Tratamento de oclusão arterial em membro superior causada por costela cervical / Treatment of upper limb arterial occlusion caused by a cervical rib

Resumo A síndrome da costela cervical ocorre quando o triângulo intercostoescalênico é ocupado por uma costela cervical, deslocando o plexo braquial e a artéria subclávia anteriormente, o que pode gerar dor e espasmo muscular. O objetivo deste estudo é discutir sobre o diagnóstico da síndrome da costela cervical e as possibilidades de tratamento. Este desafio terapêutico descreve a condução clínica e cirúrgica de uma paciente de 37 anos com obstrução arterial em membro superior causada por costela cervical.

Abstract The cervical rib syndrome occurs when the interscalene triangle is occupied by a cervical rib, displacing the brachial plexus and the subclavian artery forward, which can cause pain and muscle spasms. The objective of this study is to discuss diagnosis of the cervical rib syndrome and treatment possibilities. This therapeutic challenge describes clinical and surgical management of a 37-year-old female patient with upper limb arterial occlusion caused by a cervical rib.

Consideraciones para el examen clínico del síndrome de opérculo torácico neurogénico inespecífico / Considerations for clinical examination of nonspecific neurogenic thoracic outlet syndrome

El síndrome del opérculo torácico (SOT) es una condición causada por la compresión de las estructuras neurovasculares en su paso entre cuello y tórax. Se clasifica en vascular y neurogénico. Si las pruebas electrofisiológicas no son positivas, se subclasifica como neurogénico inespecífico. Este último constituye entre el 95 y el 98 % de los casos, pero aún no están claros sus criterios diagnósticos. En el presente artículo se revisan los principales aspectos a tener en cuenta durante el examen clínico para guiar el diagnóstico de los pacientes con SOT neurogénico inespecífico, como sintomatología, factores desencadenantes, diagnóstico diferencial, escalas de valoración y factores psicosociales

Thoracic outlet syndrome (SOT) is a controversial condition to this day, caused by compression of neurovascular structures in their passage between the neck and thorax. It is classified as vascular and neurogenic. If the electrophysiological tests are not positive it is subclassified as nonspecific neurogenic. This is between 95-98 % of cases, but its diagnostic criteria are not yet clear. The main aspects to be taken into account during the clinical examination are reviewed to guide the diagnosis of patients with nonspecific neurogenic SOT, such as symptoms, triggers, differential diagnosis, assessment scales and psychosocial factors

Síndrome de la costilla deslizante. Tratamiento agresivo pero eficaz / Slipping rib syndrome. An aggressive but effective treatment

El síndrome de la costilla deslizante (SCD) es una entidad infrecuente, que exige un diagnóstico diferencial preciso incluyendo patología digestiva, cardiaca, respiratoria, infecciosa y músculo-esquelética torácica o abdominal. Se presenta el caso de dos niñas, en edad puberal, con dolor torácico incapacitante de varios meses de evolución y sin antecedente traumático. En la exploración existía un punto de dolor a la palpación de la parrilla costal y la 'maniobra del gancho' era dolorosa. Se realizó una resección de los cartílagos costales, respetando el pericondrio. La evolución tras uno y cuatro años de seguimiento, fue satisfactoria sin complicaciones y con resolución inmediata de la sintomatología. La cirugía de resección costal parece una opción muy agresiva, aunque con resultados muy satisfactorios. Un abordaje mínimamente invasivo podría ser mejor opción a considerar en el futuro (AU)

Slipping rib syndrome (SRS) is an unusual cause of recurrent chest or abdominal pain in children. The diagnosis is elusive, including gastroenterological, cardiac, respiratory, infectious and chest or abdominal muscular pathologies. Two paediatric patients were diagnosed with SRS, both of them were female teenagers with a similar clinical pattern: crippling unilateral chest pain without a traumatic event. On physical examination, all patients had reproducible pain with the 'hooking maneuver'. Surgical excision of the costal cartilages was done, preserving the perichondrium. No complications were reported. In both cases we achieve an excellent outcome after one and four years of follow-up, resolving the symptoms completely. The surgical excision of the costal cartilages seems to be an aggressive option but with an excellent outcome. A minimum invasive approach could be a better option in the future (AU)

