C7 Transverse Process Research Articles

Kinked again! From congenital brachial plexus palsy to adult neurogenic thoracic outlet syndrome: Case Report.

Neurogenic thoracic outlet syndrome (nTOS) is a chronic, focal lesion of the lower trunk of the brachial plexus or of the T1 and C8 anterior primary rami, often arising due to distortion of neural structures by a fibrous congenital band extending from a C7 transverse process or cervical rib. Accordingly, patients present with chronic weakness or atrophy of the hand, most prominently of the thenar eminence, which receives most innervation from the T1 root. We present clinical, electrophysiologic, and imaging findings in a case of nTOS presenting in an adult with a history most suggestive of congenital brachial plexus palsy (CBPP), another pathology sharing the mechanism of nerve compression or injury within the supracostoclavicular space. The patient had new right thenar eminence atrophy and a lifelong history of medial forearm sensory deficit and she improved after first rib resection. The convergence of two disorders in the same patient arising in different phases of life illustrates how anatomic or structural variation in this space can predispose to lower brachial plexus injury.

Musculoskeletal Ultrasound to Identify Changes in Obliquus Capitis Inferior Muscle & Position of Atlas After a Manual Stretch

Introduction: Cervicogenic headache (CGH) is a prevalent condition caused by a disorder of the cervical spine that is commonly accompanied by neck pain and headaches. There is limited research regarding interventions benefiting CGH long-term. Interventions geared toward the suboccipital musculature may be used to improve CGH symptoms due to their anatomical connection to the cervical spine. Purpose: To determine if an isolated manual stretch of the obliquus capitis inferior will create a change in muscle diameter and length and position of atlas relative to axis. Methods: This quasi-experimental study used a single group of 36 subjects. Pre- and post-test measurements of the muscle diameter and length of the obliquus capitis inferior and the distance between atlas and axis were obtained using musculoskeletal ultrasound before and after our manual stretching intervention. Results: The results showed a significant increase in both measures, indicating increased length of the right Obliquus Capitis Inferior and the distance between the transverse process of C1 and spinous process of C2 after the manual stretch was applied. The average width of the right Obliquus Capitis Inferior was found to be 1.01 cm prior to applying the manual stretch and 1.99 cm after applying the manual stretch, demonstrating an increase in the width of the R OCI pre- and post-stretch. Conclusion: The results of this study indicate that the application of a manual static stretch held for 2x30 seconds will produce and immediate and significant increases in muscle length and width of the right Obliquus Capitis Inferior. Further research should be conducted to establish validated stretching parameters targeting the suboccipital muscles and further examine the effects of these muscles on CGH symptoms

Minimally invasive resection of a prominent transverse process in neurogenic thoracic outlet syndrome: new application for a primarily spinal approach. Illustrative case.

The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient's anatomy as well as the surgeon's experience. The authors present a minimally invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma. A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia. The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.

Interrater agreement and reliability of a palpation method for locating C1 transverse process in the cervical spine

ObjectivesTo examine the agreement and interrater reliability of a palpation method for locating the C1 transverse processes (C1TP) and the association between personal characteristics with the observed agreement. MethodsSingle-blinded, inter-rater reliability study. Ninety-nine participants (58 women, age 44 ± 10 years, body mass index 26.1 ± 4.3 kg/m2, neck disability index = 8.4 ± 7.3 points) were enrolled in this study. Two raters blinded to each other's assessment performed the palpation for locating the C1TP and marked it with invisible ultra-violet ink. A research assistant measured the distance between the skin marks labeled as C1TP. The association between sex, age, body mass index, neck pain intensity and disability on the interrater agreement was verified using a point-serial correlation coefficient. ResultsAbsolute and percent agreement for the right and left body sides were 90/99 (90.9 %, 95%CI 83.4 to 95.8) and 96/99 (97.0 %, 95%CI [91.4 to 99.4]), respectively. Interrater reliability was excellent for both right (Gwet's AC1 0.883, 95%CI [0.881 to 0.885]) and left body sides (Gwet's AC1 0.894, 95%CI [0.894 to 0.896]). After adjustment for multiple comparisons, no statistical evidence of correlation was observed for age, sex, body mass index, and NDI with the agreement for location of C1TP (r = −0.206 or lower, adjusted P-value = 0.328 or higher). ConclusionsThe palpatory method for the location of C1TP has excellent interrater agreement and reliability. Age, sex, body mass index, and disability show weak-to-negligible correlation with the agreement for location of C1TP. Implication for practice•A palpation method should be accurate and reliable for being introduced in clinical and laboratory settings•This is the first study to report interrater reliability results for locating C1 and the reliability is excellent•The result of our study increases our confidence in recommending the location of C1 in clinical practices when performing mobility tests for C0–C1–C2, the great nerve occipital palpation, as a start landmark for suboccipital muscle palpation and when applying direct manual procedures to restore mobility in C1–C2 segments as muscle energy technique, high-velocity low amplitude (HVLA) manipulation and mobilization with movement techniques•These results benefit the manual therapist's education process as palpatory skills and surface anatomy are core subjects in manual therapy education, including osteopathy, despite the lack of validation of most palpation methods

