17 March 2022

5 minutes read

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A woman aged 23 was brought to the clinic for an evaluation of neck discomfort, right hand, and the forearm’s ulnar region numbness and tingling. She complained of numerous months of chronic neck pain as well as left hand and upper hand “heaviness.”

Over the course of the past few months, she experienced numbness in all of her fingers , which would appear and disappear. It was particularly painful for her ring and small fingers. She was not aware of headaches or changes in color of her hands.

Steven D. Jones Jr.
Donald (DJ) Scholten

Examining revealed a decrease in the sensation of her finger on the small, with positive Tinel sign on the cubital tunnel and visible anterior dislocation of the Ulnar nerve and elbow flexion. A further examination revealed tenderness of the supraclavicular fossa. There was an elevated stress test and a negative Adson test. The imaging of the cervical spinal as well as right shoulder revealed cervical ribs that were rudimentary bilaterally, but no Pancoast tumors or other anomalies (Figure 1.).

1. Anterior-posterior (AP) (a) and Lateral (b) scans of cervical spine radiographs that show bilateral cervical ribs are illustrated.

Source: Zhongyu J. Li, MD, PhD

It was determined that the patient had neurogenic Thoracic Outlet Syndrome (TOS) with an ulnar neuritis that was caused by the ulnar nerve being unstable at the elbow.

What is the most effective next action to take in the management of this patient?

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Surgery muscle release as well as neuro and nerve root decompression

Initially, she was treated by a conservative approach, utilizing physical therapy for three months. However her right arm began to become gradually more painful and she chose to undergo surgery.

Operative details

A transverse incision was cut over the right clavicle. the platysma muscle was divided along the line of the skin incision, the lateral portion of sternocleidomastoid muscular structure was partially let go. The cervical ribs were clearly protruding in the anterior direction. The omohyoid muscular structure was exposed and pulled back. External jugular vein was tied and the fascia that covers the brachial complex was let go. The cervical ribs were notably pushing forward and laterally and encircling the subclavian artery and brachial the plexus. The brachial plexus in the upper region along with its branches which include the suprascapular nerve were retracted from the fascia, and then retracted. Phrenic nerves were located in the front of the anterior scaling muscle , and secured. The anterior scalene muscles were released close to the rib the point of insertion. The lower and middle branch nerves of the trunk were discovered, and separated of fibrous tissues. The subclavian arterial artery was identified and then liberated of the cervical rib, and retracting. The most prominent part of cervical rib was extracted using the aid of a Kerrison rongeur. The long thoracic neural, which is the longest of them, was exposed and protected. The middle scalene muscles were released following the removal of the cervical rib. The T1 and C8 nerve roots were decompressed following elimination of cervical rib.

The attention was then directed towards the elbow. An incision on the medial elbow was made in the medial antebrachial skin nerve was secured and the fascia covering the ulnar nerve was released. Ulnar nerve dislocated prior towards the epicondyle medial during elbow flexion. It was then reduced into the ulnar nerve groove during the extension of the elbow. The nerve was relieved distally through the release of Osborne’s ligament along with the fascia of flexor carpi-ulnaris. The dissection was repeated proximally, and the arcade Struthers was let go. The nerve was found as being anterior to the septum of intermuscular. Thus, the removal of septum tissue from medial epicondyle not necessary. The pronator and flexor muscle tendon were lengthened during the entry point into the epicondyle medial. They open two flaps zigzag fashion and were used to construct an sling that stabilizes the ulnar nerve and avoid dislocation. The elbow’s range of motion was measured with a passive motion. was demonstrated to show an ulnar nerve that is stable.

Radiographs of the chest postoperatively were taken and the diagnosis was ruled out as pneumothorax after cervical rib surgery (Figure 2.). The patient was advised to do exercises to help the nerve glide as well as physical therapy. She was examined 6 weeks after the operation and experienced full resolution of her symptoms.

2. The postoperative AP image of chest which shows removal from the cervical spine and no pneumothorax.


This case is unique in the sense that the patient was suffering from the concomitant neurogenic toS and an ulnar nerve disorder. Double-crush, in which the pressure on nerves at one point increases the risk of harm at a different location is likely to have caused patients’ symptoms. Studies have proven this mechanism, with connections with the compression of the cervical spine the thoracic outlet and distal locations -including the cubital and the carpal tunnels possibly due to axoplasmic flow issues.

Tos with neurogenic origins is rare condition with a prevalence estimated at between 1% and 2percent. Around 90% of cases of TOS are caused by neurogenesis, and the remaining 10 percent are arterial or venous. Patients can experience an numbness or pain radiating from the neck and upper extremities that may be caused due to position or repetitive usage. Patients suffering from “true” neurological TOS typically suffer from hypothenar and thenar atrophy (Gilliatt-Sumner hand) and sensory impairment over the medial forearm as well as the ulnar hand. But, the most commonly encountered kind of neurogenic TOS can be the “disputable” type.

Patients typically complain of shoulder and neck pain headaches, ulnar hands Numbness that radiates into the forearms of the ulnar region as well as heavy arm sensations as well as difficulties lifting the arm like brushing your teeth and hair due to the increased discomfort, fatigue, and paresthesias. Diagnostics require a high degree of suspicion since there isn’t a definitive electrodiagnostic test. Because of this, those suffering from neurogenic TOS consult multiple specialists before they can be diagnosed. This condition can be connected with cervical ribs. These symptoms can develop following an injury or surgery to the neck, head or upper extremity.

Patients are often afflicted with localized tenderness or paresthesias , with feeling to the scalene triangular or subcoracoid area. They may be positive for an upper limb tension test or an elevated stress test of the arm. The stress test for the elevated arm is also known as the Roos test is carried out by requiring the patient to raise both arms to 90deg abduction-external rotating position, with the elbows and shoulders on the chest’s frontal plane. The patient then opens and closes their hands gradually for a period of 3 minutes. The reproduction of the patient’s typical symptoms throughout the entire extremity is an affirmative test.

A possible neurogenic workup for TOS

In the case of patients who suspect neurogenic TOS The initial examination includes scans of cervical spine and chest to determine cervical ribs and Pancoast tumors. If radiographs show no abnormality or are unclear, EMG, nerve conduction studies, and angiography could be recommended to confirm the presence of cervical radiculopathy or vascular disorders. The ultrasound or auscultation of subclavian vessels can be done with a noise that provides an indication of the effectiveness of surgical decompression. The first-line treatment for this condition is physical therapy, including modifications to posture and activity in addition to medication like pregabalin and gabapentin. If treatment options are not working surgical treatment includes removal or release of an abnormal anatomy, resection or removal of the first rib, if it’s compressing the plexus and division of the middle and the anterior scalene muscles and neurolysis of the affected brachial plexus , and removal of pectoralis major tendon when needed.

Cubital tunnel syndrome can be a more frequent disease, with the reported rates of 1.9 percent to 5.9 percent. The surgical treatment for cubital tunnel syndrome is a subject of debate and includes options such as in-situ decompression and medial epicondylectomy as well as Transposition of the anterior subcutaneously, intramuscular transposition , and submuscular transposition. Previous meta-analyses have found less complications associated with in-situ decompression as compared to. transposition, however transposition of ulnar nerves that are unstable could result in better outcomes than in-situ decompression.

The most important points to take away from this case is being a high level of suspicion for neuropathies with double-crush and understanding the diagnostic criteria procedures for workup and operation that treat neurogenic tumors of the thoracic outlet as well as Cubital Tunnel syndromes.