Cervical rib case file

Cervical rib case file shows the rudimentary structures are usually of little clinical significance but occasionally they are enormous causing disturbing tingling in the arm and hand.

Note well which fingers are affected as that is of great help to the diagnostician.

X-ray revealing a very large cervical rib.

This page was last updated by Dr Barrie Lewis on 4th August, 2019.

  1. Chiropractic Help
  2. Rib Pain Treatment
  3. Cervical rib case file


Brief Review of the anatomy

The inter Scalene Triangle is a small passage in the lower neck through which the artery and nerves to the arm pass.

In two persons per thousand an extra structure may be located in the passage, viz an extra cervical rib.

In most instances cervical ribs are small structures of little clinical significance. However, very occasionally, they may be enormous having an influence on either the subclavian artery, or the brachial plexus of nerves, or both.

Hence the symptoms can be very variable; vascular and neurological, depending which trunk of the brachial plexus is affected. It could influence the thumb, the little finger side, or all the fingers.


Claudication is a condition where there's sufficient blood for the muscles at rest, but as soon as there is increased activity, there is inadequate oxygen for the muscles; a deep ache develops.

Angina is a similar condition in the heart, as is vascular intermittent claudication in the leg causing pain when walking or cycling, but not at rest.

In short, in a cervical rib case file there may be a crazy mixture of vascular and neurogenic signs and symptoms.

Complicating the story further is there may also have been previous trauma as in a whiplash causing injury to the lower cervical spine; is the pain and tingling in the arm really from the cervical rib, or is that an incidental finding?

That is, something that's true, but not relevant to the patient's symptoms.

Adding further grist to the mill is that conditions in the apex of the lung may also affect these structures. A careful and very thorough workup is called for.

Very occasionally the venous return from the arm may also pass through the interscalene triangle in which there may be swelling and even a clot in the upper limb.

The inter scalene triangle in the neck can affect the artery and nerves.

Originating from the C7 transverse process and passing through the inter scalene triangle before attaching firmly to the first rib a Cervical Rib can severely interfere with the normal function of the arm.


What is mysterious is that the cervical ribs are usually quiescent for many years until some event like a car accident or bad fall starts the radiating pain and tingling in the arm and hand.

They symptoms are very variable, depending on whether the artery primarily is affected, and which trunk of the brachial plexus. Generally, the nerves are affected more than the blood vessels.

Classically, raising the arms narrows the passage causing what is known as a thoracic outlet syndrome.

The main diagnosis for TOS usually is determined by Adson's test. The effect on the radial pulse is assessed with movements of the head, neck and arm, together with breathing. It is however a very subjective procedure, and dependent on a strong heart and sufficient blood pressure.

If the radial pulse is weak and thready then it's difficult to make a proper assessment.

In carpal tunnel the median nerve is affected causing tingling in the thumb side of the hand; in a cervical rib case file the pinkie is more likely to be symptomatic.


Cervical rib case file

Cervical rib case files often cause other syndromes in the upper limb such as shoulder pain or carpal tunnel provoking tingling in the arms and hands.

Tingling in arms and hands is invariably a large component of these cervical rib casefiles; a differential diagnosis is important. Is this true carpal tunnel syndrome, for example, or a just a byproduct of that large offending appendage in the upper torso?

The sensory distribution affected by the carpal tunnel.

Arm pain

Arm pain and tingling the hand is frequently a feature in cervical rib case files.

She has had neck pain periodically all her life since a serious fall aged 17. Three years previously surgery for her neck was recommended, but she declined. There was no mention of a Cervical Rib. The neck pain gradually resolved of itself.

Eighteen months previously she had a severe episode of right shoulder pain after yoga which resolved 90% after physiotherapy.

She has a tired feeling in her LEFT upper arm.

The ache in the right lower arm, and the tingling in the fingers began some 6 months previously, but was getting worse despite treatment by two different physiotherapists.

ON EXAMINATION:

Mrs T is a healthy looking, slightly built, non-smoker. Of concern, she was on HRT "in case of osteoporosis", despite the risks of stroke, heart disease and clots, breast cancer and incontinence.

Scroll down for more information from the Women's Health Initiative at growing green beans - legumes are part of the solution.

Range of motion of the neck was normal and painfree without referral to either arm. Kemp's test for a facet syndrome was negative, CERVICAL COMPRESSION TEST for a suspected disc injury were negative, Phalen's and Reversed Phalens for Carpal Tunnel were negative. Ranges of motion of the shoulders were normal.

The Upper Limb Tension test for a tethered nerve root was negative, and all neurological tests were negative.

Diagram showing how the pronator teres muscle can mimic the pain and tingling caused by carpal tunnel syndrome.

There was no pain in the Pronator teres muscles in the forearm, almost always painful in Carpal tunnel syndrome.

