Thoracic outlet syndrome treated with cervical rib resection
35yo female with thoracic outlet syndrome. 1 year following cervical rib resection.
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The left first rib has been resected 3.2 centimetres beyond the costotransverse joint. There is again elongation of the left C7 transverse process. A possible persistence of a fibrous band then extends anteroinferiorly from the tip of the transverse process to pass posteriorly and to the left subclavian artery. Mild asymmetric thickening and hyperintensity of the C8 and T1 nerve roots on the left persists. The C8 nerve root from the foramen to the level of this fibrous band has a mildly tortuous course.
Conclusion: Possible persistence of the fibrous band extending anteroinferiorly from the inferior tip of the left C7 transverse process with distortion of the course of the left C8 nerve root. C8 and to a lesser extent T1 nerve roots remain thickened and mildly hyperintense.
MRI is used to evaluate the presence of thoracic outlet syndrome causing brachial plexopathy. Three spaces are evaluated: the interscalene triangle, costoclavicular space, retropectoralis minor space. The costoclavicular space is the most commonly compressed, followed by the interscalene triangle. MRI or MRA imaging with the affected arm in a normal followed by hyperabducted position to make the spaces more arrow demonstrates narrow subclavian artery or brachial plexus impingement. Focal abnormal brachial plexus T2-weighted hyperintensity with or without distortion; as well as scalene muscle inflammation or fibrosis may be present 1.
Various lesions can be the cause of thoracic outlet syndrome and are visible on MRI 1,2:
- Bony – cervical rib, long transverse process of C7 vertebrae, callus, osteochondroma of clavicle or first rib, bilateral hypoplastic first ribs fused second ribs
- Soft tissue – fibrous band, hypertrophy of scalenus anterior, hypertrophy of scalenus minimus, fibrous scarring
- MRI can show fibrous band and asymmetry from elongated transverse process of C7 or cervical rib to first rib, leading to compression of C8 or T1 roots or inferior trunk
Case courtesy of A/Prof Pramit Phal.
- 1. Lawande M, Patkar DP, Pungavkar S. Pictorial essay: Role of magnetic resonance imaging in evaluation of brachial plexus pathologies. Indian J Radiol Imaging. 2012;22 (4): 344-9. doi:10.4103/0971-3026.111489 - Free text at pubmed - Pubmed citation
- 2. Vargas MI, Viallon M, Nguyen D et-al. New approaches in imaging of the brachial plexus. Eur J Radiol. 2010;74 (2): 403-10. doi:10.1016/j.ejrad.2010.01.024 - Pubmed citation