Rib notching following subclavian artery obstruction.

Abstract

Attention was first focused on rib notching as a roentgenologic sign in 1928 when Roesler (18) reported its appearance in patients with coarctation of the aorta. He later noted (19) that “the erosion of the ribs is the most unequivocal sign (of coarctation of the aorta), although it is not always present nor is it always very marked.” In 1929 Railsback and Dock (17), apparently unaware of Roesler's report, published a case of rib notching associated with aortic coarctation, the first to appear in the English literature. They asserted that costal erosion is “undoubtedly pathognomonic of coarctation of the aorta.” This roentgen finding enjoyed the distinction of being a pathognomonic sign for some years. The first evidence that rib erosion could be secondary to causes other than coarctation appeared in 1933, when Hench and Horton (10) reported notching of the inferior borders of the left 7th and 8th ribs in a thirty-three-year-old female who had a loud to-and-fro murmur over the area. There was no clinical evidence of coarctation. The case was thought to represent one of arteriovenous fistula of the intercostal vessels. In 1937, Laubry and Heim de Balsac (12) discussed the value of rib notching in the diagnosis of coarctation of the aorta; as to it being a pathognomonic sign, they conclude: “cette assertion est exagérée.” They reported rib notching in 5 patients without coarctation, as follows: Case I: A 48-year-old female suffering from aortic valvular disease and hypertension. Right 5th rib eroded. Case II: A 50-year-old male with aortic valvular disease, hypertension, and heart failure. Left 8th rib notched. Case III: A 53-year-old male with syphilitic aortitis. Notching of the left 9th and 10th ribs. Case IV: Male, 24 years old, with relatively asymptomatic mitral valvular disease. Right 10th rib eroded. Case V: Female, age 35 years, with a systolic thrill and a double murmur at the base; blood pressure in the lower extremities higher than in the upper. Right 5th, 6th, 10th, and 11th ribs and the left 10th ribs scalloped by erosion. The authors did not account for the rib changes. McCord and Bavendam (14) suggest that in some of these cases the combination of arteriosclerosis and a wide pulse pressure resulted in pulsations of tortuous intercostal arteries of sufficient force to erode the ribs. They do not attempt any explanation of the changes in the non-hypertensive patients. Dussaillant, Viviani, and Moya (7) reported the case of a 58-year-old female with generalized arteriosclerosis and pulmonary emphysema. The blood pressure was 150/80 mm. Hg in the left arm and 153/85 in the right. The radial and femoral pulses were strong and equal. Over the left 8th and 9th intercostal spaces in the posterior axillary line there were palpable pulsations and a murmur. The heart size was normal. Roentgenograms showed marked notching of the inferior borders of the left 8th, 9th and 10th ribs. This was thought to be due to intercostal arteriosclerosis.