Síndrome opercular anterior epiléptico en un adulto / Epileptic opercular syndrome in an adult patient

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Hibernoma y costilla cervical: dos enfermedades raras, la misma manifestación / Hibernoma and cervical rib: two rare diseases, the same manifestation

El hibernoma es un tumor infrecuente, benigno, de los tejidos blandos, derivado de restos de la grasa parda fetal. La costilla cervical es una costilla accesoria o supernumeraria derivada de la séptima vértebra cervical. Caso clínico. Niña de dos años, sin antecedentes personales de interés, que acudió a la consulta de pediatría por presentar un nódulo supraclavicular izquierdo. No antecedentes de enfermedades infecciosas recientes o clínica generalizada. A la exploración física presentaba un nódulo supraclavicular izquierdo, 1,5 a 2 cm de diámetro, duro, móvil, no adherido a los planos profundos. La analítica sanguínea excluye enfermedad infecciosa o signos de malignidad. En la radiografía cervical se visualizan costillas cervicales bilaterales. La ecografía reveló nódulo calcificado 0,8 cm, compatible con ganglio calcificado. Realizada la biopsia, la histología mostró un hibernoma, extirpado en su totalidad quirúrgicamente. Este caso ilustra la asociación de dos patologías poco frecuentes en pediatría y a las que se ha llegado al diagnóstico tras el estudio de unas adenopatías, un motivo frecuente de consulta en pediatría (AU)

The hibernoma is a rare benign tumor of soft tissue, derived from remnants of fetal brown adipose tissue. A cervical rib is a supernumerary or accessory rib derived from the 7th cervical vertebra. Clincal case. 2-year-old girl, previously healthy, referenced to Pediatrics consultation, for left supraclavicular mass. No history of infectious diseases or systemic symptoms. At exam presented mass in supraclavicular left region, 1.5 to 2 cm in diameter, hard, mobile, non-adherent to the deep planes. Laboratory tests exclude an infectious or lymphoproliferative disease. In cervical radiograph we observed bilateral cervical ribs. Cervical ultrasound revealed calcified nodule 0.8 cm, compatible with calcified adenopathy. Biopsy was performed and histology revealed a hibernoma, which was completely removed surgically. This case illustrates the association of two diagnoses, uncommon in children. These were made during the investigation of lymphadenopathies, a frequent reason for pediatrics consultation (AU)

A hand surgeon's advanced experience with thoracic outlet compression syndrome.

Although hand surgeons may often see patients with arm and hand pain, numbness and tingling in their practice, the possibility of the presence of thoracic outlet compression syndrome (TOCS) is not often considered. In our practice almost half of newly referred patients have the complaint of upper extremity pain, numbness and tingling. In approximately 50% of these patients detailed history and physical examination are suggestive of TOCS. For this reason it is quite important to recognize the possibility of the existence of this condition. Very often in the past, and occasionally today, this condition has been considered a controversial subject by numerous physicians because of the absence of objective findings in many patients. For several years it has been very well known that the objective findings are present in about 10% of patients and the remaining 90% of patients have subjective complaints. For this reason it has been one of the most commonly underrated, overlooked, and misdiagnosed conditions. During the last 22 years our experience with combined surgical approach for this condition (transaxillary first rib resection with immediate transcervical anterior and middle scalenectomy) has been quite satisfactory. During these years over 850 of these procedures were performed. Between 1989 and 2002 (13 years) 532 patients from a wide geographic area had this combined approach procedure. We were able to locate 358 of these patients for follow-up and of those only 102 responded to our questionnaire. Of the 102 who responded, 95 reported improvement of their symptoms. From 2003 to the middle of 2012, 350 patients from a wide region had this combined procedure. We sent a questionnaire to these patients and had only 57 to respond. Of those who responded, there were 19 bilateral interventions performed a few months apart, with a total of 76 procedures performed. Results based on these 76 procedures revealed 95% improvement of their symptoms. This combined approach for TOCS is the most complete intervention with high rate of improvement and low rate of recurrences.

