title: Anomalous first thoracic rib as a cause of thoracic outlet syndrome with upper trunk symptoms: a case report.
abstract: BACKGROUND
  Thoracic outlet syndrome is an uncommon cause of upper extremity neuropathy resulting from either neurogenic or vascular compromise in the thoracic outlet. Congenital anomalies as the cause of this disease process represent a minority of cases, and the literature regarding their surgical management is still evolving.
  
  
  METHODS
  A 42-year-old female without any relevant history presented to a clinic for evaluation of worsening neuropathic symptoms in the upper left extremity. Initial physical exam was unremarkable, and MRI identified an anomalous first rib, but no abnormality of the brachial plexus. The patient was managed conservatively for almost 4 years before symptoms became debilitating. Physical exam at that time found atrophy and weakness in the muscles supplied by the upper trunk of the brachial plexus, and CT demonstrated anomalies of the bone and brachial plexus not apparent on previous MRI. Neurolysis with local resection of the abnormal bone led to successful resolution of the patient's symptoms.
  
  
  CONCLUSIONS
  Identification of a rare congenital anomaly allowed for a precise surgical treatment of the condition. The importance of careful selection of modality and review of imaging in diagnosis and operative planning is discussed.
authors.affiliation: Department of Neurosurgery, Virginia Commonwealth University, 417 North 11th Street, P.O. Box 980631, Richmond, VA 23298 USA.
authors.forename: Douglas T
authors.initials: DT
authors.lastname: Hidlay
authors.affiliation: Department of Orthopedics, Virginia Commonwealth University, 1200 W. Broad Street, P.O. Box 980153, Richmond, VA 23298 USA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Graham
authors.affiliation: Department of Orthopedics, Virginia Commonwealth University, 1200 W. Broad Street, P.O. Box 980153, Richmond, VA 23298 USA.
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Isaacs