Cervical Rib / Thoracic Outlet Syndrome

cervical rib

What is a cervical rib?

About 1 in 200 people are born with an extra rib called a cervical rib. At the back, this rib connects to your seventh cervical vertebra in your neck. At the front, in some people a cervical rib can be 'floating' and have no connection. In other people it can be connected to your first rib by a band of tough, fibrous tissue.A cervical rib can be present just on your right side, just on your left side, or on both sides.

What is your thoracic outlet?

Your thoracic outlet is a space, or passageway, that lies just above your first rib and behind your clavicle (your collarbone). There are also some muscles that surround the thoracic outlet. The thoracic outlet runs from the base of your neck to your armpit. You have a thoracic outlet on the left and the right side of your body.A number of structures pass through your thoracic outlet, including some important blood vessels and nerves.

What is thoracic outlet syndrome and what causes it?

If you have thoracic outlet syndrome, the nerves and/or blood vessels in your thoracic outlet are compressed for some reason. In most cases, it is nerves that are compressed. This compression causes the typical symptoms (see below). In some people, the blood vessels may be compressed. Sometimes, a combination of both nerves and blood vessels may be compressed. Thoracic outlet syndrome usually only affects one side of your body. However, rarely, compression can occur in the thoracic outlet on both sides and so symptoms then occur on both sides. There are a number of different things that can cause compression of the nerves or blood vessels in thoracic outlet syndrome.

Having a cervical rib

About 1 in 10 people who have a cervical rib develop thoracic outlet syndrome. So, most people with a cervical rib do not develop any symptoms. Having a cervical rib can cause narrowing of your thoracic outlet, making compression of the structures that pass through it more likely.

Other congenital causes

Some people are born with an extra band of tissue underneath their skin around the thoracic outlet area called a fibrous band. This can act a bit like an extra rib and cause compression of the thoracic outlet in some people. Anomalous (or extra) muscles around the thoracic outlet that you may be born with can also cause narrowing and compression. Also, some people are born with an enlarged or elongated part of a vertebra in their neck which can cause compression in their thoracic outlet.

A recent accident

It is quite common for people with thoracic outlet syndrome to have a history of some kind of recent trauma to their neck. Trauma during an accident can cause structures in your neck and chest wall to move slightly and narrow your thoracic outlet. If you fracture (break) your clavicle (collarbone), broken bone fragments or bleeding due to the fracture can also cause narrowing of the thoracic outlet.

A job that involves repetitive movements

Thoracic outlet syndrome can be more common in someone who has a job that involves very repetitive movements or a lot of overhead work. Also, people who play a lot of sport, particularly sports that involve lots of arm movement are also more likely to develop thoracic outlet syndrome. For example, swimmers, javelin throwers and shot putters.

Poor posture

People with a poor posture and 'droopy' shoulders may be more likely to develop thoracic outlet syndrome. Sitting in front of a computer for long hours with a poor posture, an incorrect desk position, and an inadequate chair may be a cause. This poor posture can cause narrowing of your thoracic outlet.

Also, thoracic outlet syndrome can be a problem for women who have large breasts. Their breasts pull the muscles of their chest wall forwards and can cause narrowing of their thoracic outlet and lead to the typical symptoms.

Artery and vein problems

Narrowing and blockage of your artery or vein is another cause of thoracic outlet syndrome. Some people can have a congenital narrowing of one of these blood vessels. In these people, a blood clot can form if there is a period where the arm is overused. For example, weight lifting or working for long periods with your arms raised above your head.

In other people, the blood vessel narrowing may be caused by, for example, a cervical rib. Because of this narrowing, a blood clot is more likely to form in the artery or vein, which can lead to the typical symptoms of blood vessel compression (see below).

What are the symptoms of thoracic outlet syndrome?

The symptoms of thoracic outlet syndrome depend on what is being compressed.Symptoms are usually just felt on one side of the body. Rarely, symptoms can occur on both sides.

Symptoms due to nerve compression

Most commonly you will develop pain and pins and needles in your hand and arm,worse at night time and can sometimes wake you from your sleep.. You may particularly feel these along the inside of your arm and into your ring and little finger.

Neck, ear, upper back, upper chest and outer arm pain on the affected side. Some people also have headaches.
Your affected arm may feel weak. You may also notice that your affected hand gets very cold, especially in cold weather.

Symptoms due to blood vessel compression or blockage

In rare cases when your vein is compressed, your arm may become swollen and may sometimes appear a blue colour. The swelling may lead to pins and needles in your affected arm. Some people also develop pain in their arm. The symptoms tend to come and go and may be brought on at times when you are using your arms a lot. If you have a blood clot in your vein causing blockage of the vein, these symptoms will become constant and urgent treatment is needed.

In rare cases, when your artery is compressed blood is unable to get through to your arm and hand on the affected side as readily as it should do. Again this can lead to pain and pins and needles. Your arm and/or hand can appear pale white in colour and it can also feel cold. Like with the vein-related symptoms, the symptoms may be brought on by using your arms a lot.

How is thoracic outlet syndrome diagnosed?

Your doctor will usually start by asking you questions about your symptoms and examining you. If they suspect that you may have thoracic outlet syndrome, they may ask you to move your arms and shoulders into certain positions when they examine you. This is to try to induce, or bring on, your symptoms. They may then suggest certain tests to look for the underlying cause. Usually, thoracic outlet syndrome is diagnosed after other conditions that can cause pain or pins and needles in one of your arms have been excluded.

A chest X-ray and X-ray of your neck can show if you have a cervical rib
MRI or CT scan of your neck and upper chest area may help to rule out other causes for your symptoms, such as arthritis in your neck causing compression of the nerves in your neck.
Special tests called nerve conduction studies to show which nerves are being compressed.
Doppler test to determine blood flow through your arteries and veins.

What is the treatment for thoracic outlet syndrome?

Treatment depends on the underlying cause.

Blood vessel compression or blockage

In the rare case that you have blockage of one of your blood vessels by a blood clot, drug treatment is needed urgently to break down the clot. This drug treatment may then be continued for a period of time to prevent further clots. Surgery may also be needed to relieve any compression on your blood vessels. For example, removal of a cervical rib if present.

Nerve compression

There is not currently a consensus about what treatment is best for this type of thoracic outlet syndrome.However, in general, treatment is aimed at relieving your symptoms.

Physiotherapy may be helpful for some people and may include stretching exercises, exercises to improve posture and exercises to increase muscle strength and endurance. These exercises may all help to open up the thoracic outlet and relieve the compression.

You may also need to modify or change your work or sport activities. This may involve looking at the way that you sit in a chair or at your desk.

Drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) - for example, ibuprofen - may be helpful in relieving pain in some people. Paracetamol or stronger painkillers may sometimes be needed.

 Tricyclic antidepressants can ease nerve pain in some people separate to their action on depression.

In some cases, surgery to relieve the cause of the compression may be advised. For example, to ease pressure from a cervical rib, or from an extra muscle or fibrous band in your neck, or to repair a broken collarbone that is pressing on nerves (or blood vessels). However, in many cases, surgery is not a good option and may even be harmful. This is because there are many important structures in your thoracic outlet and there is a small risk of damage to these with surgery.

What is the prognosis (outlook) for thoracic outlet syndrome?

In most people with thoracic outlet syndrome, the outlook is generally good and symptoms often improve over time.
If compression or blockage of the artery or vein is diagnosed quickly and treated, a good recovery is possible. However, nerve compression symptoms can be difficult to treat in a few people. Chronic (persistent) pain and weakness with some loss of ability to use the affected arm may be experienced by some. This can sometimes be severe enough to affect your quality of life

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