operative procedure of symptomatic cervical ribs

1. Symptomatic cervical
rib surgery

2. Presented by
• Dr.Abu Bakar Siddique
Ms,WOC-SICOT Fellow,
Fellow Spine microsurgery
Orthopaedic consultant.

3. 0
10
20
30
40
50
60
70
80
90
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
East
West
North
Cervical rib
• Rare condition.
• approximately 1% of
total population having
cervical rib.

4. Incidence
• Though 90% are asymptomatic.
• Only 10% people produce
symptoms.

5. Thoracic outlet syndrome. since
1956, before that it was called as
Naffziger syndrome

6. • Over 90% of all TOS are
neurogenic.
• 3-5% are venous.
• Less than 1% are arterial.
nTOS

7. TOS VS CERVIAL
RIB

8. Aetiology of TOS
• Scalene muscle variants,
abnormal tendinous band,
neck trauma, etc can also may
produce TOS.

9. Rare cases
• fracture
• Arthritic condition
• Hormonal deficiency
• Lung pathology are involved.

10. Clinical presentation
Painful grasping.
Painless wasting of hand muscle.
Numbness and tingling of upper limb.
Vague aching pain of whole arm.
Non radicular pattern of involvement.

11. Anatomy
Compression, Traction or
friction of brachial
plexus, Subclavian
vessels.

15. Examination
•Disease of the neck and
arm are excluded.
•Adson’s manoeuvres .
•Spurling’s sign
•Hyperabduction
test.

17. Investigation
Blood count.
CXR

18. Pre operative x-ray

19. Cervical rib surgery
• Technically demanding surgery.
• Vital neck structures & critical
relations are very important

20. Vital structures in
thoracic outlet

21. History of Rib suurgery
• The first resection
of cervical rib was
performed Coote in
1861 due to TOS

22. 3 patients
one male, two
female

23. Impact foundation hospital
Study period:
2010-2013

24. Conservative
nonresponsive
• All patients are treated
conservatively for 3-4
wks before surgery.

25. Conservative
treatment
• Shrugging
exercise.
• Avoid heavy lifting
• Correct posture
• NSAID
• Physiotherapy

26. Operative position
Extended neck position

27. Supraclavicular incision

28. Subclavian artery,Bracheal
plexus,Phrenic nerve & apex of lung

29. Careful and meticulous
dissection

30. Blunt dissection

31. Fine curette can be use

32. Protection of vital
structures during bone cut

33. spine up cut can be use
to make a good room for
bone nibbler.

34. release should be
very gentle

35. Preservation of the
phrenic nerve

36. Phrenic nerve

37. Inter scalene
surgery

38. Scalenectomy

39. Adhesion cut

40. MEAN FOLLOW UP
PERIOD:
11 MONTH

41. Follow up

42. Follow up

43. Results
• Numbness and tingling went
up following surgery
• Painless grasping observed
on 3rd POD
• All patients relieved from
other symptoms within 3
weeks of surgery except one
who develop numbness &
tingling after surgery (Ist
POD onwards)

44. Results
• It relieved
gradually by 6
wks.
• All are happy
with surgery

45. Complications
• Respiratory distress
during reversal from
anaesthesia and
managed in operation
theatre. Later on pt.
developed mild haemo
pneumuthorax and
resolved
spontaniously.

46. Conclusion
• Early outcome after symptomatic
(neurogenic TOS) cervical rib
surgery is satisfactory.A very small
sample size is not good enough to
make a

47. Careful clinical
evaluation,Appropiate
diagnosis,application
of sound anatomical
knowledge & caring
peroperative tissue
handling are the
secrate of successd.