Thoracic Outlet Syndrome with Right Subclavian Artery Dilatation in a Child - Transaxillary Resection of the Pediatric Cervical Rib

Introduction

Thoracic outlet syndrome (TOS) is a clinical phenomenon resulting from compression of neurovascular structures at the superior aperture of the thorax, which presents with varying symptoms [[1], [2], [3]]. The term TOS was used for the first time in the literature by Rob and Standeven in 1958 [[3]]. Cervical rib is a well-documented congenital anomaly, which plays a major role in the etiology of thoracic outlet syndrome. Rib development begins at 9 weeks; secondary ossification centers appear at 15 years [[4]]. The first seven “true” ribs connect to the sternum via the costal cartilages by day 45 [[4]]. The lower five “false” ribs do not articulate with the sternum [[4]]. Cervical ribs, which occur unilaterally or bilaterally, arise from the seventh cervical vertebra [[4], [5], [6]]. The reported prevalence of cervical ribs varies from 0.2 % to 8 % [[4]]. The subclavian artery, subclavian vein, brachial plexus, or a combination of these can be affected with this syndrome [[2]]. Compression of the brachial plexus results in neurogenic TOS [[2], [9]]. Vascular TOS involving compression of the subclavian artery or vein is associated with more objective findings and is seen in 5 - 10 % of all patients with thoracic outlet syndrome [[2], [9]]. This is usually an incidental finding or is associated with the Klippel-Feil anomaly [[4], [5]].

Proper physical examination requires initial careful inspection and palpation of the supraclavicular fossae to investigate masses or abnormal pulsation. Diagnostic measures include roentgenogram of the chest and the cervical spine, pulsed Doppler ultrasonography, nerve conduction velocity testing and an arteriovenography. Recently, three-dimensional (3D) or magnetic resonance (MR) imaging has become useful for diagnosis and treatment [[1], [2], [8]].

The management of thoracic outlet syndrome is controversial. The proper diagnostic tools, the use of conservative or surgical treatment, the best timing for surgery, surgical techniques, and the appropriate incisions are still debated. Arterial lesions (thrombosis and aneurysms) are rare and almost always secondary to arterial trauma from a cervical rib.

The authors report their surgical approach in a child who had subclavian artery compression, post-stenotic moderate dilatation and severe brachial plexus compression symptoms due to cervical rib.

References

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