The significance of cervical ribs in thoracic outlet syndrome.

OBJECTIVE: The purpose of this study was to review our operative experience in patients with thoracic outlet syndrome (TOS) resulting from cervical ribs causing clinical symptoms. METHODS: This study is a retrospective review of a prospectively acquired database of patients with TOS treated with first rib resection and scalenectomy with or without cervical rib resection at the Johns Hopkins Medical Institutions. RESULTS: Between October 2003 and June 2011, a total of 23 cervical rib resections were performed on 20 patients, three of whom had bilateral cervical ribs resected during separate operations. Seven patients presented with subclavian artery thrombosis. Three of seven patients had subclavian artery aneurysms and underwent cervical rib resection through a supraclavicular approach to facilitate subclavian artery bypass. Five patients presented with an ischemic upper extremity without thrombosis and underwent transaxillary first rib and cervical rib resection. Three patients presented with subclavian vein thrombosis; two of the three patients underwent balloon dilation 2 weeks postoperatively for stenosis. Additionally, five patients presented with neurogenic TOS evidenced by pain, numbness, and weakness without vascular compromise in the affected arm. Cervical ribs with bony fusion to the first rib were found in 17 of 23 cases (74%). CONCLUSIONS: Cervical ribs causing clinical symptoms are large and frequently fused to the first rib, and can result in aneurysm formation or thrombosis. In our experience, both the cervical rib and the first rib must be removed to relieve arterial compression and can usually be done through a transaxillary approach. Only patients with aneurysms needing arterial reconstruction require resection of the artery from a supraclavicular approach.

Clinical presentation of cervical ribs in the pediatric population.

Cervical ribs may cause thoracic outlet syndrome in adults, but symptoms are poorly described in children. In our series, 88.8% of the 322 children were asymptomatic. The most common symptoms were neck mass and pain. Useful diagnostic tools were cervical spine and chest radiographs. Differential diagnosis of a supraclavicular mass includes cervical ribs.

An unusual case of the syndrome of cervical rib with subclavian artery thrombosis and cerebellar and cerebral infarctions.

BACKGROUND: Cerebellar and cerebral infarctions caused by the syndrome of cervical rib with thrombosis of subclavian artery are very unusual. CASE PRESENTATION: We report the case of a 49-year-old male patient with a right cervical rib compression leading to subclavian arterial thrombosis and both cerebellar and cerebral infarctions secondary to retrograde thromboembolisation. Follow-up imaging revealed partial resolution of the thrombosis after combined anti-coagulant and anti-platelet therapy. The cervical rib and first costa were surgically removed to prevent additional events. CONCLUSION: Cervical rib vascular compression should be promptly diagnosed and treated in order to avoid further complications, including cerebrovascular ischemic events.

Congenital lower brachial plexus palsy due to cervical ribs.

Congenital brachial plexus palsy (CBPP) usually occurs secondarily to intrapartum trauma, but this is not always the case. Cervical ribs have previously been reported to increase the risk of CBPP in association with birth trauma. We report the cases of two children (one female, one male) with congenital lower brachial plexus palsy in whom the presence of non-ossified cervical ribs was the only identified risk factor. In the female child magnetic resonance imaging (MRI) of the brain, spinal cord, and brachial plexus revealed no abnormality except for the presence of bilateral cervical ribs at the level of the seventh cervical (C7) vertebra. Chest radiography was normal, which suggested that the cervical ribs identified on the MRI were fibrous bands or cartilaginous ribs rather than ossified ribs. In the male child, MRI of the spine and brachial plexus was normal but he was noted to have bilateral cervical ribs at C7. These were not identifiable on chest radiography and, therefore, are likely to reflect fibrous bands or cartilaginous ribs.

[Falconer-Weddel's costoclavicular syndrome].