Extreme lateral infracondylar approach for internal jugular vein compression syndrome: A case series with preliminary clinical outcomes.

Internal jugular vein (IJV) stenosis is associated with several neurological disorders including idiopathic intracranial hypertension (IIH) and pulsatile tinnitus. In cases of extreme bony compression causing stenosis in the infracondylar region, surgical decompression might be necessary. We aim to examine the safety and efficacy of surgical IJV decompression. We retrospectively reviewed patients who received surgical IJV decompression via the extreme lateral infracondylar (ELI) approach between July 2020 and February 2022. Fourteen patients with IJV stenosis were identified, all with persistent headache and/or tinnitus. Six patients were diagnosed with IIH, three of whom failed previous treatment. Of the eight remaining patients, two failed previous treatment. All underwent surgical IJV decompression via styloidectomy, release of soft tissue, and removal of the C1 transverse process (TP). Follow-up imaging showed significant improvement of IJV stenosis in eleven patients and mild improvement in three. Eight patients had significant improvement in their presenting symptoms, and three had partial improvement. Two patients received IJV stenting after a lack of initial improvement. Two patients experienced cranial nerve paresis, and one developed a superficial wound infection. The ELI approach for IJV decompression appears to be safe for patients who are not ideal endovascular candidates due to bony anatomy. Confirming long-term efficacy in relieving debilitating clinical symptoms requires longer follow-up and a larger patient cohort. Carefully selected patients with symptomatic bony IJV compression for whom there are no effective medical or endovascular options may benefit from surgical IJV decompression.

The importance of the cricoid cartilage as an anatomic land mark of cervical level

BackgroundWe aimed to evaluate the correlation of the changes radiologically in the vertebral level of the cricoid cartilage according to age and gender to reduce the application difficulties and complication rates in cervical region nerve blockades and surgeries.ResultsThe mean age of all patients included in the study was 56.06 ± 17.22 years. We observed that while the line drawn from the cricoid cartilage to the vertebral column level passed over the C6 transverse process in women, it was below the C6 transverse process in men. A significant difference was also observed between the vertebral corpus level according to gender (p < 0.001). We could not find a significant difference between the transverse process and corpus level according to age.ConclusionsWe found a significant difference according to gender in the correlation of the cervical vertebra transverse process and corpus with the cricoid cartilage line which are two important levels frequently used in clinical practice to ensure successful and non-complicated blockage.

Soft Tissue Dissection in the Transcondylar Approach: A Modified Layered Technique to Maximize Lateral Access.

Objective While the transcondylar approach is technically challenging, it provides generous ventral and caudal exposure to the craniovertebral junction. This approach requires navigation around multiple eloquent neurovascular structures including the lower cranial nerves, vertebral artery and its branches, and the brainstem. Superficial exposure, including incision location and muscle dissection, can dramatically affect the surgical angle and maneuverability at depth. Methods We demonstrate the transcondylar approach in a step-by-step fashion in a formalin-embalmed, latex-injected cadaver head. Dissection within each layer of the suboccipital muscles was performed. A small cohort with an illustrative case is also included herein. Results The sternocleidomastoid (SCM) muscle was retracted anteriorly; the splenium capitis, semispinalis capitis, and longissimus capitis muscles were disconnected from the superior nuchal line and reflected inferomedially. The suboccipital muscle group was fully exposed. The superior and inferior oblique muscles were disconnected from the transverse process of C1. The superior oblique and the rectus capitis posterior major muscles were then dissected off the inferior nuchal line, and the suboccipital muscle group was retracted inferomedially en bloc . The greater auricular nerve was retracted laterally with the SCM, and the greater occipital nerve was retracted inferomedially with the suboccipital muscle group. Conclusion This technique avoids the obstructive muscle bulk that results from a myocutaneous approach while maximizing deep exposure. Understanding the detailed muscular anatomical relationship with the insertion location and suboccipital nerves is key to complete and safe extracranial dissection. Diligent dissection helps minimize postoperative pain and muscle spasm while optimizing the closure technique.

