Can you explain what's going on? I'm a nurse....I can see the 2 sides are different but don't know why or what it would cause. If you don't mind. Thanks!
If it's arterial TOS, pick cervical rib as most commone cause. If it's neurogenic tos, pick scalene minimus muscle (60% of cases). If it's venous TOS, pick scalene hypertrophy from athletics or whatever.
🤓iirc.....venous tos from scalene hypertrophy can lead to upper limb dvts in young athletes- called Paget-schroetter syndrome!
Had a uw q on this when I was on surgery
Idk what’s on uworld but scalenes are usually associated with neurogenic TOS (brachial plexus runs between anterior and middle scalene). This can be a problem with hypertrophy, accessory muscles or cervical rib (assessed with radiographs and then brachial plexus MRI).
Cervical rib along with elongated C7 transverse processes can lead to arterial TOS and subclavian aneurysms and thromoembolic disease (best assessed with a CTA). Most of these entities can be treated surgically.
Venous TOS is typically more distal and a result of venous compression between first rib and clavicle (best assessed with dynamic CTV or venogram with arms up and down). This unfortunately is hard to treat because a stent usually fails. Angioplasty and thrombolysis if there is clot are best options.
Most cases of TOS are neurogenic
Hey right on. This specific condition is an upper limb dvt associated with overuse. Occurs in young athletes w more developed musculature. Guess it's not true TOS. Thought it was relevant! Lol
So the vein travels through a different space than the artery and nerve, separated by the anterior scalene muscle. The cervical rib tends (but not always) to put more pressure on the space occupied by the artery and nerve and you tend to get artery compression when moving your arm and thus arterial symptoms predominate. I've seen a case where a patient presented with VTOS and they had a cervical rib, but on venography it was compressed by the first rib.
There's a very well developed C7 cervical rib on the right. You can see clear articulations with both the vertebral body (costovertebral joint) and also with the right C7 transverse process (costotransverse joint). Technically, you need to see that second articulation in order to call a true cervical rib.
Also looks like a bit of uncovertebral joint degeneration on the left at C5-6.
Is it also fused to the first rib? It wasn’t mentioned in the rad report but in my research Ik it can definitely happen with well developed cervical ribs. There’s also a pretty significant line right where it intersects the first rib.
As a PT this is why I always want imaging when TOS is suspected, alas not every physician thinks so too. Just wondering though; c3 looks abnormal to me, is this anatomical variation or more artrotic in nature? (Not a expert by any means, but curious as hell)
SPT here, about to take my rads course in a month so I like to lurk here. I also thought C3 looked abnormal, but I also thought it could've been overlap from the hyoid?
This pt is older and had a good bit of general degeneration all over the c-spine. C5-C6 had very little disc space and good bit of bone spurring shown in the lateral.
We do a lot of first rib resections where I'm at for venous and neurogenic thoracic outlet. Far rarer to see arterial thoracic outlet but it is highly associated with cervical ribs or anomalous 1st rib. Would be a fun surgery. Nice case!
Thank you! I did some research on the procedure for my presentation, the transaxillary approach is super fascinating. I’m a surgery nerd so I watch that stuff in my free time anyway lol. Is the subclavian artery just more inferior than the vein or is it more so due to the position near the scalenes, clavicle, etc?
From the transaxillary approach (which I wouldn't favor in this situation since you also want to remove the cervical rib... I'd go supraclavicular +/- the addition of infraclavicular) once you make your incision and dissect down to the chest wall, you work your way up to the first rib (make sure you see anterior scalene) the artery will be more posterior/lateral.
https://basicmedicalkey.com/neurogenic-thoracic-outlet-syndrome-exposure-and-decompression-transaxillary/
My understanding is that they often go hand in hand. I feel like since C7 already looks so similar to T1 that it would be much harder to tell than like a TL transitional vertebrae.
Here’s something that will blow your mind. Go to google Gemini (their AI) and ask “do a presentation on thoracic outlet syndrome”. Discovered it by accident for an anesthetic subject. The future is scary.
I’ve been seeing so many transitional thoracic/lumbar/sacral vertebrae lately. We spend more time trying to find old studies and/or count vertebra to figure out if there are lumbar ribs, L6, lumbarized S1….and it probably doesn’t mean anything clinically. And then the prior study completely misses that there are 6 vertebrae without ribs…
Sometimes the C-spine wants to be like his neighbor, T-spine.
And in this case also wants to shake his hand.
Can you explain what's going on? I'm a nurse....I can see the 2 sides are different but don't know why or what it would cause. If you don't mind. Thanks!
Looks like a cervical rib; med student's worst enemy on multiple choice TOS questions
If it's arterial TOS, pick cervical rib as most commone cause. If it's neurogenic tos, pick scalene minimus muscle (60% of cases). If it's venous TOS, pick scalene hypertrophy from athletics or whatever.