Analysed herein are the findings of examination and outcomes of surgical management of fifty-eight patients (25 men and 33 women) presenting with Falconer-Weddel's costoclavicular syndrome in which the subclavian artery and vein and the brachial plexus at the thoracic outlet appear to be compressed. Of the 58 patients,five subjects were found to have a rudimentary cervical rib and three more (5.3%) patients had trophic disorders on their digits fingers: dystrophy of the nail plates, their fragility, periodically opening trophic ulcers at the digital tips and one patient presented with gangrene of the inguinal phalanx of the middle finger. Three patients had hyperemia of the face. A further four patients had roughening, hyperkeratosis of the skin of the hands, cracks. The presence of the supernumerary ribs was determined roentgenologically. Haemodynamics was studied using Doppler ultrasonography making it possible to reveal disordered blood flow in the upper-limb arteries in the physiological position assumed, in the Adson test as well as with Raynaud syndrome, which was observed in 39 patients. The function of the nerves was studied using electroneuromyography (ENMG). All patients were operated on under endotracheal anaesthesia. Decompression-medical operations were carried outperformed in all 58 patients, with the following four types of interventions being performed: transaxillary resection of the first rib combined with sympathectomy carried out in 23 patients, resection of the first rib without sympathectomy in eighteen patients, resection of the first rib via a surpraclavicular approach in four patients, scalenotomy and selective cervicothoracic sympathectomy in 13 patients.

[Unusual reason for unilateral (corrected) Raynaud's phenomenon with intensification when the arms are elevated]. / Einseitiges Raynaud-Phänomen mit Verstärkung bei Elevation des Arms.

Thoracic outlet syndrome (TOS) is a broad term for compression of the neurovascular structures in the area of the 1. rib and the clavicle. The cause can be either fibrous bands, cervical ribs, anomalous muscles or posttraumatic changes as well as tumors. Symptoms depend on the affected structure, in most cases (up to 97% of TOS patients) neurologic symptoms are present. In case of an arterial compression, for example due to a cervical rib like in our case, embolism of the arm and finger arteries can occur. For mild or moderate symptoms a conservative approach with physiotherapy can be helpful. For severe cases surgical resection of the compressing structure and the first rib is necessary. In our case, the cervical and first rib were excised after an initial lysis therapy. Furthermore, the aneurysm of the subclavian artery was excised.

[Thoracic outlet syndrome: differential diagnosis and surgical therapeutic options]. / Thoracic-outlet-Syndrom : Differenzialdiagnose und chirurgische Therapieoptionen.

The thoracic outlet syndrome (TOS) is a disputed syndrome in the field of the so-called compression syndromes of the upper extremity. This is no surprise, as the TOS is a complex and multifactorial compression syndrome diagnosed by different medical specialities. On average 6.5 physicians of different specialities need 4.3 years to come up with the diagnosis of TOS. The correct diagnosis is of great importance and crucial for successful operative treatment. The necessary diagnostic tests can only be accomplished by team work, especially interdisciplinary cooperation. This expressly includes physiotherapy and not just the medical disciplines. This contribution presents a summary of the approaches and interactions involved in effective diagnosis and treatment of TOS.

Seventh cervical rib associated with subclavian artery occlusion and multiple infarcts: case report.

A cervical rib, or supernumerary (extra) rib arising from the 7th cervical vertebra, is a congenital abnormality that occurs in less than 1% of the population. Clinically, it can cause obscure nervous or vascular symptoms and be difficult to diagnose. In this rare case, a 37-year-old woman developed a subclavian artery occlusion after undergoing a chiropractic manipulation for neck, shoulder, and arm pain. The occlusion led to multiple cerebellar infarcts, frontal subarachnoid hemorrhage, myocardial infarction, and right-hand vascular compromise. The patient was subsequently diagnosed with a 7th cervical rib, which likely caused compression of the subclavian artery after a hyperextension injury sustained during the chiropractic procedure. The departments of vascular surgery, neurosurgery, cardiology, and neurology collaborated to review all elements of the patient's diagnosis and care. After the patient was stabilized, she spent 6 weeks in acute inpatient rehabilitation; upon discharge, her symptoms were greatly improved but still present. Three months later, the patient underwent a subclavian-artery-to-axillary-artery bypass with resection of the left cervical rib. She tolerated surgery well with no complications. As a result of the devastating insults sustained secondary to the presence of the 7th cervical rib and her subclavian artery occlusion, this patient faced months of recovery. Treatment involved a structured interdisciplinary plan of care.