Paracondylar process and epitransverse process on cone beam computed tomography: a pictorial review based on a serie of 9 patients

Objective: Paracondylar (PCP) and epitransverse processes (ETP) represent rare types of articulations that can occur between the occipital bone and the transverse process of atlas vertebra.&#x0D; Material and methods: Five systematic search strings were conducted on PubMed database on 14.01.2022. The search was conducted by one observer to identify studies on PCP, and on ETP in living patients. Open and close access articles were selected as this topic is infrequently described in the main medical literature.&#x0D; Results: We provided with a pictorial review of 1) Paracondylar tubercle, 2) Unilateral PCP with cylindrical shape, 3) Unilateral PCP with pyramidal shape, 4) Unilateral PCP with lateral joint with transverse process, 5) Unilateral PCP with superior joint and partial fusion with transverse process, 6) Unilateral ETP with neo-condyle and joint with occipital condyle, 7) Unilateral ETP with joint with occipital bone, 8) Unilateral ETP with a bony bridge with lateral mass (ponticulus lateralis), and 9) Bilateral variation: paracondylar mass and ETP.&#x0D; Conclusions: Six figures were found in the selected literature and belong only to articles published in closed access. We provided with additional 41 open access freely available figures. We were first to present CBCT reference figures of: 1) Unilateral paracondylar tubercle, 2) Fusion of PCP with the transverse process of C1, 3) Joint between ETP and the lateral side of occipital condyle, and 4) Presence of bony bridge (ponticulus lateralis) between ETP and the lateral mass of C1. We were also first to describe a bilateral mixt variation with paracondylar mass on one side and ETP on the other side of C1. An open and accessible knowledge support (such as Nemesis journal) is needed to easily find clinical reference CBCT figures of craniocervicofacial bone variations.&#x0D;

Prevalence of cervical ribs and elongated transverse processes in Omani population: a computed tomography-based study

Cervical ribs are the supernumerary ribs that usually arise from the seventh cervical vertebra. Ethnic and geographical variations in cervical ribs and elongated transverse processes have been reported. Therefore, we aimed to study the prevalence of cervical ribs and elongated transverse processes and morphometry of cervical ribs in Omani subjects using computed tomography (CT). A total of 1165 consecutive patients' CT scans of the cervical spine who had visited the tertiary care hospital from January 2016 to December 2020 were included in the study. The CT scans were screened for cervical ribs and elongated C7 transverse processes. Fisher's exact test was used to determine the gender influence. Cervical ribs were identified in 0.94% of patients with a male-to-female ratio of 0.37:1. Most cervical ribs were unilateral (54%). The elongated C7 transverse process was identified in 18.45% of patients, with a male-to-female ratio of 1.36:1. Female patients are more likely to have cervical ribs (effect size = 5.98, 95% CI = 1.58-22.6, p = 0.005) than male patients. In contrast, the elongated C7 transverse process is more frequent in males (effect size = 1.82, 95% CI = 1.34-2.47, p < 0.001). The length and width of the cervical ribs are presented. The prevalence of cervical ribs in Omani subjects is close to that of accepted prevalence worldwide. However, the elongated C7 transverse process prevalence is comparatively high and close to the Saudi population.

Entrance and origin of the extracranial vertebral artery found on computed tomography angiography

To investigated morphological variability of vertebral artery (VA) origin and its entrance level into cervical transverse foramina by computed tomography angiography (CTA). To retrospectively investigated CTA of 223 subjects (446 VA courses). Investigated were origin of the VA and its level of entrance into vertebral transverse foramen with notification of the sex and side of variation. The VA entered the C6 transverse process in 91.70% of specimens (409 out of 446 VA courses). Abnormal entrance of VA was observed in 8.30% of specimens (37 VA courses), with the level of entrance into the C3, C4, C5, or C7 transverse foramen at 0.22%, 2.47%, 4.71% and 0.90% respectively. Comparably, the overall variability of abnormal origin of VA was 1.57% (7 out of 466 VA courses), in which the left vertebral arteries all arose from aortic arch. The variation rate of vertebral entrance rose up to 50% in abnormal origin subgroup. When comparing subgroups of subjects with normal and abnormal origin, there was significance difference in the frequency of entrance variation in the level of transverse foramen (p < 0.001). Abnormal entrance and origin of VA were observed in 8.30% and 1.57% of VA courses, which can be accurately appeared by CTA. Regarding to the subgroups of abnormal origin, the frequency of entrance variation was significantly increased in the level of transverse foramen compared to that of normal origin.

