Rudimentary cervical rib?

[vicky7749]

Hello,

I am a 22 year old female medical student with a past medical history of a L4/L5 disc prolapse with chronic radicular pain (a caudal epidural and a L5 nerve root block failed to provide long term relief). I take a combination of drugs to manage the pain, including gabapentin.

For the past year I have had persistant pain down my left arm and hand (C7-T1 dermatomes), which is sharp and constant in nature. I also have left shoulder pain and my trapezius is in constant spasm with severely reduced cervical spine range of motion. The hand/arm pain is worse when I use my arm, and when I wear a rucksack. I have dysthesia and paraesthesia in the left hand in the C7 and C8 dermatomes and weakness of the intrinsic muscles of the hand, in particular finger flexion, thumb adduction and finger adduction and abduction.

I also have acrocyanosis to both hands, but much worse on the left. In the cold my arm becomes globally weak, with no active movement possible and is numb; such sympoms are relieved by warming.

I have had a cervical MRI which did not show a cervical prolapse, only mild degenerative changes. It did show apparent stretching of the lower cervical spinal cord and bulging CSF of the lower cervical spine. I returned to radiology to have a thoracic MRI which was normal, so this was just put down as an anomaly. I have had nerve conduction studies of the median and ulnar nerve which were normal. My investigations by orthopaedics were stopped at this point, and the pain management service have put the neurological findings down to Wind-up/central sensitisation.

I am left hand dominant, and being a medical student in my clinical years of training the hand weakness and dysthesia severely limits my clinical work.

I have recently changed GP, and after her examining me she was not convinced that the neurovascular features were down to wind-up. I suggested a rudimentary cervical rib and I am currently waiting for a chest x-ray to look for this. Abduction of the arms exaccerbations my symptoms and causes a reactive hyperaemia of the left hand when the arm was adducted.

I wondered what your opinion was? as I would really like to get to the bottom of it. I have learnt to cope with my pain, (although sometime it can be just awful!) but the neurological deficits in my hand severly hinder my function, and I feel that my specialists have given up too soon looking for a diagnosis.

Thank you for your time
With best wishes
Vicky

[vicky7749]

Hello,

Thank you both for your replies.

In answer to dr_simran's questions, cervical spine range of motion is severely restricted in all directions but this is mostly due to muscle spasm as I have previously had short term benefit from acupuncture/benzodiazepines which improved range of motion, but my neurovascular symptoms were unchanged. I do not have a low hairline, in fact I have a long neck - why do you ask?

On palpation of the supraclavicular fossae, it is clear the scalene muscles are in spasm and in fact it is difficult to palpate any structures in this region because of it. In the lateral aspect of both supraclavicular fossae a hard band can be felt...I don't know whether this is of significance.

If I have had a cervical spine MRI would a rudimentary rib have been visible, as nothing was mentioned.

In reply to midasrex, I had EMG of adductor pollicis only and this was said to be normal.

Do you think its worthwhile I have a referral to neurosurgery? My orthopaedic surgeon has pretty much left it up to pain management as he did not understand what wind-up was, so therefore assumed this must be the correct diagnosis and he stopped investigating the cause.

Do you think I am onto the correct cause or am I clutching at straws at this point?
Thank you for your time
Vicky

[midasrex]

Your CXR will probably be normal, as above most people with thoracic outlet syndrome do not have calcified "ribs" at C7 that will show up on an Xray. You should have an MRI of the thoracic inlet/brachial plexus. I appreciate your median and ulnar conduction was normal but this test is pretty operator-dependent and you should have an EMG to look for denervation potentials as well. If all these tests are still inconclusive then it may still be reasonable for a surgeon with experience in this area, usually a neurosurgeon, to explore the area with a view to division of the head of scalenus medius and hence decompression of the lower trunks and subclavian vein.

[dr_simran]

Hello vicky7749,

Cervical rib syndrome: indefinite term, equally applicable to two different syndromes:
1) arterial thoracic outlet syndrome, in which the subclavian artery is compromised by a fully formed cervical rib, and
2) true neurogenic thoracic outlet syndrome, in which the proximal lower trunk of the brachial plexus is compromised by a translucent band extending from a rudimentary cervical rib to the first rib. Do you also have a decresd range of movements, low hairline, short neck? Answers to these questions would further help.

Best