937 - Cervical Rib–Related Thoracic Outlet Syndrome in a 50-Year-Old Woman with Ehlers-Danlos Syndrome: A Multidisciplinary Case with Cervical Rib Resection

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

CZ

Christopher Q. Zhang, MD

Resident Physician
Northwell
Danville, Pennsylvania, United States

Co-Author(s)

PG

Pearl Galido, DO

Resident Physician
Northwell
Manhasset, New York, United States
MI

Matthew Inra, MD

Physician
Northwell
New York, New York, United States
DT

Daniel Torres, MD

Physician
Northwell
New York, New York, United States
PZ

Philip Zaneteas, MD, PhD

Physician
Northwell
New York, New York, United States

Corresponding Author(s)

JZ

Jeremy Zbili, DO

Physician
Northwell
New York, New York, United States

Submitter(s)

CZ

Christopher Q. Zhang, MD

Resident Physician
Northwell
Danville, Pennsylvania, United States

Case Diagnosis: Thoracic Outlet Syndrome

Case Description: We report a 50-year-old right-handed female with a past medical history significant for May-Thurner syndrome and Ehlers-Danlos syndrome presenting with chronic bilateral upper-extremity numbness and paresthesias that have recently worsened on the left. She has trialed and failed physical therapy. On exam, she had diffuse 4/5 left upper extremity strength, symmetric reflexes and sensation, and a positive Adson’s and Roos test on the left. C-spine X-ray showed bilateral elongated transverse processes at C7 with a left-sided cervical rib. C-spine MRI was unremarkable. Further workup included an MRI with a TOS protocol, which was negative for vascular TOS, and an EMG, which was largely unremarkable. A left anterior scalene block was performed under ultrasound guidance; although technically challenging due to atypical anatomy, it provided significant but temporary relief. CT surgery subsequently recommended left cervical rib resection. The patient underwent left VATS robotic-assisted cervical rib resection with scalenectomy with favorable postoperative improvement.

Discussions: This case highlights the complexity of TOS in the setting of a congenital cervical rib, Ehlers-Danlos syndrome, and a vascular disorder requiring coordinated input from physiatry, vascular surgery, neurosurgery, neurology, cardiothoracic surgery, hematology, and rheumatology. A comprehensive workup, including c-spine MRI and EMG, helped rule out alternative diagnoses such as cervical radiculopathy. Ultrasound-guided diagnostic nerve blocks confirmed TOS, highlighted the aberrant anatomy, and guided management. Given the unsuccessful conservative therapy and the patient’s significant anatomic variation, surgical decompression was determined to be appropriate, with a plan tailored to her unique vascular and connective tissue considerations.

Conclusions: This case underscores the value of multidisciplinary collaboration in complex TOS. Multidisciplinary input guides targeted imaging, diagnostic blocks, and surgical planning to address cervical rib–related TOS.