Visualizing stellate ganglion with US imaging for guided SGB treatment: A feasibility study with healthy adults.

ObjectiveAs for ultrasound (US) guided stellate ganglion (SG) block, unsatisfactory curative outcomes and complications still remain. This problem could be greatly improved by identifying and monitoring SG. To the best of our knowledge, there are few reports to directly visualize SG in literature. This study explored the feasibility of detection of SG and summarized the findings of SG through US.MethodsFifty healthy adults with 100 SGs were enrolled. The size, shape, echogenicity, margin, the inferior pole of SG, the relationship between the superior pole of SG and the transverse process, the relationship between the superior pole of SG and the inferior thyroid artery, and the relationships between SG and other surrounding tissues were evaluated by US.ResultsThe SG was identified in 79% of the participants. No significant differences were found between the right and left sides regarding thickness, cross-sectional area (CSA), and position (all p > 0.05); however, there was a significant difference in the width of the right and left sides (p < 0.05). Side was associated with SG visibility (p < 0.05), however, the gender was not (p > 0.05). A total of 42% of SGs were oval-shaped. All SGs were hyperechogenic and had an ill-defined margin. In fact, 63% of SGs were located in the C7 transverse process level, 77% of SGs were located under the inferior thyroid artery, and all of these SGs were located lateral to the thyroid and medial to the anterior scalene muscle and the vagus nerve.ConclusionOur preliminary study demonstrates that US imaging provides the capability of detecting SG. This may be helpful in minimizing complications and improving the accuracy of US-guided SG block.

Accuracy of Palpation Procedures for Locating the C1 Transverse Process and Masseter Muscle as Confirmed by Computed Tomography Images

ObjectiveThe purpose of this study was to examine the accuracy of palpation methods for locating the transverse processes of the first cervical vertebra and masseter muscle using radiographic images as the gold-standard method and the association between personal characteristics with the observed accuracy. MethodsThis was a single-blinded, diagnostic accuracy study. Ninety-five participants (49 women, 58 ± 16 years of age) were enrolled in this study. A single examiner palpated the neck and face region of all participants to identify the transverse processes of the first cervical vertebra and masseter muscles bilaterally. In sequence, participants underwent a multislice computed tomography scan for assessment of the superimposed inner body structure. Two radiologists assessed the computed tomography images using the same criteria and were blinded regarding each other's assessment and the anatomic landmarks under investigation. The palpation accuracy was calculated as the proportion of the correctly identified landmarks in the studied sample. The correlation of the palpation outcome (correct = 1; incorrect = 0) with age, sex (male = 1; female = 0), and body mass index was investigated using the point-biserial correlation coefficient. ResultsThe right and left transverse processes were correctly located in 76 (80%) and 81 (85%) participants, respectively, and bilaterally in 157 events (83%), as evaluated by the consensus of the 2 radiologists. The masseter muscles were correctly localized bilaterally in 95 of 95 (100%) participants. Body mass showed statistical evidence of a weak, positive correlation with the correct location of the transverse processes of the first cervical vertebra at the right body side (r = .219; 95% confidence interval, 0.018-0.403; P = .033). ConclusionPalpation methods used in this study accurately identified the location of the first cervical vertebra spinous processes and the masseter muscles.

Effects of Stellate Ganglion Block Through Different Approaches Under Guidance of Ultrasound.

