巨大肩袖损伤并发肩关节假性瘫痪的危险因素分析

徐青镭 李飞 韩国一

·论著·

巨大肩袖损伤并发肩关节假性瘫痪的危险因素分析

徐青镭 李飞 韩国一

目的 研究慢性巨大肩袖损伤类型与肩关节活动范围受限的相关性，调查假性瘫痪的危险因素。方法 自2011年3月至2015年3月青岛解放军第401医院经影像学检查确诊2个以上慢性巨大肩袖肌腱损伤，脂肪浸润3级以上且无骨关节炎的门诊患者78例并分为五个类型。分析VAS评分与损伤分型的相关性；分析主动前屈上举、体侧外旋、外展外旋和内旋与损伤分型的相关性，确定假性瘫痪的分布规律和危险因素，为临床治疗慢性巨大肩袖损伤提供指导。结果 慢性巨大肩袖损伤可分为上前、上后和上前后三大类五个亚型，累及三个肩袖肌腱的损伤类型发生假性瘫痪的危险性显著增大，这其中肩胛下肌腱完全损伤导致假性瘫痪的危险性尤其明显。结论 治疗慢性巨大肩袖损伤应该重视肩胛下肌腱的修复，没有条件完全修复者可通过部分修复逆转假性瘫痪恢复肩关节活动范围和功能。

肩关节；巨大肩袖；损伤；活动范围，关节；假性瘫痪；危险因素

巨大肩袖损伤是临床上常见的肩关节疾患，以肩关节疼痛和肩关节主动活动受限为主要表现。关于巨大肩袖损伤的定义，Cofield[1]提出根据撕裂大小将肩袖撕裂>5cm者界定为巨大肩袖损伤；Gerber等[2]则将累及2个及2个以上的肩袖肌腱损伤定义为巨大肩袖损伤。

慢性的巨大肩袖损伤伴严重肌肉组织退变的患者，临床表现常呈现很大的差异。一部分患者仅表现轻中度疼痛而肩关节活动度(rangeofmotion,ROM)特别是主动前屈上举并无受限；而另一部分患者表现为肩关节中重度疼痛，并且伴有肩关节假性瘫痪，即被动ROM无受限，而主动前屈上举<90°，严重影响日常生活。这为此类患者的临床评估和治疗方案选择带来了困难和诸多不确定性。

本研究尝试分析累及不同肩袖肌腱的巨大肩袖损伤与肩关节主动ROM受限程度的相关性，确定导致慢性巨大肩袖损伤患者出现假性瘫痪的危险因素，为临床治疗的方案选择提供指导。

资 料 与 方 法

一、一般资料

自2011年3月至2015年3月，分析符合本研究纳入及排除标准的患者共78例，所有患者均为单侧受累，其中男性38例、女性40例，平均年龄65.2(58～77)岁，优势侧受累达70.5%(55/78)。

二、纳入与排除标准

纳入标准：(1)病史、查体和肩关节MR检查T2加权脂肪抑制序列确诊2个及2个以上肩袖肌腱慢性损伤患者。包括：理学检查Jobe试验阳性、力弱伴相应MR影像表现诊断为冈上肌腱损伤；肩关节体侧外旋(外展0°位)力弱或延滞试验阳性伴相应MR影像表现诊断为冈下肌腱损伤[3]；肩关节外展外旋(外展90°位)力弱或延滞试验阳性、吹号征阳性(hornblower′ssign)及相应MR影像表现诊断为小圆肌腱损伤[4]；Lafosse改良的压腹试验(bellypresstest)存在力弱或延滞试验阳性伴相应MR影像表现诊断为肩胛下肌损伤[5]。(2)肩关节MR检查T1加权影像显示肩袖肌肉脂肪浸润Goutallier分级[6]达到3级与4级者。(3) 肩关节正位X线片检查确定盂肱关节骨性关节炎Hamada分级[7]符合0～2级。

排除标准：(1)肩关节被动ROM受限者；(2)肩关节MR检查显示肩袖肌肉退变Goutallier3级以下者；(3)肩关节正位X线片检查确定盂肱关节骨性关节炎Hamada3级以上者；(4)临床资料记录不全者；(5)既往有肩关节周围手术史。

二、肩关节区域划分

根据Lafosse的肩关节区域划分标准[8]，将冈上肌作为上方肩袖结构单元，冈下肌和小圆肌分别作为后方肩袖结构单元，肩胛下肌上2/3腱性部分和下1/3肌性部分分别作为前方肩袖的结构单元，对所有符合纳入标准患者的肩袖损伤区域分布类型，根据查体和MR检查结果，按此5个结构单元进行记录。

