Penn State Health St. Joseph Allentown, Pennsylvania
Introduction: Neck and upper thoracic back pain are common complaints seen in a primary care office. these nonspecific neck and back symptoms have a broad differential. Thorough history and exam along with appropriate imaging are essential to establishing an appropriate diagnosis. While there are many possible etiologies, most of which can benefit from osteopathic manipulative treatment (OMT), this case describes a rare congenital abnormality that may contribute to chronic pain and affect which OMT techniques that can be utilized. Through this unique case, further discussion can be facilitated with regards to directing the diagnosis and management of neck and upper thoracic pain in the primary care setting.
Case Study: A 27-year-old female presented with right sided neck and upper back pain that she reported had been ongoing since she was in a MVA at age 18. A CT neck was done at that time which revealed a previously unknown absence of the right first rib as well as T1 with absent transverse process, pedicle, and lamina on the right. On exam, patient presented with no neurologic deficits and no radicular symptoms. Osteopathic exam notable for right sided paraspinal tenderness, T1 rotated left, and right first rib nonpalpable. Patient attempted to treat with over-the-counter pain management and supportive care. Patient previously completed physical therapy with some improvement but noted continued pain. Imaging was reviewed and OMT was done with avoidance of HVLA given concern for possible destabilization and damage to underlying structures. Patient educated on home exercise regimen with moderate relief of pain.
Discussion: This case serves as a reminder of the importance of both structure and function, especially when approaching ongoing musculoskeletal pain. Any anatomical abnormality, although rare, is important to keep in mind when treating pain as well as utilizing OMT. Congenital absence or hypoplasia of the ribs has limited available information in the current literature, with this case being particularly atypical due to the absence of the first rib specifically. The absence of ribs leads to downstream structural problems, such as scoliosis, with other cases documented where this has led to further health complications, including changes in respiration and circulation. In this case, HVLA techniques were avoided due to concerns for the risk of destabilization as well as possible damage to the brachial plexus. Instead, the preference had been treating with an emphasis on soft tissue and muscle energy techniques in addition to facilitated positional release.