At this stage, I was at loss. What is wrong with this lady? Then I did Adson's test and immediately struck gold. On the left, there was distinct diminution of the radial pulse when she turned her head to the left, extended her neck and took in a deep breath. The pulse returned when she returned her head to the neutral position, and breathed normally.

On the right, for the first time in my whole clinical life, I COULD DETECT ABSOLUTELY NO RADIAL PULSE. ZILCH! So it was impossible to do Adson's test which is dependent on a healthy radial pulse.

I ordered new X-rays.

Adson's test for the cause of tingling in the arms and hands.

CERVICAL RIB CaseFile: Consult 2

I traced Mrs T's history carefully, looking for anything that I may have missed, asking about other things she may have remembered, and reported to her the mysterious lack of expected findings at the first examination, with the exception of the inexplicable absence of a radial pulse in her right wrist.

I then opened the X-ray folder.

  • Marked loss of disc space at two levels in the neck. C4-C5 and C5-C6.
Lateral x-ray showing old compression fracture and cervical rib.
  • Foraminal encroachment due to arthritis in the Joints of Luschka and a small cervical rib on the left. That explained the numb ache in the left upper arm.
  • Minimal encroachment in the foramina on the left, confirming the less severe symptoms are being caused by the small cervical rib on the left.
  • A HUGE right cervical rib with a most peculiar extra synovial joint, mid cervical-rib.
Oblique x-ray showing a very large cervical rib.

TREATMENT PROTOCOL

At the second consultation I always tell the patient what they can expect:

  1. Phase I: 6-8 treatments in the next 3-4 weeks in the initial treatment phase.
  2. Phase II: 2-3 rehab treatments.
  3. Phase III: An occasional but regular treatment, perhaps every 6 weeks. There was no hope of curing her condition, and occasional regular management, as in most chronic medical conditions was essential. Would she be satisfied if the condition was 50-70% better? I doubted we could hope for more. Can we achieve that? Visit this page regularly for the next couple months and find out. It's not going to be plain sailing...

Strong recommendation that she get a telephonic headset.

Pinched nerve in the neck caused by holding a telephone with the shoulder.

The first treatment of her scalene muscles and an adjustment of the LEFT first rib. I decided to start on the less symptomatic side first.

CERVICAL RIB CaseFile:

Consult 3

Not much change. Today we adjusted the RIGHT first rib, avoiding the supernumary cervical rib. Extensive work on the scalenes, the left shoulder, the right forearm and wrist.

CERVICAL RIB CaseFile:

Consult 4

Definite improvement in the tingling and ache in the lower arms. I "thought" I could detect a slight radial pulse after the treatment. Was I hallucinating?

CERVICAL RIB CaseFile:

Consult 5

The power of chiropractic never ceases to amaze me. Mrs T declared today that she woke for the first time in six months without tingling in either hand. Perhaps more important, BEFORE the treatment today, she had a distinctly palpable pulse in the right wrist.

CERVICAL RIB CaseFile:

Consult 6

The improvement continues. Sometimes there is tingling in the arms in the morning, for fifteen minutes, but the pain in her right arm has improved by at least 80%.

At my suggestion, she has purchased a multiamedia headset as described at pinched nerve in neck so that she does not have to raise her right arm for long periods. That too seems to be helping.

A weak radial pulse is now present.

At the next consultation we will begin with the rehab of her arm. It's going to be trial and error: with such a large space-occupying rib in the Inter Scalene Triangle I simply cannot be sure that exercises prescribed for most folk with neck pain will work for her.

Consult 7:

Mrs T is improving far beyond our expectations. After a two month lay off in the summer without treatment, which was not recommended, she has again that deep ache in her arm within a week after starting school. Pressure, telephone, stress, traveling in the car, and computers are doing her in; absolutely zero radial pulse once more.

One of the concerns is a thrombosis as the subclavian artery and vein must be compromised in the thoracic outlet. Fortunately she's not overweight, knows all about the foods that lower cholesterol without having to be told, and has never smoked. A clot is very serious, causing the arm to swell. However, there are concerns about that HRT which does increase her risk of cardiovascular complications.

This week I had an email about another cervical rib casefile; a patient who went the surgical route for this problem. The surgery was quite successful in one arm, but the arm has been a disaster. Severe weakness and numbness in the hand; they must have nicked the brachial plexus of nerves.

Update: As expected Mrs T varies between 50-80% better. There are disappointing times, some very good times. The complicating factor of course is that she really has two different condition:

  1. The huge cervical rib.
  2. Advanced lower cervical degenerative change from an old whiplash.
  3. Add to that a stressful job...

She is adamant she won't go for surgery to remove the rib. The right decision in my book. Some would say that's because I have a vested interest! True. But when you read the letters I receive at C-H asking for advice after a cervical rib excision that has gone horribly wrong, you'll understand my viewpoint.

Useful links


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. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

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. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

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.