Omar Viswanath1, Allan F Simpao2, Gerald P Rosen3. 1. Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. 2. Department of Anesthesiology and Critical Care, Perelman School of Medicine at The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, Pennsylvania, USA. 3. Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami Beach, Florida, USA.
Madam,An 8-year-old boy with a 3-month history of right-sided neck and shoulder pain presented to his pediatrician for evaluation. As reported by the patient and his parents, there was no trauma or inciting event and the discomfort was intermittent in presentation. Movements involving his right upper extremity and neck precipitated the pain, which had been progressively worsening. He also had intermittent paresthesias, but no weakness of gross strength. A cervical X-ray revealed an additional rib coming off the C7 vertebrae on the right side [Figure 1]. A subsequent surgical referral explained that if this rib was not resected, it could result in worsening of the current symptoms, additional C7 radiculopathy in his right upper extremity, and potential for thoracic outlet syndrome (TOS). The decision was made to remove the cervical rib.
Figure 1
Chest radiograph anterior/posterior view showing a right-sided C7 rib
Chest radiograph anterior/posterior view showing a right-sided C7 ribThe surgical resection was performed successfully, with the only complication intraoperatively was that the first rib was found adhered to the pleura, so the surgeon purposefully had to enter the pleura and a chest tube was placed for precautionary reasons. On postoperative day 4, the chest tube was removed, and on postoperative day 5, the patient was discharged home. The patient began physical therapy with the focus of strengthening and range of motion on the surgical upper extremity. At physical therapy and subsequent surgical follow-up, it was found that the patient needed focused strengthening as a result of an extended duration of time of compensation for the affected extremity.TOS is a well-described upper extremity disorder comprising neurovascular complications caused by thoracic outlet compression.[1] Neurogenic TOS is the most common manifestation of this disorder and is characterized by arm and hand pain, paresthesias, and weakness resulting from compression of the brachial plexus within the thoracic outlet.[2] There are many patients who do not show symptoms and therefore remain undiagnosed, yet may present for nonrelated procedures. Clinicians must be cognizant of TOS manifesting during the perioperative period when there are acute changes such as sudden loss of arterial pressure waveforms, contralateral upper extremity swelling, and ischemic changes of the ipsilateral side that may potentially be provoked by prone positioning and head rotation away from the affected side.[34]
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Figure 1