![]() A medial elbow incision was made, the medial antebrachial cutaneous nerve was protected and the fascia over the ulnar nerve released. The C8 and T1 nerve roots appeared decompressed after removal of the cervical rib.Īttention was then turned to the elbow. The long thoracic nerve was exposed and protected, and the middle scalene muscle was released after cervical rib removal. The prominent portion of the cervical rib was removed with a Kerrison rongeur. The subclavian artery was exposed, freed from the cervical rib and retracted. The middle and lower trunk nerves were identified and freed from fibrous tissue bands. The anterior scalene muscle was released near the rib insertion. The phrenic nerve was identified over the anterior surface of the anterior scalene muscle and protected. The upper brachial plexus and its branches, including the suprascapular nerve, were mobilized from the fascia and retracted. The cervical rib was notably pushing anteriorly and laterally, tenting the subclavian artery and brachial plexus. The external jugular vein was ligated and the fascia over the brachial plexus was released. The omohyoid muscle was exposed and retracted. The cervical rib was visibly protruding anteriorly. Operative detailsĪ transverse incision was performed above the right clavicle, the platysma muscle divided in line with the skin incision, and the lateral portion of the sternocleidomastoid muscle partially released. The patient was initially managed conservatively with physical therapy for 3 months however, her right arm became progressively more painful, and she subsequently elected to undergo surgical treatment. Surgical muscle release, nerve and nerve root decompression What is the best next step in management of this patient? ![]() ![]() The patient was diagnosed with neurogenic thoracic outlet syndrome (TOS) with concomitant ulnar neuritis which was due to ulnar nerve instability at the elbow. Anterior-posterior (AP) (a) and lateral (b) radiographs of the cervical spine demonstrating bilateral cervical ribs are shown. Imaging of the cervical spine and right shoulder revealed rudimentary cervical ribs bilaterally with no Pancoast tumor or other abnormalities (Figure 1). Further examination revealed tenderness in the supraclavicular fossa, a positive elevated arm stress test and negative Adson test. Donald (DJ) ScholtenĮxamination revealed diminished sensation to her small finger, with a positive Tinel sign at the cubital tunnel, and palpable anterior dislocation of the ulnar nerve with elbow flexion. She denied headaches or color changes in her hand. This was the worst in her small and ring fingers. She reported several years of neck pain and right upper extremity “heaviness.”ĭuring the past few months, she had developed numbness to all her fingers that would come and go. If you continue to have this issue please contact to HealioĪ 23-year-old woman presented to clinic for evaluation of neck pain, right hand and ulnar forearm numbness and tingling. ![]()
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