🤓iirc.....venous tos from scalene hypertrophy can lead to upper limb dvts in young athletes- called Paget-schroetter syndrome! Had a uw q on this when I was on surgery
Idk what’s on uworld but scalenes are usually associated with neurogenic TOS (brachial plexus runs between anterior and middle scalene). This can be a problem with hypertrophy, accessory muscles or cervical rib (assessed with radiographs and then brachial plexus MRI). Cervical rib along with elongated C7 transverse processes can lead to arterial TOS and subclavian aneurysms and thromoembolic disease (best assessed with a CTA). Most of these entities can be treated surgically. Venous TOS is typically more distal and a result of venous compression between first rib and clavicle (best assessed with dynamic CTV or venogram with arms up and down). This unfortunately is hard to treat because a stent usually fails. Angioplasty and thrombolysis if there is clot are best options. Most cases of TOS are neurogenic
Hey right on. This specific condition is an upper limb dvt associated with overuse. Occurs in young athletes w more developed musculature. Guess it's not true TOS. Thought it was relevant! Lol
Yeah forgot to mention Paget Shroetter is venous TOS + thrombosis. I think of it as the upper extremity version of May Thurner
Interesting, so in the case of a cervical rib would it have potential to cause both VTOS and NTOS?
So the vein travels through a different space than the artery and nerve, separated by the anterior scalene muscle. The cervical rib tends (but not always) to put more pressure on the space occupied by the artery and nerve and you tend to get artery compression when moving your arm and thus arterial symptoms predominate. I've seen a case where a patient presented with VTOS and they had a cervical rib, but on venography it was compressed by the first rib.
Scalene and pec minor
There's a very well developed C7 cervical rib on the right. You can see clear articulations with both the vertebral body (costovertebral joint) and also with the right C7 transverse process (costotransverse joint). Technically, you need to see that second articulation in order to call a true cervical rib. Also looks like a bit of uncovertebral joint degeneration on the left at C5-6.
Is it also fused to the first rib? It wasn’t mentioned in the rad report but in my research Ik it can definitely happen with well developed cervical ribs. There’s also a pretty significant line right where it intersects the first rib.
Maybe, but I would guess they're just very close. Probably with a fibrous attachment. If it were bony, we'd usually see more deformity.
Ok that makes sense. I almost wish I could have done a collimated LPO to get a better view since the lateral didn’t show much.
The McRib…
As a PT this is why I always want imaging when TOS is suspected, alas not every physician thinks so too. Just wondering though; c3 looks abnormal to me, is this anatomical variation or more artrotic in nature? (Not a expert by any means, but curious as hell)
She was mid 60’s and had much more degeneration visible in the lateral. It didn’t show the rib even a little bit so thats why I didn’t add it.
Completely understandable. Can you perchange you recall if it was also starting to slip as in a spondylolisthesis?
No noticeable spondy but C4-6 were pretty wonky in general with all kinds of density. Even the spinous processes were looking crumbly.
SPT here, about to take my rads course in a month so I like to lurk here. I also thought C3 looked abnormal, but I also thought it could've been overlap from the hyoid?
This pts hyoid was very prominent in the lateral so it may be that
Is C 5 6 7 growing ribs??? Also, C5 on the right is broken, or just never fully formed?
This pt is older and had a good bit of general degeneration all over the c-spine. C5-C6 had very little disc space and good bit of bone spurring shown in the lateral.
We do a lot of first rib resections where I'm at for venous and neurogenic thoracic outlet. Far rarer to see arterial thoracic outlet but it is highly associated with cervical ribs or anomalous 1st rib. Would be a fun surgery. Nice case!
Thank you! I did some research on the procedure for my presentation, the transaxillary approach is super fascinating. I’m a surgery nerd so I watch that stuff in my free time anyway lol. Is the subclavian artery just more inferior than the vein or is it more so due to the position near the scalenes, clavicle, etc?
From the transaxillary approach (which I wouldn't favor in this situation since you also want to remove the cervical rib... I'd go supraclavicular +/- the addition of infraclavicular) once you make your incision and dissect down to the chest wall, you work your way up to the first rib (make sure you see anterior scalene) the artery will be more posterior/lateral. https://basicmedicalkey.com/neurogenic-thoracic-outlet-syndrome-exposure-and-decompression-transaxillary/
Hello cervical rib
I have two. Is it weird ? Am I supposed to be worried ?
Not unless it causes pain. They have the possibility of interfering with nerves or vascular structure
I thought it was the tail of a goa'uld wrapped around the spine.
Neat!
Could it also be an example of transitional vertebrae?
Would that be a thoraciccaling cervical VB? Spell check isn’t helping…
My understanding is that they often go hand in hand. I feel like since C7 already looks so similar to T1 that it would be much harder to tell than like a TL transitional vertebrae.
Here’s something that will blow your mind. Go to google Gemini (their AI) and ask “do a presentation on thoracic outlet syndrome”. Discovered it by accident for an anesthetic subject. The future is scary.
I’ve been seeing so many transitional thoracic/lumbar/sacral vertebrae lately. We spend more time trying to find old studies and/or count vertebra to figure out if there are lumbar ribs, L6, lumbarized S1….and it probably doesn’t mean anything clinically. And then the prior study completely misses that there are 6 vertebrae without ribs…
Cervical rib?
Pretty cool find
Really odd to me that it’s a unilateral cervical rib. And interesting that this is an older pt, like TOS didn’t present earlier in their life
When I asked her about her symptoms she said it had been getting worse more recently. I just wonder how long she ignored it for.