CERVICAL RIBS

Ache and tingling in arms and hands

Keywords: CERVICAL RIBS, tingling in arms and hands, Thoracic Outlet Syndrome, Inter Scalene Triangle

Normally speaking, only the twelve thoracic vertebrae have a pair of ribs, beginning at the spine, and attached to the sternum or other lower rib cartilage, and a couple of "floating ribs", forming the ribcage.

This vital structure serves to protect the vital organs, particularly the heart, but is moveable to allow breathing.

Cervical rib syndrome

At the upper end of the thoracic spine, at the junction with the neck, normally T1, the first thoracic vertebra has the first rib. But in 2 per 1000 people, there is a rib above the first rib. A cervical rib.

If there is a cervical rib then it penetrates through a very restricted passage called inter scalene triangle bounded by the first rib below, and two muscles, the scalenes on the sides of the triangle.

Why all the hype? Because at the cervico thoracic junction is the critical area where the large artery, the subclavian artery, and a large group of nerves, called the brachial plexus, emerge from the chest cavity to supply the arm.


The significance is that this syndrome may produce a crazy mixture of both arterial and neurological deficiency in the arm.

These ribs are usually rudimentary and of little or no clinical significance, but occasionally a very large space occupying cervical rib, originating from the transverse process of the lowermost cervical vertebra, passing through the inter scalene triangle and joining onto the normal first rib, may cause severe symptoms in the arm.

Remember, normally the cervical vertebrae have no ribs. Ribs pertain to the thoracic vertebrae.

A vascular and or neurological restriction in the inter scalene triangle is known as a thoracic outlet syndrome producing classically pain and tingling in the arm, particularly when lifting the arms as in hanging washing.


ADSON'S TEST


However a low grade irritation in the inter scalene triangle is often the underlying cause of a frozen shoulder for example, or a carpal tunnel syndrome.


Notice how the cervical rib can affect both the subclavian artery above, and the lowermost cord of the brachial plexus both.

So, both artery and nerve symptoms and signs are possible, though not necessarily so.


The classical test to confirm a thoracic outlet syndrome is the test of Adson. Your chiropractor will locate your radial pulse in the wrist, and then ask you to turn your head and breathe in. Does the pulse die away, and return when you return your head to neutral and breathe out?

It's a difficult test, very subjective, and I like to do it with the arm on the lap to eliminate false positives. Done in the normal way with the arm abducted and externally rotated many quite normal people have a positive Adson's test.

The key sign that will alert your chiropractor to the fact that all is not well in the state of Denmark, is that she simply can't find a radial artery pulse in the wrist. The first time it happened to me, I was bowled over: how could there be no pulse in the arm? Had my palpation skills suddenly diminished? Nope, a very large cervical rib.



There's just enough blood getting through to the arm when it's at rest, but start to use the muscles in your arm, or raise your arm so the inter scalene triangle is further diminished in size, and bingo, pain and tingling in the arm.

It's known as intermittent claudication, not dissimilar to angina. When the body is at rest, there's enough blood to supply the muscles. But as soon as you start to exercise, the muscles require more oxygen, and there's not enough. Pain.

So, of course, it's quite impossible to do Adson's test if you can't locate the radial pulse. An xray is mandatory.



Cervical ribs 

What is hard to explain is that the C7 rib lies silently in the inter scalene triangle for years minding its own business, its owner none the wiser. Then suddenly, one day, for no obvious rhyme or reason, the arm starts to ache and tingle.

It may have a carpal tunnel syndrome appearance, or a frozen shoulder, or tennis arm; the signs and symptoms are very variable. 

In the case below, I believe it was taking a job where the patient took a job and started holding the phone between her neck and shoulder, a real no-no that could have been the trigger that provoked the incipient rib to start giving her pain and tingling in the arms and hands.


Why didn't it cause pain years ago? If there's a big lump of bone in the way, how on earth can chiropractic help.

The medical treatment for the offending rib is not nice. The surgeon enters the inter scalene triangle via the arm pit, and surgically removes the offending rib. Frankly, I have no idea how successful the operation is, or what the morbidity is, but it's very close to extremely sensitive structures, the brachial plexus, the subclavian artery and the apex of the lung.

I have had numerous letter from patients at chiropractic help complaining that the operation either didn't help, or the condition was worsened because of injury to the brachial plexus.


PANCOAST TUMOUR

Talking of lungs, in you have tingling in the arms and hands, and are a smoker and have a bad cough, your chiropractor should consider a nasty tumour in the apex of the lung that can mimic a C7 Rib.

