【英语讨论】肩胛上神经卡压综合征
英语病例讨论
病例来源于 ACR 网站
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History :A 38-year-old woman presents with shoulder pain
Soso 20:02
1.1Which of the following muscles demonstrate an abnormality in this STIR image obtained at a level inferior to the spine of the scapula?
A Subscapularis
B Infraspinatus
C Supraspinatus
D Deltoid
E Teres minor
杨涛 20:04 b
Soso 20:04 great! Has who a different answer?
刘飞 20:05 b
雨涟 20:06 B
Soso 20:06 show true key?
雨涟 20:07 up to you
Soso 20:09
n Question2.1
n What abnormality is demonstrated by the images shown?
n A Reverse Hill-Sachs deformity of the humeral head
n B Biceps tendon peritendinitis
n C Hemarthrosis
n D Fibrous tumor
n E Cystic lesion
彭俊萍 20:10 be
Soso 20:11 single
刘飞 20:11 b？
杨涛 20:11 ce See the blood signal, but not in joint capsule[抓狂] c？
Soso 20:14 Has who a different answer?
张恒 20:14 C
刘飞 20:17 answer？
Soso 20:17 Bold
Soso 20:21
n 3.1What is the most common etiology of the abnormality seen on the prior images?
n A Fracture
n B Cervical radiculopathy
n C Labral tear
n D Prior infection
n E Idiopathic
Soso 20:36
n 4.1Which nerve is likely affected in this patient?
n A Suprascapular nerve
n B Axillary nerve
n C Dorsal scapular nerve
n D Long thoracic nerve
n E Infrascapular nerve
刘飞 20:37 [撇嘴]difficult i guess e
杨涛 20:37 b
Soso 20:39 continue..
雨涟 20:39 e
Soso 20:40 very good; maybe, U RT
Soso 20:45
Axial T1 fat-suppressed MR arthrogram through the right shoulder demonstrates increased signal in the infraspinatus muscle (red arrow).
Soso 20:46
Axial T1 fat-suppressed MR arthrogram through the right shoulder demonstrates a T1 hypointense lesion (yellow arrow).
Soso 20:48
Axial T2-weighted MR arthrogram through the right shoulder demonstrates that the T1 hypointense lesion is T2 hyperintense, consistent with a cystic lesion (yellow arrow).
Soso 20:50
Coronal T1 fat-suppressed MR arthrogram through the right shoulder demonstrates a tear of the superior labrum (yellow arrow) and the T1 hypointense paralabral cyst (red arrow).
Soso 20:50
Coronal T1-weighted MR arthrogram through the right shoulder demonstrates a tear of the superior labrum (yellow arrow) and the T1 hypointense paralabral cyst (red arrow).
Soso 20:52
Coronal T2-weighted MR arthrogram through the right shoulder demonstrates the T2 hyperintense paralabral cyst (red arrow).
Soso 20:52
Diagnosis
Spinoglenoid notch suprascapular nerve entrapment
Soso 20:53
Case Points
Soso 20:53
Findings of suprascapular nerve entrapment on MR arthrography include edema that may involve the infraspinatous muscle alone or the infraspinatous and the supraspinatus muscles, depending on the location of entrapment.
Soso 20:53
Different causes for suprascapular nerve entrapment include tumors, paralabral cysts due to labral tears, veins/varicosities, posttraumatic scarring/fractures, or heterotopic calcifications. However, a paralabral cyst is the most common cause.
Soso 20:53
Treatment of suprascapular nerve entrapment may include percutaneous drainage and steroid injections for symptomatic relief. However, surgical treatment of the cause is required eventually for definitive treatment.
Soso 20:54
Discussion
Soso 20:54
The suprascapular nerve provides motor innervation to the supraspinatus and infraspinatus muscles. It also provides sensory innervation to the acromioclavicular and glenohumeral joints. The nerve courses in an anterior-posterior direction above the scapula in the suprascapular notch, where it provides motor innervation to both the supraspinatus and infraspinatus muscles. Distally it then courses through the spinoglenoid notch, where it provides motor innervation to the infraspinatus muscle only.
