Thoracic inlet syndrome

and cervical rib

By Kushal Hippalgaonkar

THORACIC INLET SYNDROME

INTRODUCTION
It is the compression of subclavian
and axillary vessels and trunks of
brachial plexus as they pass from
the neck to the arm

CAUSES
1. DYNAMIC FACTORS
Arm in hyperabduction
Axillary artery bent at 180 degrees , pulling
it across the coracoid

Compression of axillary artery

 2. STATIC FACTORS
A) Increased muscle bulk
Less space
compression
B) Inactive middle aged adults(decreased bulk)
sagging shoulders
angulation and compression of structures

3.CONGENITAL FACTORS
- Cervical rib
4. ATHEROSCLEROTIC FACTORS
Unusual vigorous activity in such people
Further narrowing of structures
5.TRAUMATIC FACTORS
-fracture clavicle
6. MISCELLANEOUS FACTORS
- Tumours of upper lobe
- Cervicothoracic scoliosis
- Anatomical variations in scalene muscle insertion

CLINICAL PICTURE

NEUROLOGIC
VASCULAR

 NEUROLOGIC SYMTOMS
- Lower part of brachial plexus affected most
because it overlies the first rib
Therefore sensory impairment of C8 and T1
Medial aspect of the arm , forearm and hand .
- Numbness , tingling and pain (intermittent and
burning)
- Objective signs of neuro deficit are uncommon

 VASCULAR SYMPTOMS
-Coldness of fingers
-intolerance to cold
-pallor and cyanosis of fingers
-raynauds phenomenon in 1/4th
patients

 Impaired blood flow may not be

evident unless some maneuvers are
performed , which will worsen the
flow and cause temporary pallor .
They are :

 1. Intermittent claudication test :

- both arms are elevated in abducted
and
externally rotated
position
- Fingers are flexed rapidly
- Normally 1 minute ( pt can do this )
- Thoracic inlet syndrome within
seconds (arm collapses

 2. Costoclavicular manuever
- Patient sits with hands on thigh
- Asked to throw shoulders downwards
and backwards
- Radial pulse is felt and supra and
infraclavicular regions are
auscultated .
- Positve test absence of pulse +
bruit on auscultation

COMPLICATIONS

Post stenotic dilation of vessel

Thrombus formation in this area
Embolus to distal vessels
Sometimes ulceration and gangrene

INVESTIGATIONS
1. X-ray cervical rib , malunited
fracture clavicle , anuerysmal
shadow ,
2. Arteriography stenosis ,
aneurysmal dilation , emboli
3. Nerve conduction studies slowing
of conduction in affected nerve .

TREATMENT
1. CONSERVATIVE
- Effective in majority .
- Avoid injurious positions during
working or sleeping which aggravate
the condition
- Postural positions avoiding the
shoulders to droop down
- Therapeutic exercises

 2. SURGICAL
Small percentage cases decompression
Principle remove 1st thoracic rib and if
present , the cervical rib and arterial
reconstruction
Three approaches :
a) Posterior approach
b) Transaxillary approach
c) Anterior approach

Cervical rib
INTRODUCTION
It is a supernumerary rib that usually
arises from the 7th cervical vertebra .
Frequently bilateral .

DEVELOPMENTAL ANATOMY
In the embryo , nerves are much larger in proportion to ribs than in adults .
Larger the nerve , more is the interference with development of costal
process .
2 types of brachial plexus :
1. prefixed well developed 4 th cervical root and poorly developed 1 st thoracic
root .
Therefore , a costal recess develops from this 1 st thoracic root . This is the
cervical rib
Extends from transverse process of 7 th rib , varying in size from rudimentary to
complete ( extending upto sternum).
When rib is underdeveloped , a fibrous band extends from rib to end on scalene
tubercle on 1st thoracic rib .
2. postfixed well developed 1st thoracic and poorly developed 4th cervical root
. Therefore no cervical rib formation

PATHOLOGICAL ANATOMY
Due to presence of complete cervical rib or
fibrous band
Brachial plexus and subclavian vessels must
pass over a higher barrier before passing
down into arm
So compression of these structures
( especially lower trunk of plexus (ulnar
nerve affection))

CLINICAL PICTURE AND

INVESTIGATIOONS
Similar to thoracic inlet syndrome
features( already discussed)
Special findings are :
On palpation , bony prominence of
cervical rib felt at base of neck
ON XRAY , cervical rib seen extending
from 7th cervical vertebra transverse
process .

TREATMENT
CONSERVATIVE
For mild symptoms exercises to increase
the tone of trapezius and levator scapulae .
Arm rested in elevated state to relieve
compression
SURGICAL
When symptoms are severe , the rib is
resected .

THANK YOU .