三、测量指标

1.肩关节主动ROM：记录所有患者的肩关节主动前曲上举角度、外展0°体侧外旋角度和外展90°位外展外旋角度，分析肩关节主动ROM受限与肩袖肌腱撕裂类型的相关性。

2.肩关节疼痛：采用VAS评分(0～10分)标尺记录患者主观的疼痛程度，并分析其与肩袖肌腱撕裂类型的相关性。

3.分析假性瘫痪和吹号征阳性患者的分布规律以及其与肩袖肌腱撕裂类型的相关性。

四、统计学分析

采用SPSS14.0软件进行统计学分析。所有五种肩袖肌腱损伤类型的肩关节疼痛评分差异用方差分析进行两两比较，显著水平设定为0.05；所有五种肩袖肌腱损伤类型的主动ROM范围(前屈上举、体侧外旋、外展外旋、内旋)的差异采用方差分析进行两两比较，显著水平设定为0.05。

结 果

表2 肩袖损伤分型与活动度比较±s)

注：SA-1：上前型-1型；SA-2：上前型-2；SP-1:上后型-1；SP-2:上后型-2；SAP:上前后型

一、肩袖损伤类型与VAS评分的相关性

损伤类型分布方面，所有患者均有冈上肌腱受累，同时合并前方、后方和前后方肩袖肌腱损伤。冈上肌腱损伤合并前方肩胛下肌损伤，命名为上前型(superior-anterior, SA)，占25例。其中冈上肌合并肩胛下肌上2/3腱性结构损伤者，为SA-1型，占15例；冈上肌合并肩胛下肌全部损伤者，为SA-2型，占10例。冈上肌腱损伤合并后方冈下肌腱、小圆肌腱损伤，命名为上后型(superior-posterior, SP)，占39例。冈上肌腱合并冈下肌腱损伤者，为SP-1型，占27例，冈上肌腱合并冈下肌腱和小圆肌腱损伤者，为SP-2型，占12例。冈上肌腱损伤合并前方肩胛下肌上2/3腱性结构损伤以及后方冈下肌腱损伤，命名为上前后型(superior-anterior-posterior, SAP)，占14例。各个肩袖损伤类型之间肩关节疼痛的VAS评分两两比较差异无统计学意义(P>0.05，表1)。

表1 肩袖损伤分型与VAS评分比较±s)

二、肩袖损伤类型与肩关节主动活动范围的相关性

本组患者肩关节主动前屈上举活动受限以累及肩胛下肌全部的SA-2型最为明显，其主动前屈上举范围(75°±27°)与SA-1型(162°±21°)、SP-1型(156°±26°) 相比较差异有统计学意义(P<0.01)；与SP-2型(133°±48°)比较差异有统计学意义(P<0.05)。另外，累及冈上肌、肩胛下肌上2/3以及冈下肌三个肌腱的SAP型主动前屈上举活动范围(111°±41°)与SP-1和SP-2型比较差异有统计学意义(P<0.01)，见表2。

本组患者肩关节体侧外旋活动受限以累及后方肩袖肌腱的SP-2型(2°±2°) 、SP-1型(25°±11°) 、SAP型(29°±14°)最为明显，与累及前方肩袖肌腱的SA-2型(50°±17°)和SA-1型(61°±12°) 比较差异有统计学意义(P<0.01)。

外展外旋活动受限方面，以累及后方肩袖肌腱的SP-2型(19°±4°)与累及前方肩袖肌腱的SA-1型(90°±17°) 比较差异有统计学意义(P<0.01)。

本组患者肩关节内旋活动受限以累及前方肩袖肌腱的SAP型(L3)和SA-2型(L2) 最为明显，累及后方肩袖肌腱的SP-1型(T11)、SP-2型(T12)内旋受限不明显。

三、肩袖损伤类型与假性瘫痪的分布

假性瘫痪分布方面，累及肩胛下肌全部的SA-2型发生假性瘫痪的比例最高，达到80%；其次是累及冈上肌、肩胛下肌上2/3以及冈下肌三个肌腱的SAP型，达到48%，见图1。

