Case History #2

Patient 2 is a 52 year-old woman injured in a fall down stairs. She suffered the immediate onset of diffuse pain in left greater than right upper extremities, with neck pain, thoracic spine pain and headaches.

Physical examination revealed left-sided supraclavicular edema, impaired scapular motion, and brachial plexus irritation.  Deep palpation of the cervical spine and supraclavicular fossa reproduced the patient's chest wall, axillary, and periscapular pain. Also noted was restricted motion of the cervical spine and the left-sided ribs.  Poor venous drainage of each upper extremity was demonstrated.

MRI scanning clearly demonstrated the presence of a cervical rib, with severe compression of the brachial plexus and subclavian artery occurring on elevation of the patient's arms (Figures 1 through 5).  Focal thickening of the brachial plexus and post-stenotic dilatation of the subclavian artery suggests chronic and permanent damage to these structures.


Figure 1: A cervical rib decreases the scalene triangle dimensions.  The subclavian artery and brachial plexus pass through this narrowed space.


Figure 2: With the arms in neutral position, the thickened brachial plexus is seen immediately adjacent to the cervical rib.


Figure 3: With the patient's arms elevated, the brachial plexus is severely compressed between the clavicle and a cervical rib.



Figure 4: With the patient's arms elevated, there is moderate right and marked left extrinsic compression of the subclavian arteries, with post-stenotic dilatation evident on the left.



Figure 5: Marked compression and post-stenotic dilatation are clearly demonstrated in his inferior view