Soso 20:55
Suprascapular nerve entrapment syndrome is an uncommon disorder affecting primarily young athletes (mean age 20-40 years old), males more commonly than females, and especially overhead athletes such as in baseball, tennis, and volleyball players. It was originally described in weightlifters who had shoulder pain and eventually developed weakness and muscle atrophy. A variety of causes may lead to entrapment of the suprascapular nerve along its course. These include tumors, paralabral cysts due to a labral tear, veins/varicosities, posttraumatic scarring/fractures, or even heterotopic calcifications. A paralabral cyst secondary to an anterior-posterior tear of the superior labrum, such as the one presented in this case, is the most common cause of suprascapular nerve entrapment. Depending on where the entrapment occurs, it may affect both the supraspinatus muscle and the infraspinatus muscle, if more proximal in the suprascapular notch. It may affect the infraspinatus muscle only, if entrapment occurs more distally in the spinoglenoid notch. Early findings may be subtle edema in the muscle(s) affected, which is best seen as subtle hyperintense signal within the muscle on MRI fluid-sensitive sequences, such as T2 and STIR sequences. If left untreated, this eventually leads to muscle atrophy and fatty replacement of the muscle(s), best seen as high signal on T1 MR imaging.
Soso 20:55
Percutaneous drainage and steroid injections may help with the symptoms initially; however, surgical treatment of the cause, which is most commonly a labral tear, is eventually needed for definitive treatment. The differential diagnosis may include brachial neuritis (Parsonage-Turner syndrome) where muscles of the rotator cuff are affected variably, a rotator cuff tear (that would be visualized on MRI), cervical radiculopathy, or a neural tumor.
Soso 20:56
If there are no other comments, I’d like to wrap this discussion up.
