Conservative Management of Cervical Rib- A Case Report

Background: An additional rib that develops from the seventh cervical vertebra is known as a cervical rib, a congenital anomaly placed above the typical first rib, affecting 0.20.5 percent of the total population. It may be seen on either the left or right sides. The majority of patients have little or no complaints and are identified by chance during an X-ray or CT scan. Due to the extreme compression on the arteries, veins and nerves caused by the position of the rib, which varies in shape and size, they might develop thoracic outlet syndrome. A cervical rib is a prolonged ossification of the lateral costal segment of the Cervical 7 th vertebra. Clinical Presentation: A 18 years old female patient was diagnosed with cervical rib on X-ray due to persistent pain at right hand. Patient concern with reduced mobility of the right upper limb and unable to lift the hand. The patient went physiotherapy treatment which comprise of exercise and electro therapy for 10 weeks which resulted in improvements in pain and range of motion and functional activities Conclusion: The case report suggest that a prompt structured physical rehab let to improving the functional goals progressively and significantly which is a measured aspect leading to a successful recovery. Case Study Agrawal et al.; JPRI, 33(48A): 218-222, 2021; Article no.JPRI.73184 219


INTRODUCTION
A cervical rib, sometimes termed as an accessory or a supernumerary rib, is a congenital abnormality that generally originates from the seventh vertebra and exceedingly rarely from the fifth or sixth vertebra. It generally comprises of a head, neck, and tubercle.A fibrous band around the insertion of the anterior scalene muscle attaches it to the first rib from behind. To be termed a rib, cervical ribs must articulate with the transverse process. The lateral costal part of the C7 vertebra tenaciously been ossified for a long time [1].
It may wind up in the soft tissues of the neck by accident, articulating with the first thoracic rib and sternum, or connecting to a fibrous band. The left side of the neck has more unilateral cervical ribs than the right side.Bilateral cervical ribs are more common than unilateral cervical ribs [1]. Cervical ribs can develop bilaterally in roughly 50% of individuals [2].
Cervical ribs are most commonly found in middle-aged people. It is a congenital anomaly that occurs above the normal first rib and affects between 0.2 and 0.5 percent of the population. Cervical ribs are twice as frequent in women as males (68 percent vs 32 percent), are bilateral in more than half of cases, and are asymptomatic in 90 percent of cases. The 10% of individuals with cervical rib who are symptomatic have neurogenic symptoms most of the time, although some have vascular symptoms as well. The pathophysiology of cervical ribs and aberrant first ribs is based on their physical connections, with the brachial plexus and subclavian artery and veins passing via the scalene triangle [3].
Trauma, overuse, and bad posture are all factors that predispose people to symptoms. The cervical rib generally compresses these tissues against the scalene muscles. Any pressure on a nerve causes neurogenic TOS, but pressure on vascular structures causes vascular TOS Compared to vascular TOS, neurogenic TOS is significantly more common. The cervical rib itself or a fibrous band(s) might put pressure on the neck.
Thoracic outlet syndrome is caused by the tension on the nerves produced by the existence of the rib, which varies in size and shape. When the subclavian artery is squeezed, moving the neck to the other side might cause the afflicted arm to lose its pulse (Adson maneuver). To fully examine thoracic outlet syndrome, a CT scan, nerve conduction tests, and an MRI may be required [4].
Physical therapy is used to treat nerve compression. When conservative therapy fails, the cervical rib and scalene muscles may need to be removed [3].

Patient Information
An18-year-old female patient with right hand dominance had pain from 14 th oct 2020 after consultation to an orthopedic surgeon X-ray was done which revealed congenital extra cervical rib. Patient underwent physiotherapy sessions following the next day of diagnosis. The patient was having the chief complaint of pain in right hand which patient describe as chronic pain with 8/10 at movement and 7/10 on rest swelling was not present and patient complaint oflimited mobility and unable to move the extremity

Clinical Findings
Physical examination was done. She was examined in supine and sitting. The extra rib was palpated and inspected. The chances for other deformity were also checked. Grade 2 tenderness was present. Local temperature was normal.

Investigation
It may be seen on either the left or right sides. The majority of patients have little or no complaints and are identified by chance during an X-ray or CT scan.

Assessment
A thorough clinical history and examination were recorded, which included a neurological and locomotor systemic evaluation, cervical neck xray, a chest x -ray, and nerve conduction tests to the median and ulnar nerves.
Pain assessment on NPRS pain was 7/10 on rest and 8/10 on slight movement. Swelling was absent. On observation, patient had forward head, protracted shoulder, kyphotic thoracic spine.
Physiotherapy intervention-patient specific rehabilitation protocol was structured. Patient underwent physiotherapy treatment for 10 weeks, 6 days per week.

Management
The main goal of management was reducing the pain and to increase the mobility of the upper limb.  [5].
Throughout many cases, we think that ablation of both of the cervical and first ribs is sufficient to relieve symptoms and avoid anything like a second surgery. Davies et al. [6] looked at removing just the cervical rib without the first rib. In a study of 58 individuals with TOS, 22 were reported to just have cervical ribs: five experienced arterial symptoms, six experienced neurogenic symptoms, and eight seemed to have a mix of neurogenic and arterial symptoms. In their group, 15 patients had cervical rib resection alone and were symptom-free.
Individuals who only had the cervical rib excised without the first rib eliminated, according to Toso et al. [7], started to experience problems following the procedure [8][9][10]. We've discovered that extracting both the cervical and first ribs in one surgery provides for plenty of room for the vein, artery, and brachial plexus [11,12].   To reduce pain and improve ROM.

Breathing Exercise 10 repetition every hourly
To maintain lung compliance(due to faulty posture lung cannot expand completely.) Strengthening for scapular, shoulder and cervical musculature 20 reps 3 times daily.
To strengthen and offloading the joint.
Stretching of pectorals, neck flexors 30sec 3 reps To lengthen the tight structure and correct posture

CONCLUSION
We conclude that a tailored made physical therapy program with proper ergonomic advices and medication has reduced the pain, increases the ROM and strength on the muscle and reduced the compression on the vasculature in the outlet region. Stretching and strengthening of the causative muscle have shown a significant improvement in the condition of the patient.

CONSENT
Written and Oral informed consent was obtained from the patient included in the study.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).