Preliminary Diagnosis: Cervical rib syndrome

I. What imaging technique is first-line for this diagnosis?

Routine PA chest radiograph

II. Describe the advantages and disadvantages of this technique for diagnosis cervical rib syndrome.

Advantages

  • Diagnostic of cervical ribs

  • Inexpensive

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Disadvantages

  • Does not reliably provide other differential etiologies of thoracic outlet syndrome

  • Uses ionizing radiation

  • Although diagnostic of cervical ribs, it is not diagnostic of thoracic outlet obstruction due to cervical ribs. The examination will need to be coupled with the clinical examination and other tests such as EMG.

III. What are the contraindications for the first-line imaging technique?

No contraindications exist for this examination.

IV. What alternative imaging techniques are available?

  • Color flow duplex ultrasound

  • CT angiogram of the subclavian artery with contrast

  • Conventional angiogram/venography: conventional angiography has similar indication as CT angiogram. Venogram is indicated when there is persistent edema, unilateral cyanosis, and venous prominence in the affected upper extremity.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of cervical rib syndrome.

Color flow duplex ultrasound
Advantages

  • Noninvasive assessment of arterial and venous system

  • Relatively inexpensive

  • Can be performed in different anatomic positions

Disadvantages

  • 10%-20% false positive rate. Positive findings are usually followed up with angiography.

CT angiogram of the subclavian artery with IV contrast
Advantages

  • CT not only can diagnose a cervical rib but also can potentially offer other etiologies of thoracic outlet syndrome. Additionally, it can provide relevant anatomic detail and relationships between the osseous and vascular structures. This should not be the first imaging test.

  • Definitive test in evaluating vascular lesions

Disadvantages

  • Cost

  • Radiation exposure

  • Utilization of IV contrast

Conventional angiography and venography (arteriography indicated if signs of ischemia)
Advantages

  • Evaluation of both arterial and venous systems can be performed as indicated.

  • Evaluation in different anatomic positions

  • Considered gold standard.

Disadvantages

  • Invasive and has bleeding and vascular risks

  • Uses iodinated IV contrast

  • Cost

VI. What are the contraindications for the alternative imaging techniques?

Color flow duplex ultrasound

  • None

CT angiogram of the subclavian artery with contrast

  • Anaphylactoid reaction to IV iodinated contrast media is an absolute contraindication. For mild and moderate reactions, a preprocedural steroid preperation can be used.

  • Renal dysfunction: use of IV iodinated contrast media is relatively contraindicated when the GFR is <30.

  • Relative contraindication exists in pregnancy.

Conventional angiogram/venogram

  • Anaphylactoid reaction to IV iodinated contrast media is an absolute contraindication. For mild and moderate reactions, a preprocedural steroid preperation can be used.

  • Renal dysfunction: use of IV iodinated contrast media is relatively contraindicated when the GFR is <30.

  • Relative contraindication exists in pregnancy.

  • Significant coagulopathy, thrombocytopenia, and/or anemia

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