You do know, don't you, that smoking will knock ten years off your life, and the end will most likely be very S-H-one-T?


CHIROPRACTIC CARE

It's not well understood why the Cervical Rib suddenly starts to misbehave. In fact, we think that often the symptoms are not caused by the rib at all - otherwise, if the Cervical Rib was there ten years ago, why was there no pain and tingling in the arms and hands back then?

But it is an aggravating factor, the space in the Inter Scalene Trianle is even more limited than normal.

The thinking is that there is either a fixation of the first Thoracic Rib, or the Scalene muscles go into spasm because of a Cervical Facet Syndrome or perhaps a whiplash, poor posture at the computer (do you have support under your elbow?), sleeping on your tum, or anyone of a host of other facts. Long journey, sleeping in an aeroplane...


Can Chiropractic help?

A guarded yes, the hesitation because there aren't enough cases for us to do reliable research, which would tell you that in 80% (or 50%, or 10%) of cases chiropractic management of the Scalene muscles, the cervical vertebrae, the first rib can help you. Here you can follow a casefile currently under treatment. Very successfully, I might say, but a "cure" is unlikely, like many medical conditions and chiropractic conditions too. Cervical Rib CaseFile ...

CERVICAL RIB vs THORACIC OUTLET syndromes

Cervical ribs are but one cause of the so-called Thoracic Outlet syndrome. Any invasive process, be it a cervical rib or a Pancoast tumour, or an old fracture of the first rib or clavicle can irritate and impinge on the Subclavian artery and the Brachial plexus.

But so can a Scalene spasm, be it due to a whiplash, cervical facet syndrome, sleeping in the upright position, long journeys... or an imbalance between the Trapezius msucles and the the smaller Scalenes and SCMs for example.

From a chiropractic standpoint, a fixated first rib is another very common cause of the Thoracic Outlet Syndrome, causing scalene muscle spasm, but with no invasion of the inter scalene triangle.

CLOT Very occasionally a clot may form in the subclavian vein causing swelling of the whole arm. This is a very serious condition requiring immediate medical attention. Intial treatment would probably be blood thinners and perhaps a stent.

Further resection of the first rib, and if present a cervical rib, may be necessary, but it's a difficult operation, not without attendant dangers:



"1st rib resection of my left shoulder (2 months ago) has squared up my shoulders but has increased the strain on my neck, mid and lower back. Nerve damage sustained due to the operation has serverely effected the first three fingers with hyper sensitivity, signs of muscle wasteage around the base of the thumb and forearm is apparent. Overall I have ailments from the finger tips through the wrist up my arm, within my elbow and shoulder down the spine,at the base of my back through my left hip joint and in the back of the knee."

Letter received at Chiropractic Help.


First lumbar rib

At the lower end of the thoracic spine, quite often the first lumbar vertebra may have a rib, and it may be very significant in the patient who has four (known as a sacralisation) or six (known as a lumbarisation) lumbar vertebrae, instead of the usual five.


USEFUL LINKS

Go from CERVICAL-RIB to CHIROPRACTIC HELP home page …

Go from CERVICAL RIBS to NECK PAIN home page …



Did you find this page useful? Then perhaps forward it to a suffering friend. Better still, Tweet or Face Book it.












Interesting challenges of the day

1. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks she was 75 percent improved; no longer vomiting or falling. She's not enjoying the Brandt Daroff home exercises.

2. Mr S, a 48 year old man, has right low back pain, groin pain and a numb feeling in his lower leg when he sports. For six months he's been off football. He too has two problems; a very treatable lumbar facet syndrome and a very serious blocked artery in the groin; it's called intermittent claudication. Smokers beware.  

3. Mr S looks like the leaning tower of Pisa; he has a slipped disc at L5 making him lean towards the opposite side. It's called the postero lateral disc hernia; we'll fix it, but he has to stop for a week or two. Antalgias are serious so take them seriously. 

4. Mrs V too has  two conditions; a chronic low grade sciatica giving her an ache in the right leg, and a threatening Morton's neuroma. She's glad I'm back in Holland; chiropractic fixed it before, and we'll fix it again. 

5. Mrs W is one of the lucky ones, says her doctor. I agree. He says only 40% of patients with lumbar stenosis have a successful operation. We fixed a nasty slipped disc three years ago, but it came back two years later; the surgeon did a fine job but she has a weak ankle now giving her subtalar joint pain; it's routine stuff. 

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment of the new strain by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?


Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.