Cervical Rib and TOS

H&P

• HPI:
  • Presented to neurosurgery clinic
  • Progressive left neck and posterior shoulder pain for years
  • Now radiating to left palm with numbness and tingling
  • Left hand weakness
  • Denies gait changes or incontinence of bowel/bladder
• PE:
  • LUE grossly 4/5
  • +b/l Hoffman's
  • -clonus
  • Decreased sensation to light touch on LUE (medial 2.5 fingers)
  • Tenderness on left paraspinous/trapezius
• Workup:
  • Cervical spine MRI without contrast
  • Neck X-ray
  • Cervical spine CT
  • Nerve conduction study:
    • Grossly normal except minimal decrease of left ulnar motor amplitude at wrist which does not match exactly with cubital tunnel syndrome
    • No electrophysiological evidence of entrapment neuropathy, left cervical radiculopathy, large fiber polyneuropathy or myopathy
  • EMG
    • Mild left ulnar neuropathy at the elbow
    • Mild median mononeuropathy in the right wrist seen in carpal tunnel syndrome
    • No electrodiagnostic evidence of left cervical radiculopathy

Imaging

Cervical Spine MRI without Contrast

Cervical Spine CT - Coronal Reconstruction

Cervical Spine CT

Cervical X-ray, PA

Bilateral cervical ribs seen on the plain X-ray film, right (yellow arrow) > left (red arrow).

Differential Diagnosis

• Thoracic outlet syndrome - neurogenic, secondary to cervical rib
• Cervical radiculopathy - symptoms do not correlate with certain dermatomes
• Peripheral neuropathy - ruled out by NCS and EMG

Surgical Intervention

• Intraoperative neuro-monitoring with nerve stimulation
• Supine
• Left shoulder roll
• Rightward head turn
• Posterior cervical triangle
• Incision along the posterior border of left SCM
• Dissection of platysma muscle
• Dissection of anterior scalene fat pad
• Identification of phrenic nerve on the anterior scalene muscle
• Identification and decompression of upper, middle, and lower trunks
• Identification and resection of cervical rib
• Closure

Intra-Op Imaging

A vessel loop was used to isolate the upper, middle, and lower trunks, respectively.

This picture is slightly out of focus.

Intra-Op X-ray

From left to right: a clamp was used to identify the cervical rib; the tip of the Penfield No. 4 was at the costovertebral junction of C7; after the resection of the cervical rib.

Post-Op Recovery

• Chest X-ray in PACU to rule out pneumothorax and phrenic nerve injury
• Floor care withe very 4 hours neuro-checks
• Sling for comfort
• Medical 2.5 fingers numbness improved
• New left lateral 3 fingers tingling

Post-Op X-ray

Pre-(left) and Post-(right)Op X-rays

Discussion

• Thoracic outlet syndrome
• Surgical techniques