概述
肩胛上神经卡压是肩部疼痛最常见的原因之一国外有学者认为本征占所有肩痛患者的1%～2%。
1909年Ewald描述了一种创伤后肩胛上“神经炎”。1926年，Foster报道了16例有肩胛上神经病变的病例1948年，Parsonage和Turner报道的136例肩痛病例中有4例患肩胛上神经炎。这些就是最早的有关肩胛上神经卡压症的报道1959年，Kopell和Thompson对肩胛上神经在肩胛上切迹部的卡压作了详尽的描述，并称之为肩胛上神经卡压综合征(suprascapular nerve entrapmentSNE)。以后有关肩胛上神经卡压的病例报道逐渐增多。1982年Aiello等报道了SNE在肩胛冈上关节盂切迹处卡压的病例。1987年，Ferretti等报道了排球运动员出现SNE的病例近年来还有有关肩胛下肌萎缩及一些特殊卡压病例的报道。
病因
(一)发病原因
肩胛上神经卡压可因肩胛骨骨折或盂肱关节损伤等急性损伤所致肩关节脱位也可损伤肩胛上神经肩部前屈特别是肩胛骨固定时的前屈,使肩胛上神经活动度下降易于损伤肿瘤肱盂关节结节样囊肿以及肩胛上切迹纤维化等均是肩胛上神经卡压的主要原因有报道认为肩袖损伤时的牵拉也可致肩胛上神经损伤各种局部脂肪瘤和结节均可压迫肩胛上神经的主干或肩胛下神经分支引起卡压
(二)发病机制
Sunderland认为肩胛上神经在通过肩胛上切迹时神经相对固定使其易于在重复运动时受损肩胛骨和盂肱关节的重复运动使神经在切迹处摩擦出现神经的炎性反应及水肿这样就可导致卡压性损害已经知道肩胛骨远端的运动可致肩胛上神经拉紧引起“悬吊效应”使神经在切迹处绞索引起神经病变Mizuno等报道当副神经麻痹后肩胛骨向下外侧下垂可使肩胛上神经受到肩胛上横韧带的牵拉肩胛上神经肩关节支可引起盂肱关节疼痛这是临床最常见的症状肩胛上神经病变以单侧为主也有双侧发病的报道
症状
患者常有肩周区弥散的钝痛位于肩后外侧部可向颈后及臂部放射但放射痛常位于上臂后侧患者常感肩外展外旋无力进行性病例可有冈上肌萎缩然而多数病例无明显的肌萎缩因此临床诊断比较困难
通常患者有创伤或劳损史例如肩部受到直接创伤或间接伤如摔倒时伸手导致肩关节过度外展以致扭伤;还有部分患者有肩关节过度劳损如运动性劳损(如从事排球篮球网球等运动)肩部劳作性损伤史
有创伤或劳损的患者肩部以锐痛为主肩部活动时可加重疼痛可为持续性严重者影响睡眠无明显的肌萎缩抬臂困难或患侧手不能达对侧肩部有些患者除有肩部疼痛外无其他症状疼痛可持续数年
肩胛上切迹部压痛或位于锁骨与肩胛冈三角间区的压痛是肩胛上神经卡压最常见的体征斜方肌区也可有压痛如肩胛切迹处卡压压痛点在肩胛切迹处肩外展外旋肌力减弱;冈上肌冈下肌萎缩特别是冈下肌萎缩;由于有肩胛上关节支支配肩锁关节可出现肩锁关节压痛如肩胛冈盂切迹处卡压则疼痛较肩胛上切迹处卡压轻压痛位于冈盂切迹处局部除冈下肌萎缩外其他表现不明显
肩胛上神经卡压综合征的诊断需通过仔细询问病史以及系统的物理检查及肌电检查来确诊
1.肩胛骨牵拉试验 令患者将患侧手放置于对侧肩部并使肘部处于水平位使患侧肘部向健侧牵拉可刺激卡压的肩胛上神经诱发肩部疼痛
2.利多卡因注射局部封闭 于肩胛上切迹压痛点注射1%的利多卡因如果症状迅速缓解有助于肩胛上神经卡压综合征的诊断
3.肌电检查 肌电检查和神经传导速度检查有助于肩胛上神经卡压综合征的诊断Khaliki发现肩胛上神经卡压综合征患者诱发电位潜伏期延长冈上肌肌电可出现正向波纤颤波以及运动电位减少或消失
4.X线检查 使肩胛骨在后前位X线片上向尾部倾斜15°～30°以检查肩胛上切迹的形态有助于诊断
治疗
(一)治疗
1.基本要求 肩胛上神经卡压的治疗仍以手术松解为主保守治疗如休息理疗止痛药物的应用以及局部封闭治疗也可选用对以创伤或牵拉引起的肩胛上神经损伤早期可保守治疗如为明确的慢性卡压应早期手术治疗进行神经松解及肩胛上切迹扩大术
2.手术疗法 肩胛上神经卡压松解术常采用三种入路：后入路前入路和颈部入路后入路是最常用的手术入路手术步骤如下：
(1)麻醉与切口： ①麻醉：全身麻醉取侧卧位 ②切口：从肩峰开始沿肩胛冈向内侧延长至肩胛骨的脊柱缘长约250px(图1)
(2)手术步骤：游离切口上侧皮缘切开深筋膜辨明斜方肌止点顺切口方向切断该肌止点找到斜方肌与冈上肌的肌间隙做钝性分离向下分离达肩胛骨的上界继续向外侧分离找到肩胛上神经和肩胛上血管将肩胛上血管向外侧牵开充分显露肩胛上神经可能存在的卡压因素如肩胛上横韧带及各种纤维束带等并对卡压因素进行松解将肩胛上神经游离牵开用骨凿对肩胛上切迹进行扩大术后将肢体远端悬吊并尽早进行功能锻炼
(二)预后
预后尚佳