What is the workup for Costoclavicular (costoclavicular) Syndrome?

From the Guidelines

The workup for Costoclavicular Syndrome should begin with a comprehensive clinical evaluation, including a detailed history and physical examination with provocative maneuvers, followed by imaging studies such as plain radiographs, vascular studies, and electrodiagnostic studies to assess for neurovascular compression. The clinical evaluation should focus on symptoms like arm pain, numbness, weakness, and vascular changes triggered by arm positioning 1. Physical examination should include provocative maneuvers such as the costoclavicular test (military brace position), Adson's test, and the elevated arm stress test (EAST) to assess for compression of neurovascular structures.

Imaging studies are essential in the workup of Costoclavicular Syndrome, starting with plain radiographs of the chest, clavicle, and cervical spine to identify bony abnormalities like cervical ribs or clavicular deformities 1. Vascular studies, including duplex ultrasound, CT angiography, or MR angiography, should be performed to assess for vascular compression, particularly during positional changes. Electrodiagnostic studies (EMG/NCS) help evaluate neurogenic involvement and rule out other neurological conditions.

Some key points to consider in the workup of Costoclavicular Syndrome include:

• The use of CT with IV contrast to evaluate anatomical narrowing that could cause neurovascular compression, as well as to define adjacent vascular structures 1
• The use of MRI without IV contrast to diagnose neurogenic thoracic outlet syndrome (nTOS) and to evaluate the brachial plexus and cervical spine 1
• The importance of dynamic thoracic outlet syndrome testing with positional changes during imaging to reveal intermittent compression
• The need to exclude inflammatory or autoimmune conditions that might mimic symptoms through laboratory tests

Overall, a comprehensive approach is necessary in the workup of Costoclavicular Syndrome due to the varying combinations of neurologic, arterial, and venous symptoms that can present due to compression of neurovascular structures between the clavicle and first rib 1.

From the Research

Costoclavicular Syndrome Workup

The workup for Costoclavicular Syndrome involves several steps to diagnose and treat the condition. The following are some of the key aspects of the workup:

• Imaging Studies: Four-dimensional computed tomography (4D CT) scanning can be used to diagnose costoclavicular impingement causing thoracic outlet syndrome 2.
• Clinical Evaluation: A thorough clinical evaluation is necessary to identify the symptoms and signs of costoclavicular syndrome, including pain, numbness, and weakness in the affected arm.
• Electrodiagnostic Studies: Electrodiagnostic studies, such as electromyography (EMG) and nerve conduction studies (NCS), can be used to evaluate the function of the nerves and muscles in the affected arm 3.
• Radiographic Studies: Radiographic studies, such as X-rays and CT scans, can be used to evaluate the anatomy of the costoclavicular space and identify any abnormalities, such as a displaced midclavicular fracture or an exuberant callus 3, 4.

Diagnostic Considerations

The diagnosis of costoclavicular syndrome can be challenging, and several conditions need to be considered in the differential diagnosis, including:

• Thoracic Outlet Syndrome: Thoracic outlet syndrome is a condition that involves compression of the neurovascular structures crossing the interscalene triangle, costoclavicular space, or retropectoralis minor space 2.
• Scalenus Anticus Syndrome: Scalenus anticus syndrome is a condition that involves compression of the nerves and vessels in the neck, which can cause symptoms similar to costoclavicular syndrome 5.
• Cervical Rib Syndrome: Cervical rib syndrome is a condition that involves an extra rib in the neck, which can cause compression of the nerves and vessels in the costoclavicular space 5.

Treatment Options

The treatment of costoclavicular syndrome depends on the underlying cause and severity of the condition. The following are some of the treatment options:

• Surgical Intervention: Surgical intervention, such as resection of the callus formation or reconstruction of the original length of the clavicle, may be necessary to relieve compression of the nerves and vessels in the costoclavicular space 5, 4.
• Physical Therapy: Physical therapy can be used to improve range of motion and strength in the affected arm.
• Pain Management: Pain management, such as medication or injection therapy, can be used to control pain and discomfort associated with the condition.