Mims Gage

Scalenus anticus (naffziger) syndrome

T HE presence of supernumerary ribs in the cervica1 region has been known since the origina observations of WiIIshirel to cause symptoms in some cases because of the pressure exerted by the rib on the brachia1 pIexus and subcIavian artery. CIinicians have, however, repeatedIy observed that cervica1 ribs may occur without producing symptoms and that in many cases with a uniIatera1 cervica1 rib symptoms may occur on the contraIatera1 side in which no rib is demonstrabIe. ToreIIi2 reported IOO cases of cervica1 rib, onIy 9 of which produced symptoms. Adson and Coffey3 found that cervica1 rib occurs more often on the Ieft side, but symptoms are present more commonIy on the right side. The fact that pressure symptoms identica1 with those produced by cervica1 ribs can occur in the absence of supernumerary ribs in the cervica1 region had Ied many4+14 to concIude that the subcIavian structures are compressed by the first rib. The position of the first thoracic rib is only reIative and even though it may be eIevated with respect to the vertebra1 coIumn, few, if any, symptoms wiI1 resuIt unIess it is raised with respect to the subcIavian structures as symptoms occur onIy when the brachia1 pIexus and subcIavian artery are compressed. ConverseIy, in the absence of eJevation of the first rib with respect to the vertebra1 coIumn, symptoms occur if there is depression of the shouIder with a resuIting puI1 on the subcIavian structures or a reIativeI;v Iow origin of the brachia1 pIexus, causing anguIation over the first rib. Thus it may be concluded that symptoms occur onIy when there is aIteration * From the Departments of Surgery, Tulane University School of Medicine, Charity Hospital, and Touro Infirmary, New Orleans, 12a.

Scalenus anticus syndrome

T HE scaIenus anticus syndrome is a definite cIinica1 entity characterized by a train of symptoms resuhing in a nonfata disabiIity of the upper extremities. These symptoms are the resuIt of pressure upon the component parts of the brachia1 pIexus and the subcIavian artery by the scaIenus anticus, scaIenus minimus and scaIenus medius muscIes and the first rib. The condition can be recognized by the clinical manifestations of pain, numbness, tingIing, sensory changes and muscuIar weakness amounting sometimes to compIete paraIysis of the extensor muscIes of the wrist and fingers. These neurogenic signs and symptoms may be associated with muscIe spasm in the arm, forearm, shouIder and neck as we11 as with various vascuIar changes of the arterial suppIy to the upper extremity. Vasomotor phenomena may or may not be primary or secondary to these vascuIar changes. In 1934, Ochsner, Gage and DeBakeyz3 described this syndrome and reported six cases in five of which operation compIeteIy relieved the symptoms. The various prevaiIing theories were discussed and we advanced the hypothesis that the symptoms are produced by spasm of the scaIenus muscIe with secondary hypertrophy which presses the brachia1 pIexus and subcIavian artery against the scaIenus medius and first rib; the first rib, in turn, is eIevated by the muscIe spasm and this increases the irritation or pressure on the Iower trunk of the brachia1 pIexus, thus causing a vicious circIe. The etioIogic factors responsibIe for the spasm of the scalenus muscIe couId not be adequateIy expIained except by the theories of Todd3” and Jones.14 Todd believed that the failure of descent of the sternum with the shoulder descent resuIted in high fixation of the first rib, producing brachial plexus irritation, whereas Jones feIt that the dorsa1 nerves joining the Iower cord of the brachia1 pIexus were compressed by the first rib. In accepting these two theories, we stated that irritation of the brachial pIexus resuIted in spasm of the scaIenus