Cervical rib Q76.5

The first description of a compression syndrome of the brachial plexus was by Sir Astley Cooper in 1817, that of the cervical rib syndrome in 1861 by Coote et al., that of compression of the 1st rib by Murphy et al. in 1910, the scalenus anticus syndrome described in 1935 by Ochsner et al., the costoclavicular compression syndrome Falconer et al. in 1943.

It was not until 1956 that Peet recognized the similarity of symptoms and grouped them together as the generic term "thoracic outlet syndrome" (König 2008).

The first surgical resection of a cervical rib for neurovascular symptoms was performed by Coote as early as 1861. Resection by the transaxillary route was published by Roos in 1966, and this procedure gained special importance until the mid-1970s because of its good results. A supraclavicular resection procedure was described by Murphy et al. in 1980. In the meantime, endoscopic procedures have also been described (Bürger 2014).

A cervical rib is a rib variant or anomaly (Wirth 2004). It is congenital and represents an overdevelopment of the transverse process in the cervical spine (Fliegel 2023).

The accessory rib usually originates from the 7th cervical vertebra and can occur unilaterally or, in up to 50% of cases (Checa 2019), bilaterally (Brossmann 2001).

One differentiates between 4 different types of a cervical rib:

- Type 1: In this case a complete rib is found which articulates with the 1st rib or the manubrium.

- Type 2: An incomplete rib with a free distal tip is found.

- Type 3: In this case, the rib is also incompletely formed, but it shows a distal fibrous ligament attachment.

- Type 4: In type 4 there is only a short piece of bone. This protrudes beyond the transverse process C 7 (Fliegel 2023).

Wanke (1937) gave the incidence of cervical rib as 6% (Brossmann 2001). According to Fliegel (2023), the incidence is approximately 0.5 - 1% in the population. Women are more commonly affected than men (Checa 2019).

According to Panther (2022), thoracic outlet syndrome occurs as a rare condition in approximately 1 - 3 per 100,000.

Cervical ribbing manifests predominantly in middle-aged adults (Fliegel 2023).

Cervical ribs are located preferentially on the 7th cervical vertebra. They are partly synoptic, partly articulated with the transverse process and can have different shapes (see above under "Classification"). (Brossmann 2001)

Cervical ribs are found strikingly often in combination with the Ullrich-Turner syndrome (Brossmann 2001).

The vast majority of cervical ribs remain unnoticed throughout life and do not cause any symptoms. It often represents a radiological incidental finding (Fliegel 2023).

However, a minority experience pain and/or symptoms due to compression of surrounding structures (Fliegel 2023). See also "Complications.

- Clinical examination

Here, an indolent, firm mass may typically be palpable in the neck. Attention should also be paid to circumferential increases, discoloration of the arms, and variable pulse qualities (Checa 2019).

- Adson maneuver:

This is used to provoke symptomatology in cervical ribbing. In this maneuver, the head is rotated ipsilaterally and reclined in deep inspiration. At the same time, the arm is pulled downwards. The test is considered positive if the radial pulse weakens. However, the test is often false positive (Bischoff 2007).

The final diagnosis of cervical rib is usually made by an x-ray of the upper thoracic aperture (Bischoff 2005).

However, a CT scan, MRI, and nerve conduction velocity examination may also be required for accurate diagnosis (Fliegel 2023).

A cervical rib can lead to the following complications:

- Thoracic outlet syndrome (TOS).

On the one hand, motor disturbances of the following muscles occur: thenar muscles, M. abductor digiti V. and the Mm. interossei, on the other hand sensory disturbances of the IV. and V. finger (Bischoff 2005).

The following syndromes are also subsumed under the term "TOS":

- Scalenus- cervical rib syndrome: This is a narrowing of the posterior scalenus gap with triggering of various symptoms such as pain in the shoulder- neck area, paresthesias of the ulnar forearm, the edge of the hand and the 4th or 5th finger, atrophy of the small hand muscles or paresis of the small hand muscles in certain postures (Hettenkofer 2003).

- M. scalenus anterior syndrome

- Hyperabduction syndrome

- pectoralis minor syndrome

- costoclavicular syndrome (Bürger 2014)

- Compression of the subclavian artery: This results in a change in color and temperature of the affected arm. The pulse is attenuated on this side (Fliegel 2023).

- Compression of the subclavian vein: In this case, the affected limb is bluish in color and swollen because the blood cannot flow back (Fliegel 2023).

- secondary Raynaud's syndrome (Hettenkofer 2003)

- compression can lead to deep vein thrombosis of the upper extremity (Herold 2022)

If complaints exist, the patient should be treated with physiotherapy (Fliegel 2023). This therapy brings a positive effect in 27 - 59 % of cases (Dengler 2022).

Only if this form of treatment does not bring the desired success, a surgical measure is indicated. This consists of a resection of the cervical rib (Hettenkofer 2003). S. "Surgical therapy".

After ventral exposure of the cervical rib and epiperiosteal separation of all soft tissues, resection is performed at the level of the transverse process (Wirth 2004).

However, the surgical procedure should be performed only in exceptional cases because of the risk of plexus and vascular lesion during the procedure (Wirth 2004).

Resection improves the symptoms in 56-90% of patients (Dengler 2022).

Increased numbers of children with congenital cervical ribs have been observed:

- Germ cell tumors

- astrocytomas

- acute lymphatic leukemia (ALL)

(Fliegel 2023).

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