Costoclavicular Compression Associated with Cervical Rib *

E. S. BRINTNALL, M.D., 0. R. HYNDMAN, M.D., M. W. VAN ALLEN, M.D.

From the Surgical Service, Veterans Administration Hospital and the College of Medicine, State University of Iowa, Iowa City, Iowa SYMPTOMS of neurovascular compression, carried out. Symptoms were not relieved. in patients with cervical rib, may be due At the second operation (November 1951) completely or partially to costoclavicular a notch was cut from the first rib beneath compression. Unless the costoclavicular in- the neurovascular bundle. A 4 cm. segment terval is widened in such patients, symp- of the mid-portion of the clavicle was re- toms are unrelieved or are only partially re- sected, and the lower part of the scalenus lieved by the standard operation of scalen- anticus was excised. Partial relief of symp- otomy and cervical rib excision. toms followed this second operation. The The costoclavicular space should always clavicle healed with shortening. At a third be investigated after removal of a cervical operation (July 1953), an attempt was rib. Our experience prompts us to empha- made to lengthen the foreshortened right size the importance of this examination. clavicle with a fibular graft. Normal clavic- The "finger-pinch" test 2 is a helpful means ular length was not obtained and the of evaluating the role that a narrowed in- wound became infected. Deformity of the terval between clavicle and first rib may clavicle and bulky callus formation resulted. play in causing vascular or neural symp- Shoulder and arm pain persisted but symp- toms. Extraperiosteal excision of the first toms of vascular compression appeared only rib effectively relieves costoclavicular com- with a "shoulder droop" position. pression and is not disabling or deforming. Examination. On the left side there was a palpable cervical rib in the left supra- CLINICAL OBSERVATIONS clavicular region. The left radial pulse was The following case report clearly illus- obliterated by bracing the shoulders back trates the coexistence of costoclavicular and by moving the horizontally outstretched compression and cervical rib. left arm to a plane behind the coronal plane R. E. P. (RE 15914), a white male physi- of the trunk. There was hypalgesia of the cian, aged 34, entered the hospital January distal portions of the first three fingers of 4, 1954, complaining of symptoms of vascu- the left hand. Examination of the right side lar insufficiency in the left upper extremity. revealed the mid-portion of the clavicle to These symptoms were aggravated by cer- be bulky and deformed. A grating sensa- tain shoulder positions and by cold, tobacco tion was palpable in the acromioclavicular and coffee. Use of the left hand was handi- region. The right hand was cool and moist. capped by cramping pain in the forearm The right radial pulse was strong but and by rapid loss of strength. seemed to be reduced in strength by brac- History Relating to Right Upper Extrem- ing the right shoulder back and by forcibly ity. Similar symptoms beginning three years depressing the right shoulder. There was no previously in the right upper extremity led sensory loss in the right upper extremity. A to a series of operations at another hospital. radiograph of the chest revealed a complete At the first operation (October 1951) left cervical rib with its tip reaching the scalenotomy and cervical rib resection were first rib anteriorly. The right clavicle was * Submitted for publication March, 1956. deformed and shortened and the posterior 921 BRINTNALL, Annals of Surgery 922 HYNDMAN AND VAN ALLEN November 1956

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FiC;. I A. FiI;. 1B. FIG. 1. A. Preoperative roentgenogram (R.E.P.) showing right clavicle deformity and resec- tion of cervical rib on the right. A complete left cervical rib articulates with first rib. B. Roent- genogram of January 8, 1954, following resection of left cervical rib and left first rib. segment of a right cervical rib was seen hand were relieved. From the patient's (Fig. 1, A). point of view, the extremity had been re- Operation on the Left Side. On January stored to normal. The patient was re-ex- 6, 1954, an exploration of the left supra- amined frequently as an out-patient be- clavicular space was carried out through cause of pain and symptoms of mild inter- an anterior (supraclavicular) incision. The mittent neurovascular compression in the lower 4 cm. of the scalenus anticus muscle right upper extremity. It was felt that pre- and the complete left cervical rib were vious operations and infection in the region excised. This appeared to relieve elevation of the right cervico-axillary canal would and lateral compression of the artery and make first rib excision on this side tech- nerve trunks. However, with the shoulder nically difficult and perhaps hazardous. The depressed and braced backward, a finger residual symptoms were considered to be tip placed alongside the neurovascular due as much to deformity of the clavicle as structures was severely pinched between to costoclavicular compression. Pain and the clavicle and first rib. This indicated an grating in the region of the right acromio- abnormally narrow costoclavicular interval. clavicular joint prompted excision of the Therefore, the first rib was removed extra- lateral 1 cm. of clavicle under local anes- periosteally from its tubercle to its cartilage. thesia (August 25, 1954). This procedure This provided an adequate space for the did not afford relief. With someL reluctance, passage of neurovascular structures from right claviculectomy was advised to relieve neck to axilla (Fig. 1, B). costoclavicular compression and to relieve Postoperative Course. The patient's re- pain that was felt to be related to malunion covery from operation was uncomplicated. and shortening of the bone. All symptoms referable to the left arm and Operation on the Right Side. Total (ex- Volume 144 COSTOCLAVICULAR COMPRESSION Number 5 923

