Long Cervical Costae Articulating with the First Ribs: A Salient Case of Thoracic Outlet Syndrome

Abstract

The complex of signs and symptoms caused by compression of brachial plexus and subclavian vessels in the cervicoaxillary region is known as thoracic outlet syndrome (TOS).1 Bones and the surrounding soft tissues may play an important role in its pathogenesis. Bony factors include the long transverse process of the seventh cervical vertebra, a cervical rib, an anomalous first rib, or fractures of the clavicle or first rib.2 The most common symptoms of TOS patients are pain and paresthesias in the supraclavicular, interscapular, subscapular, and cervical regions or in the upper limbs. Although less common, some patients also experience tachycardia, dyspnea, dysphagia, angina-like chest pain, occipital headache, Raynaud's phenomenon, or complex regional pain syndrome.2–4 The diagnosis of TOS is established clinically when relevant complaints of the patients are provoked during maneuvers such as Adson, costoclavicular, hyperabduction, or Roos tests. Radiologic evaluations may shed light on the underlying pathogenesis, and cervical radiographs are simply the initial step in this regard. More sophisticated tools such as Doppler sonography, magnetic resonance imaging/angiography, and three-dimensional computed tomography can also be used for further assessment. Herein, besides presenting a rare, interesting articulation bilaterally between the cervical costae and the first ribs in a patient with TOS, we highlight the importance of oblique cervical radiographs for better delineation of such deformities. A 44-yr-old man was seen for numbness and a tingling sensation in his hands that had persisted for 3–4 mos. Physical examination revealed ulnar hypoesthesia on the left side, and provocative maneuvers for TOS (Roos and costoclavicular) were bilaterally positive. Laboratory evaluations for neuropathies and electrodiagnostic studies including median and ulnar nerve motor/sensory conduction tests, F-wave measurements, and medial antebrachial nerve conduction tests were unremarkable. Cervical radiographs were taken as the initial step for radiologic diagnosis and evaluation. Posteroanterior views suggest an anomalous cervical rib (Fig. 1A), and oblique views clearly demonstrate bilateral long cervical costae (Fig. 1B). He was diagnosed to have TOS clinically—with regard to his symptoms and physical findings—and radiologically due to the aforementioned anomalies in the cervical region. Because he was decided to be treated conservatively, a home-based exercise regimen for strengthening the shoulder elevators was prescribed. He was found to have improved clinically on the first control visit after 3 mos.FIGURE 1: A, posteroanterior cervical radiograph depicting bilateral cervical costae articulating with the first ribs; B, right cervical radiograph (oblique view) clearly delineating the articulation