence
of a cervical rib can cause a form of thoracic outlet syndrome
due to compression of the brachial plexus or subclavian artery.
Compression of the brachial plexus may be identified by
weakness of the muscles around the muscles in the hand, near
the base of the thumb. Compression of the subclavian artery is
often diagnosed by finding a positive Adson's sign on
examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder.
human-lateral-cervical-spine human-anterior-cervical-spine human-posterior-cervical-spine

Cervical (Cx) Rib History

150 AD: Galen, the Greek anatomist and court physician to Marcus Aurelius, first describes the Cx rib in human
dissections.

1500’s: Andreas Vesalius, who is responsible for the revival of Galen’s work (which had fallen into disfavor in the
Dark Ages), again describes the Cx rib in human cadavers.

1742: Francois-Joseph Hunauld describes and categorizes supernumerary ribs in humans, including the Cx rib.

1821: Sir Astley Cooper first describes arterial thoracic outlet syndrome in a young woman with arm ischemia, and
demonstrates the relationship between a Cx rib andcompression of the subclavian artery.

1831: Henry Mayo in London reports the first subclavian artery aneurysm due to thoracic outlet syndrome, caused
by an exostosis of the first rib.

1853: John Hilton, a British surgeon, describes gangrene of the arm in a patient with compression of the
subclavian artery caused by an exostosis of the first rib.

1860: W. H. Willshire notes the relationship between a Cx rib and paresthesias of the upper extremity.

1861: Richard Holmes Coote at St. Bartholomew’s Hospital in London performs the first surgical resection of a
cervical rib, with relief of arterial TOS.

1903: F. Bramwell describes neurovascular compression in the presence of a normal first rib, without a cervical
rib.

1905: John Benjamin Murphy of Chicago was the first surgeon to resect a cervical rib that was associated with a
subclavian artery aneurysm.

1907: Dr. William Keen at Thomas Jefferson University in Philadelphia publishes a review of 42 cases of resected
cervical ribs, and describes a clinical definition and surgical treatment for this disorder.

1931: Telford and Stopford propose that the variable distribution of sympathetic fibers in the brachial plexus could
explain the variable degrees of vascular disturbance seen inpatients with symptomatic cervical ribs.

1943: Murray Falconer and L.G. Weddell describe several military recruits with neurovascular compression caused
by heavy backpacks and assuming the "military" position, with the shoulders thrust backwards. They believe that
this neurovascularcompression is caused by compression of the neurovascular bundle between the normal clavicle
and first rib on assumption of an unusual posture, even in the presence of normal anatomy, and coined the term
“costoclavicular syndrome”. Dr. Falconer publishes a second paper with Dr. Franklin W. P. Li, describing an
additional 11 patients who underwent first rib resection with good results. Several of these patients had been
previously treated for carpal tunnel syndrome, without relief.

Clinical Features
Local Symptoms

There is often a tender supraclavicular lump which is bony hard and is fixed when palpated.

Sensory Symptoms

(a) Tingling in hands or fingers; confined either to radial side or ulnar side or sometimes involve even whole hand.

(b) Pain may sometimes radiate downwards from the arm.

Motor Symptoms

(a) Loss of gripping power of the hand.

(b) Tendency of dropping things from the hand.

(c) Wasting of palmar muscles; either thenar or hypothenar or interossei muscles.<BR.< p>

Vascular Symptoms

(a) Cold and clumpsy extremities, particularly the fingers.

(b) Skin colour changes to blue associated with trophic changes.

(c) There is rare risk of gengrene.

(d) Radial pulse becomes feeble or may even be absent.

Diagnosis

1- Mainly by X-ray to detect presence of Cervical ribs , which could be easily palpated.

2-Adson's Test

• Indications- Evaluation of Cervical Ribs/Thoracic Outlet Syndrome.

• Technique- Patient breathes deeply,Neck extended,Chin turned toward affected side.The examiner lifts the
arm away to the side to 90 degrees and performs external rotation of the shoulder, and notes whether the
radial pulse disappears. However there are many false positives, as the radial pulse may disappear in
normal people as the head of the humerus (upper arm bone) compresses the brachial vessels when the
arm is taken beyond 90 degrees. Repeat test with chin to opposite side.
• Interpretation- Positive test finding ( Decreased Radial Pulse and/or Distal extremity pain reproduced )
suggests interscalene compression.

Foraminal Compression Test/Spurling's Test

Spurling's test is an orthopedic test used to diagnose nerve root compression primarily at the cervical level. It
should not be used in instances in which vertebral instability is suspected.

Shoulder Abduction Test

Shoulder Abduction Test is an orthopedic test used to help diagnose a cervical nerve root injury or cervical disc
herniation. It is performed by having the patient abduct their shoulder and place their hand on top of their head. A
positive test will involve a decrease in radiculopathy or pain.

Differential Diagnosis
The differential diagnosis for Cervical Ribs is quite broad and includes neurologic, vascular, pulmonary, cardiac, and
esophageal disorders.

1)Some of the more common conditions include herniated cervical disk, cervical spondylosis, and peripheral
neuropathies.

2) Peripheral vascular disease like Raynaud's disease.

3) Neurological conditions-like syringomyelia, polio, muscular dystrophy, motor neuron disease.

Medical treatment

Anti-inflammatory drugs and analgesics are provided as a conservative means of treatment.

Surgical treatment

surgery is essential in conditions of severe, progressive vascular and neurological signs and symptoms which are
unbearable for the patients. It includes:
(a) Removal of extra segment.
(b) Dividing the scalene group of muscles.

Physiotherapy treatment

On the basis of symptoms of the patient, the regime of physiotherapy is planned.

• For pain relief- Heat modalities are used like short wave diathermy but it should not be applied in case
of sensory impairments.
• To improve distal circulation- Exercises of hand and finger should be started.
• TO improve tone, power and endurance- Strengthening exercises of whole arm perticularly small
muscles of the arm.
• Correction of posture by postural guidance- In this, patient is taught to use postural mirror to see
that his shoulders are in level, head is straight, looking forward.
• Planning specific exercises- To develop particular muscles groups for specific movements of shoulder
girdle like elevation, retraction, and raising the arm overhead as these movements brings spontaneous
relief. The important exercises are-
Self resisted scapular elevation.
Self resisted scapular adduction.
Endurance training exercise for the shoulder girdle muscles.
Progressive resistance exercises for shoulder girdle muscles with weight.
• Deep Tissue Massage for TOS ( thoracic Outlet Syndrome).