FIG. 2. R. E. P. (RE 15914). The photograph reveals droop and medial position of the right shoulder and the scars resulting from several operations. No deformity of the left shoulder has resulted from resection of cervical rib, first rib and lower part of the Scalenus anticus on the left.

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FIG. 3. Diagramatic illustration of the boundaries of the cervico-axillary canal. Symptoms may result from lateral compression between cervical rib and scalenus anticus or from vertical compression between first rib and clavicle. These compression mechanisms may coexist in the same patient. traperiosteal) resection of the right clavicle Some deformity (shoulder droop) resulted was performed June 17, 1955. Scarring of and the shoulder was abnormally mobile. the supraclavicular region was extensive, Shoulder, arm and hand function were The "finger-pinch" test was not applicable. good. Six months after his last operation, Postoperative Course. No complications the patient had no serious complaints. The followed removal of the right clavicle. All left upper extremity remained normal 18 symptoms referable to vascular compres- months after resection of cervical rib, first sion were relieved and most of the shoulder rib and lower portion of scalenus anticus. region discomfort disappeared. Pain refer- The right upper extremity was free of able to the clavicular joints was relieved. neural and vascular symptoms 6 months BRINTNALL, HYNDMAN AND VAN ALLEN Annals of Surgery 924 November 1956 after resection of the clavicle. The right neither was there evidence of costoclavicu- shoulder drooped moderately, was some- lar space narrowing at operation and hence what unstable and was the site of occa- the first ribs were not removed. sional mild and vague aching discomfort (Fig. 2). TECHNICAL CONSIDERATIONS The anatomical boundaries of the cervico- COMMENTS axillary canal must be considered in pa- Although this patient had cervical ribs tients with evidence of neurovascular com- on both sides which articulated with the pression at this site. The axillary artery and first ribs, the symptoms were due more to the trunks of the brachial plexus lie on the costoclavicular compression than to the first rib and beneath the clavicle and be- cervical ribs themselves. The persistence tween scalenus anticus and cervical rib, or of costoclavicular compression accounted between scalenus anticus and medius if for the failure of scalenotomy and cerv- no cervical rib exists. In the patient with a ical rib excision to relieve symptoms on complete cervical rib, the boundaries en- the right side. Finally, resection of the close a quadrilateral space as indicated in clavicle was required to afford relief.3 The Figure 3. relief obtained by claviculectomy is consid- The operation for relief of symptoms in ered satisfactory though the shoulder is not the patient with cervical rib is regarded as functionally normal and slight deformity is an exploratory procedure. The anterior ap- evident. On the left side costoclavicular proach is utilized. The supraclavicular space compression was suspected preoperatively and the cervico-axillary canal are exposed and was confirmed by investigation at the through a transverse incision above clavicle time of operation. Complete relief of symp- which parallels lines of skin tension at the toms followed effective enlargement of the base of the neck. The incision divides skin, cervico-axillary canal by resection of the platysma and cervical fascia. Transverse first rib, the cervical rib, and resection of scapular vessels are divided and the phrenic the lower portion of the scalenus anticus. nerve is retracted medially. The scalenus Excision of the first rib caused no functional anticus is severed at its insertion on the or cosmetic disability. first rib and its lower portion is excised. Our recent experience includes two addi- This provides wide exposure of the arch tional patients (W. S. and V. H.) in whom of the subclavian artery. The trunks of the costoclavicular compression was determined brachial plexus and the subclavian artery by "finger-pinch" test at the time of opera- are lifted from the first rib and a Penrose tive removal of cervical ribs. In both in- drain is looped about them to enable gentle stances first rib removal was performed and retraction. The cervical rib thus exposed is both patients obtained complete relief of freed extraperiosteally and is divided in its symptoms. One patient (V. H.) had wing- midportion. The posterior segment is re- ing of the scapula postoperatively. Recovery moved to its tubercle. The anterior segment of function occurred a few weeks later. is completely removed, being disarticulated The temporary paralysis of the long tho- at its junction with the first rib. The interval racic nerve probably was the result of in- between first rib and clavicle is then ex- jury to this nerve in freeing the scalenus amined. medius from the first rib. Two additional The examination consists of placing the patients (D. K. and J. K.) have been com- tip of the index finger alongside the sub- pletely relieved of symptoms