Cervical Rib

Original Editor - Chelsea Mclene

Top Contributors - Chelsea Mclene and Aminat Abolade  

Introduction

Cervical rib also known as "neck rib" or "supernumerary rib in cervical region" is an extra rib[1] that forms above first rib[2] which grows from the base of the neck just above the collarbone. It is a congenital overdevelopment of transverse process of cervical spine vertebra[3]. It can be on right, left or both sides and may be floating with no connection[4], fully formed bony rib or a thin strand of tissue fibre. They vary in size and shape.

In few cases, people having cervical rib may develop thoracic outlet syndrome[4] because of pressure on the nerves that may be caused by the presence of the rib. Partially formed extra rib may end in a swelling that shows as a lump in neck or it may tail off into a fibrous band of tissue that connects to the first proper rib[5]. Most cases are not clinically relevant and do not have symptoms. They are generally discovered incidentally during x-rays and CT scans.[6]

A cervical rib represents a persistent ossification of the C7 lateral costal element. During early development, this ossified costal element typically becomes re-absorbed. Failure of this process results in a variably elongated transverse process or complete rib that can be anteriorly fused with the T1 first rib below.[7]

[8]

Structure And Function

The cervical rib consists of a head, neck, and tubercle. It is attached posteriorly to the first rib by a fibrous band near in the insertion of the anterior scalene muscle. Cervical rib has no physiological function.

There are four types of cervical ribs:

  • Type 1: Complete rib that articulates with the first rib or manubrium
  • Type 2: Incomplete rib with a free distal tip
  • Type 3: Incomplete rib with a distal fibrous band attachment
  • Type 4: Short piece of bone extending beyond the C7 transverse process

Associated Conditions

  • Thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery.
  • Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand.
  • Compression of the subclavian artery is often diagnosed.
  • Compression of the sympathetic chain may cause Horner's syndrome.[5]

Symptoms

Local Symptoms

  • Tender supraclavicular lump which is bony hard and is fixed when palpated.

Sensory Symptoms

  • Tingling in hands or fingers; confined either to radial side or ulnar side or sometimes involve even whole hand.
  • Pain which may radiate down the arm.

Vascular symptoms

  • Cold and clumsy extremities, particularly the fingers.
  • Skin colour changes to blue associated with trophic changes.
  • There is rare risk of gangrene.
  • Radial pulse becomes feeble or may even be absent.

Motor Symptoms

  • Loss of hand grip.
  • Tendency of dropping things from the hand.
  • Wasting of palmar muscles[9][10]

Diagnosis

Imaging

Cervical ribs are a rare occurrence in the population with an incidence of under 1% and are often an incidental finding on radiographic imaging. they can be distinguished because their transverse processes are directed inferolaterally, whereas those of the adjacent thoracic spine are directed anterolaterally.[11][12]
Cervical-ribs.jpg
[13]

Special Tests

  • Adson's test
  • Spurling's test
  • Shoulder Abduction test: It is an orthopaedic test used to diagnose a cervical nerve root injury or cervical disc herniation. It is performed by having the patient abduct their shoulder and place their hand on top of their head. A positive test will involve a decrease in radiculopathy or pain.

Differential Diagnosis

Management

1. Medical Management

  • Anti-inflammatory drugs
  • Analgesics

2. Surgical Management

  • Removal of extra segment.
  • Complete resection of the rib.
  • Dividing the scalene group of muscles.
  • Resection of cervical ribs for thoracic outlet syndrome.

3. Physiotherapy Management

On the basis of symptoms, the regime is planned.

  • Pain relief: Short wave diathermy is used but it is contraindicated in case of sensory impairments.
  • To improve distal circulation: Gripping exercise.
  • Strengthening exercises of whole arm to improve tone, power and endurance.
  • Posture Correction.
  • Specific exercises like Self resisted scapular elevation and adduction.
  • Endurance training.
  • Progressive resistance exercises for shoulder girdle muscles.[9]

References

  1. Cervical Rib. Healthily. Available from https://www.livehealthily.com/neck-pain/cervical-rib [last accessed 05/11/2020]
  2. Cervical Rib. NHS. Available from https://www.nhs.uk/conditions/cervical-rib/ [ last accessed 05/11/2020]
  3. Fliegel BE, Menezes RG. Anatomy, Thorax, Cervical Rib.[updated 2020 Aug 22]. In:StatPearls[Internet].Treasure Island(FL): stat pearls publishing; 2020 jan.
  4. 4.0 4.1 Dr. Colin Tidy. Cervical Rib. Thoracic outlet syndrome. Patient. Available from https://patient.info/bones-joints-muscles/cervical-rib-thoracic-outlet-syndrome [last accessed 05/11/2020]]
  5. 5.0 5.1 Giles, Lynton G. F. (2009-01-01), Giles, Lynton G. F. (ed.), "Case 67 - Cervical ribs"100 Challenging Spinal Pain Syndrome Cases (Second Edition), Edinburgh: Churchill Livingstone, pp. 311–314, doi:10.1016/b978-0-443-06716-7.00067-0, ISBN 
  6. Guttentag, Adam; Salwen, Julia (1999). "Keep Your Eyes on the Ribs: The Spectrum of Normal Variants and Diseases That Involve the Ribs". RadioGraphics19 (5): 1125–1142. doi:10.1148/radiographics.19.5.g99se011125. PMID 10489169
  7. Tani, Edneia M.; Skoog, Lambert (2008-01-01), Bibbo, Marluce; Wilbur, David (eds.), "CHAPTER 22 - Salivary Glands and Rare Head and Neck Lesions"Comprehensive Cytopathology (Third Edition), Edinburgh: W.B. Saunders, pp. 607–632, ISBN.
  8. Physio Vibes. Cervical Rib And Physiotherapy Management. Available from https://www.youtube.com/watch?v=y_fpaqRg69M [last accessed 05/11/2020]
  9. 9.0 9.1 Physiotherapy treatment.com. Cervical Rib Syndrome. Available from https://www.physiotherapy-treatment.com/cervical-rib.html [last accessed 05/11/2020]
  10. Cervical Rib. Available from https://samarpanphysioclinic.com/2018/03/30/cervical-rib/ [last accessed 05/11/2020]
  11. Balan, Nisha Sharma, Anu (2008). Get through FRCR part 2B : rapid reporting of plain radiographs. London: Royal Society of Medicine. ISBN .
  12. Cervical Rib. Learning Radiology. Available fromhttps://learningradiology.com/notes/chestnotes/cervicalrib.htm [last accessed 05/11/2020]
  13. Dr. Bradshawdc. Cervical Rib. Available from https://www.youtube.com/watch?v=cI4-kCNfLcs [last accessed 05/11/2020]