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Cervical Rib

Original Editor - Chelsea Mclene

Top Contributors - Chelsea Mclene, Khloud Shreif, Aminat Abolade and Kim Jackson  

Introduction

Cervical rib (CR) also known as "neck rib" or "supernumerary rib in cervical region" is an extra rib, that forms above first rib, just above the collarbone. It was initially described by Galen and Vesalius in the second century. It is a congenital overdevelopment of transverse process of cervical spine vertebra and thought to result from mutations in Hox genes that is responsible for the development of axial skeleton in humans and vertebrates. It can be on right, left or both sides and may be floating with no connection or have a fused terminal connection with the first rib, fully formed bony rib or a thin strand of tissue fibre[1].

Bilateral cervical rib C7

However it is one of the earliest known anatomic variants and are often discovered incidentally during radiographic imaging unless they cause symptoms[2], the clinical manifestations of neurovascular compression caused by cervical ribs were first observed in 1818 by Cooper[3]. In few cases, people having cervical rib may develop thoracic outlet syndrome because of pressure on the nerves that may be caused by the presence of the rib, however TOS is 10 times higher in people with a cervical rib, especially after whiplash injuries[4]. 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.

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[6]. Tubbs found cervical rib could also originate from the sixth or the fifth cervical vertebrae[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 and generally divided into 2 classes; complete and incomplete CR.

There are four subgroups of cervical ribs[9]:

  • Type 1: only an extension of the transverse process is present.
  • Type 2: the transverse protrusion is long enough to touch the first rib.
  • Type 3: the cervical rib is separate from the transverse process but connected to it and linked to the first rib with fibrous cartilage.
  • Type 4: complete cervical rib that fully articulate with the lateral superior part of the first rib.

Prevalence

The prevalence of cervical ribs is difficult to determine as they are often discovered incidentally. Their occurrence is influenced by demographic, regional, and population-based differences, as well as immigration rates.

According to meta-analyses study[1] we can find cervical rib in about 1% of the healthy population, and about 30% of patients with TOS. In the Anatolian (Turkish) population, the prevalence of CR is around 3%, with women show a higher occurrence rate (2.17%) than men, and incomplete cervical ribs are found in 2.24% of case[9]. While another study found the prevalence of cervical ribs varies across populations, from 0.58% in Malawi to be about 6.2% between Turkish population[10]. CR prevalence ranged between 0.5% and 1% in USA, and about 0.74% in London. In Nigeria, prevalence is 0.65%, and the right-sided unilateral ribs are more common[11]. In India its prevalence varies significantly between 0.6%–1.22%, with higher rates in men in some studies and women in others[12][13]. In Omani population it was found in 0.94% of patients with females are more likely to have CR than males[14].

Associated Conditions

  • Thoracic outlet syndrome due to compression of the lower trunk of the brachial plexus or subclavian artery, nearly 49% of patients with a cervical rib have vascular thoracic outlet syndrome (TOS)[1].
  • 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 color 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[15][16]

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.[17][18]

[19]

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, a study found resection of CR along with the first rib in those patients show decrease in the recurrence rate of symptoms[20].

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[21].

References

  1. ↑ 1.0 1.1 1.2 Henry BM, Vikse J, Sanna B, Taterra D, Gomulska M, Pękala PA, Tubbs RS, Tomaszewski KA. Cervical rib prevalence and its association with thoracic outlet syndrome: a meta-analysis of 141 studies with surgical considerations. World neurosurgery. 2018 Feb 1;110:e965-78.
  2. ↑ Guttentag AR, Salwen JK. Keep your eyes on the ribs: the spectrum of normal variants and diseases that involve the ribs. Radiographics. 1999 Sep;19(5):1125-42.
  3. ↑ Spadliński Ł, Cecot T, Majos A, Stefańczyk L, Pietruszewska W, Wysiadecki G, Topol M, Polguj M. The epidemiological, morphological, and clinical aspects of the cervical ribs in humans. BioMed Research International. 2016;2016(1):8034613.
  4. ↑ Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. Journal of vascular surgery. 2002 Jul 1;36(1):51-6.
  5. ↑ 5.0 5.1 Giles, Lynton G. F. Giles, Lynton G. F. (ed.), "Case 67 - Cervical ribs", 100 Challenging Spinal Pain Syndrome Cases (Second Edition), Edinburgh: Churchill Livingstone, 2009 Jan 1 (pp.311–314). 
  6. ↑ Tani EM, Skoog L. Salivary glands and rare head and neck lesions. InComprehensive Cytopathology 2008 Jan 1 (pp. 607-632). WB Saunders.
  7. ↑ Tubbs RS, Muhleman M, Miller J, Shoja MM, Loukas M, Wellons JC, Oakes WJ. Cervical ribs with neurological sequelae in children: a case series. Child's Nervous System. 2012 Apr;28:605-8.
  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 Köksal V. Cervical Rib Which Resembles Original Thoracic Rib Presenting with Thoracic Outlet Syndrome (TOS): Literature Review with a Case Report. International Journal of Morphology. 2019 Dec 1;37(4).
  10. ↑ Erken E, Ozer HT, Gulek B, Durgun B. The association between cervical rib and sacralization. Spine. 2002 Aug 1;27(15):1659-64.
  11. ↑ Abimbola EO, Willido AA. Prevalence of cervical ribs in a Nigerian population. Journal of Medical and Dental Sciences. 2014 Feb;13:5-7.
  12. ↑ Sharma D. K., Vishnudutt, Sharma V., Rathore M. Prevalence of ‘Cervical Rib’ and its association with gender, body side, handedness and other thoracic bony anomalies in a population of Central India. Indian Journal of Basic and Applied Medical Research. 2014;3(2):593–597.
  13. ↑ Agarwal S, Choudhury PR, Baro A, Baruah P, Nath D. Cervical ribs: a study on radiographs in a tertiary care hospital of Assam. Int J Anat Res. 2018;6(13):4994-8.
  14. ↑ Al Subhi M, Al Ajmi E, Al Lawati A, Al Aswami H, Chan MF, Sirasanagandla SR. Prevalence of cervical ribs and elongated transverse processes in Omani population: a computed tomography-based study. Surgical and Radiologic Anatomy. 2022 Oct;44(10):1361-6.
  15. ↑ Dashti G, Ghasemi N. Evaluation of neurovascular complication of cervical ribs.2015:111-114.
  16. ↑ Desurkar A, Mills K, Pitt M, Jan W, Sinsi M, Male I, Wraige E. Congenital lower brachial plexus palsy due to cervical ribs. Developmental Medicine & Child Neurology. 2011 Feb;53(2):188-90.
  17. ↑ Balan, Nisha Sharma, Anu (2008). Get through FRCR part 2B : rapid reporting of plain radiographs. London: Royal Society of Medicine. ISBN .
  18. ↑ Cervical Rib. Learning Radiology. Available fromhttps://learningradiology.com/notes/chestnotes/cervicalrib.htm [last accessed 05/11/2020]
  19. ↑ Dr. Bradshawdc. Cervical Rib. Available from https://www.youtube.com/watch?v=cI4-kCNfLcs [last accessed 05/11/2020]
  20. ↑ Chang KZ, Likes K, Davis K, Demos J, Freischlag JA. The significance of cervical ribs in thoracic outlet syndrome. Journal of vascular surgery. 2013 Mar 1;57(3):771-5.
  21. ↑ Agrawal A, Uttamchandani S, Deshmukh M, Lakhwani M, Wadhokar OC. Conservative management of cervical rib-a case report. Journal of Pharmaceutical Research International. 2021 Nov 6;33(48A):218-22.
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