by removal clavian artery and between the clavicle and of cervical ribs and resection of the lower first rib. If the finger is pinched when the portions of scalenus anticus muscles. In patient's shoulder is forced backward and Volume 144 COSTOCLAVICULAR COMPRESSION Number 5 925 depressed, the test is considered positive, We consider scalenotomy to be an inade- indicating that the first rib should be re- quate procedure for relief of symptoms as- moved. The rib is partially freed extra- sociated with cervical rib. The remaining periosteally and a segment excised from its cervical rib, if complete, will continue to mid-portion. The posterior segment is then elevate and angulate the neurovascular bun- mobilized and excised at the level of its dle. The concept that severance of the at- tubercle. The anterior segment is excised at tachment of the scalenus anticus to the first or near its cartilaginous part. If a rent is in- rib results in a lowering of the rib which, advertently made in the pleura it is re- in turn, results in enlargement of the costo- paired while the anesthetist inflates the clavicular interval is probably erroneous. lungs. Costoclavicular compression as an entity If the "finger-pinch" test is negative, re- is well understood,2 3,4,5, 6 but its associa- moval of the first rib is, of course, not felt tion with cervical rib is not generally ap- to be indicated. However, a protuberance preciated. Perhaps the first rib is relatively may be present on the first rib at the locus high in patients with cervical rib, particu- where it and the cervical rib were joined. larly if the latter is complete with articula- This, in itself, may partially obstruct the tion to the first rib. Our attempts to deter- cervico-axillary canal and should be re- mine the adequacy of the costoclavicular moved with a rongeur. The wound is closed space by roentgenographic views in various by layer suture of cervical fascia, platysma shoulder positions have been unrewarding. and skin. No immobilization or special post- The only certain method of determining operative care is required. costoclavicular compression is direct ex- ploration.2 We feel that a positive "finger- DISCUSSION pinch" test reveals a real abnormality and Of the several pathologic mechanisms not just a normal variation in chest wall which may result in neural or vascular com- structure or shoulder mobility. The test has pression at the thoracic inlet and cervico- been performed in a group of patients un- axillary canal,6 cervical rib is the best dergoing biopsies of scalenus fat pad, pa- known and the most easily recognized. The tients with no symptoms of compression, variations in shape and extent of cervical and in this group of patients the test has rib have been well described as have the been regularly negative. symptoms associated with it.1 6 The pres- The routine use of the "finger-pinch" test ence of a cervical rib may, however, lead at the time of excision of cervical rib is ad- to a deceptively simple explanation for vised. This reliable test enables the surgeon symptoms and a disregard of associated ab- to determine whether or not costoclavicular normalities which are partly or wholly re- compression exists. Relief of costoclavicular sponsible for the disability. The occasional compression associated with cervical rib failure of remission of symptoms following will materially improve the results of opera- cervical rib excision suggests that an asso- tions for cervical rib. ciated mechanism of compression was over- looked. The occasional association of cerv- SUMMARY ical rib with other abnormalities, such as a malformed first rib, asymmetry of the tho- 1. Costoclavicular compression has been racic inlet, steep rib angle and flattened found in three patients with complete cerv- upper chest, has been described.' 4 It is not ical ribs. surprising that a mechanism of costoclavic- 2. The operation upon the cervical rib ular compression is so often associated with is considered exploratory and search is cervical rib. made for other mechanisms of compression. 926 BRINTNALL, Annals of Surgery 3. The "finger-pinch" test is used to eval- Vein: Relation to the Scalenus Anticus Syn- uate the adequacy of the costoclavicular drome. Lancet, 2: 539, 1943. 3. Lord, Jere W., Jr.: Surgical Management of interval. Shoulder Girdle Syndromes. Arch. Surg., 66: 4. The costoclavicular interval is effec- 69, 1953. tively enlarged by extraperiosteal removal 4. McGowan, J. M.: The Role of the Clavicle in of the first rib. Occlusion of the Subclavian Artery. Ann. Surg., 124: 71, 1946. 5. Removal of the first rib does not de- 5. McGowan, J. M. and M. Vehnsky: Costo- form or disable the patient. clavicular Compression, Arch. Surg., 59: 62, 1949. BIBLIOGRAPHY 6. Walshe, F. M. R.: (Chapter XVII, Nervous and Vascular Pressure Syndromes of the 1. Adson, A. W. and J. R. Coffey: Cervical Rib. Thoracic Inlet and Cervico-axillary Canal), Ann. Surg., 85: 839, 1927. Modem Trends in Neurology, Feiling, An- 2. Falconer, M. A. and G. Weddell: Costoclavicu- thony, pp. 542, Paul B. Hoeber, New York, lar Compression of the subclavian Artery and 1951.