ObjectiveThis study aimed to investigate the effects of stellate ganglion block (SGB) through different approaches under guidance of ultrasound.MethodsA total of 130 patients undergoing SGB in our hospital between February 2019 and February 2020 were enrolled as the research subjects. According to the random number table method, these subjects were divided into two groups: a modified 6th cervical vertebra (C6) group (n = 65) and a 7th cervical vertebra (C7) group (n = 65). Under the guidance of ultrasound, the subjects in the modified C6 group were punctured at the level of the C6 transverse process, and the subjects in the C7 group were punctured at the level of the C7 transverse process. The operation duration, number of puncture angle adjustments, block effects, and adverse reactions for SGB were compared between the two groups.ResultsThe modified C6 group showed shorter SGB operation duration and a lower number of puncture angle adjustments than the C7 group, and the differences were statistically significant (P < 0.05). Horner Syndrome occurred in both groups after SGB. The incidence of adverse reactions in the modified C6 group was 4.62%, comprising 1 case of hoarseness and 2 cases of slowed pulse, while that in the C7 group was 6.15%, with 1 case of hoarseness and 3 cases of slowed pulse; the difference between the two groups was not statistically significant (P > 0.05).ConclusionThe operation duration for modified SGB guided by ultrasound puncturing at the C6 transverse process is shorter and requires fewer puncture angle adjustments than puncturing at the C7 transverse process; however, there is no significant difference between the incidence of adverse reactions or the blocking effects of the two methods.

Evaluatation Of Rib Variations In Chest Radiograph

Rib variations are usually incidental findings on imaging studies and are rarely symptomatic. If in adequately evaluated they are easily overlooked as most of the X-ray is aimed at evaluating the lung parenchyma. Trauma related lesions might usually be misinterpreted as rib variations and sometimes rib lesions may mimic a variant of rib and radiologists should be familiar with a number of normal variants of the ribs to avoid mistaking them for an abnormality. In this article we will discuss and illustrate variety of anatomical rib variants and their incidence in this given population. Anatomical rib variants include developmental deformities, cervical rib, Bifid (forked), fused rib and hypertrophied transverse process of C7 be used. The aim of our study is to have a comprehensive evidence-based morphological assessment of normal anatomical variations of ribs and their prevalence in this population. A Retrospective study of Chest radiographs of 1000 adults who visited our hospital for a routine check-up or for various medical examinations from September 1st 2018 to September 30th 2018, were consecutively reviewed for normal variations of rib. In our study of 1000 radiographs (Male 652 and female 348), there are 10 cervical ribs, 5 bifid ribs, 16 cases of hypertrophied transverse process and 3 fused rib. Thus in conclusion, the knowledge of incidence of normal anatomical variations of ribs and their appearance in a given population is important for radiologist as it avoids any misinterpretation of these relatively normal variants and signals a possibility of neurovascular compression if clinically relevant.

Styloidogenic-cervical spondylotic internal jugular venous compression, a vascular disease related to several clinical neurological manifestations: diagnosis and treatment-a comprehensive literature review.

Internal jugular vein (IJV) stenosis is associated with several central nervous system disorders such as Ménière or Alzheimer’s disease. The extrinsic compression between the styloid process and the C1 transverse process, is an emerging biomarker related to several clinical manifestations. However, nowadays a limited number of cases are reported, and few information are available about treatment, outcome and complications. Our aim is to collect and identify clinical-radiological characteristics, diagnosis and treatment of the styloidogenic internal jugular venous compression. We performed a comprehensive literature review. Studies reporting patients suffering from extracranial jugular stenosis were searched. For every patient we collected: demography, clinical and radiological characteristics and outcome, type of treatment, complications. Thirteen articles reporting 149 patients were included. Clinical presentation was non-specific. Most frequent symptoms were headache (46.3%), tinnitus (43.6%), insomnia (39.6%). The stenosis was monolateral in 51 patients (45.9%) and bilateral in 60 (54.1%). Anticoagulants were the most common prescribed drug (57.4%). Endovascular treatment was performed in 50 patients (33.6%), surgery in 55 (36.9%), combined in 28 (18.8%). Improvement of general conditions was reported in 58/80 patients (72.5%). Complications were reported in 23% of cases. Jugular stenosis is a complex and often underestimated disease. Conservative medical treatment usually fails while surgical, endovascular or a combined treatment improves general conditions in more than 70% of patients.

Venous Thoracic Outlet Syndrome in Three Greek Children: a Single-Centre Experience

Thoracic outlet syndrome (TOS) is underdiagnosed in children/adolescents. We describe three cases of children/adolescents with TOS diagnosed within one year in our Haemostasis and Thrombosis Unit: 1) a 14-year-old girl with sudden onset of left arm oedema- thrombosis of the left subclavian vein and filling defect in both subclavian veins due to an elongated C7 transverse process, 2) a 13-year-old swimming champion with sudden onset of right arm oedema and 3) an eight-year-old girl with left arm discomfort (already on anticoagulation due to cerebral sinovenous thrombosis) and complete outflow interruption of the left subclavian vein. All three girls have been on anticoagulation for 18, 6 and 4 months respectively without symptoms. Conclusion: These three cases underline physicians TOS awareness concluding in diagnosing in children/ adolescents and demonstrate a clinically satisfying outcome of pediatric TOS with initially conservative treatment, surgery planning and continuing follow-up.

Modern Diagnosis and Surgical Management of Thoracic Outlet Syndrome: A Comprehensive Review

Conventionally TOS has been thought to represent a group of diverse disorders that result in compression of the neurovascular bundle exiting the thoracic outlet. Until recently, TOS classification has been based on symptoms, rather than the underlying pathology, with the subgroups consisting of neurogenic (NTOS), venous (VTOS or PSS), and arterial (ATOS). Neurogenic TOS accounts for over 95% of the cases, followed by venous (3–5%) and arterial (1–2%). Neurogenic TOS (NTOS) has been further divided into True NTOS (TNTOS) and Disputed NTOS (DNTOS), with DNTOS reportedly representing 95–99% of all neurogenic cases. In order to decrease confusion and to improve therapeutic results with TOS, the disease should be classified based on the underlying pathologic entity. Acquired and traumatic abnormalities of the clavicle and first rib should be classified separately. Clearly after the more common and objectively supported diagnoses of conditions that result in neurovascular symptoms of the upper extremity, such as cervical spine disease, carpal tunnel disease, and nerve entrapment syndromes, have been ruled out, there remains a group of patients who are suspected of having TOS. In these patients, rather than the more usual classification such as arterial, venous, or neurogenic, the more accurate approach from a diagnostic and therapeutic approach is to classify them as: Cervical Rib Disease: Patients with cervical rib syndrome (CRS) can have complications relating to compression of the subclavian artery (previously referred to as ATOS) and the brachial plexus(previously referred to as True NTOS) secondary to a well-formed cervical rib, or to an incompletely formed first rib, fibrous band associated with a rudimentary cervical rib, or a giant transverse process of C7. Thoracic Outlet Disease or “Subclavian Vein Compression Syndrome”: In these patients an abnormal first rib at its junction with the sternum results in compression of the subclavian vein at the subclavian-innominate junction. Compression of the vein results in venous hypertension in the upper extremity and resultant neurologic symptoms. With prolonged compression of the subclavian-innominate junction, the vein clots giving rise to Paget–Schroetter syndrome. Therefore, patients who have been previously classified as Disputed Neurogenic and Venous TOS represent a variable symptomatic presentation of the same pathologic entity, which affects the subclavian vein. Presently MRA of the thoracic outlet with arm maneuvers is the test of choice in patients suspected of having TOS. This test shows the abnormal bony tubercle on the first rib with extrinsic compression of the subclavian innominate junction, which is exacerbated with elevation of the arm above the shoulder. Robotic resection of the medial aspect of the first rib along with disarticulation of the costo-sternal joint has the best reported results to date.

In Reply: C1 Transverse Process Resection for Management of Jugular Stenosis.

In Reply: C1 Transverse Process Resection for Management of Jugular Stenosis.

Transaxillary Approach for First Rib Resection in Combined Neurogenic and Vascular Thoracic Outlet Syndrome with Elongated C7 Transverse Process and Status Post Breast Implantation: A Case Report

Combined neurogenic and arterial Thoracic Outlet Syndrome (nTOS and aTOS) is a rare disease. First rib resection with scalenectomy is a mainstay of treatment. TOS results from pathology in the interscalene triangle. Many etiologies were described as its contributing factors, however, to the author’s knowledge, axillary breast implantation had not yet been described. In patients who have mild anatomical pathology, scar formation from axillary surgery may aggravate TOS symptoms. The author wishes to present a case of mild elongated C7 transverse process that then underwent breast implantation, subsequently developed combined nTOS and aTOS, successfully managed through transaxillay first rib resection and scalenectomy.

Commentary: C1 Transverse Process Resection for Management of Jugular Stenosis.

Commentary: C1 Transverse Process Resection for Management of Jugular Stenosis.