图1 肩袖损伤类型与肩关节假性瘫痪的分布

讨 论

巨大肩袖损伤的治疗目前仍然缺乏共识。究其原因，首先在于关于巨大肩袖损伤的定义和界定存在不同的标准。Cofield[1]1982年首先提出肩袖撕裂无论在前后方向还是内外方向上>5cm即可定义为巨大肩袖损伤，但是由于CT、MR断层扫描的角度以及关节镜检查的视角原因很难精确测定肩袖撕裂的大小，所以本研究采用Gerber等[2]提出的至少2个以上肩袖肌腱完全断裂才可认定为巨大肩袖损伤的标准。其次，即使是累及2个以上肩袖肌腱完全损伤的患者，临床表现可能迥异，从轻微疼痛且无活动受限到严重疼痛、假性瘫痪严重影响生活均有可能，这提示巨大肩袖损伤的类型和活动受限的相关性尚有待于进一步研究阐明。第三，相同的巨大肩袖肌腱损伤类型采用同样的修补方法，却往往由于肩袖肌肉本身的脂肪浸润程度不同而表现为完全不同的临床疗效和预后转归[4]，这提示在评估巨大肩袖损伤和选择治疗方案时应该考虑到肌肉退变的因素。

传统上分析肩袖损伤时都将肩胛下肌作为一个整体单元纳入评估，其作用力总量可以达到其他3个肩袖肌腱肌肉作用力的总和。解剖学研究发现，肩胛下肌上2/3作为腱性部分附着于小结节，而其下1/3则是以肌肉结构的形式附着于小结节下方的区域[9]，这与后方肩袖肌腱的冈下肌腱和小圆肌腱的排列附着方式非常相似。此外，解剖学和肌电图研究发现肩胛下肌的上2/3和下1/3分别为肩胛下神经的上方和下方的不同分支支配[10]，而在肩胛下肌上2/3发生脂肪浸润后其下1/3的肌性部分可以作为一个独立的结构单元发挥类似后方小圆肌腱的作用，因此本研究把肩胛下肌的上2/3腱性部分和下1/3的肌性部分作为两个结构单元进行分析。

本研究结果表明，如果把肩胛下肌的上2/3和下1/3作为两个肩袖肌腱功能单元，则假性瘫痪均发生于累及三个肩袖肌腱的损伤类型，其中累及冈上肌和肩胛下肌上、下部的SA-2型比例最高(占80%)，其次为累及冈上肌、肩胛下肌上2/3和冈下肌的SAP型(占48%)，累及冈上肌、冈下肌和小圆肌的SP-2型也有1/3的患者发生假性瘫痪。这显示累及3个肩袖肌腱以及肩胛下肌的完全损伤是巨大肩袖损伤发生肩关节假性瘫痪的危险因素。累及2个肌腱的肩袖损伤很少发生假性瘫痪。因此临床上治疗巨大肩袖损伤，要逆转假性瘫痪首先应该重视修复肩胛下肌的损伤，其次应该尽可能地完全修复所有可修补的损伤肌腱，如果没有条件也应该争取通过部分修补把累及3个肌腱的肩袖损伤修补为2个或1个肌腱。

综合上述，本研究发现对于巨大肩袖损伤应该基于查体和MR[11]、CTA和X线片影像学评估进行分型；其中累及2个肩袖肌腱者很少发生假性瘫痪，临床治疗上应该力争修复并解除疼痛；而累及3个肌腱的巨大肩袖损伤发生假性瘫痪的危险性陡增，其中肩胛下肌完全断裂发生假性瘫痪的概率可达80%，临床治疗此类型的巨大肩袖损伤应该重视肩胛下肌的修复，无条件完全修复的应力争通过部分修补逆转假性瘫痪，恢复肩关节功能和活动度。本研究的不足之处在于样本量偏小，所提出的5种损伤分型不一定能够涵盖所有的巨大肩袖损伤，有待于进一步研究论证。

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(本文编辑：李静)

徐青镭，李飞，韩国一.巨大肩袖损伤并发肩关节假性瘫痪的危险因素分析[J/CD]. 中华肩肘外科电子杂志,2016,4(1):35-40.

Risk factors for pseudoparalysis in patients with massive rotator cuff tear

XuQinglei,LiFei,HanGuoyi.

DepartmentofOrthopedics,PLA401Hospital,Qingdao266071,China

Correspondingauthor:XuQinglei,Email:drxuql@hotmail.com

Background Massive rotator cuff tear is a common clinical disorder of the shoulder, which mainly manifests as shoulder joint pain and limited range of motion (ROM). Cofield proposed the definition of massive rotator cuff tear as massive rotator cuff tears > 5 cm; on the other hand, Gerber et al. defined rotator cuff tears involving 2 or more rotator cuff tendons as massive rotator cuff tears. Patients with chronic massive rotator cuff tears and severe muscle degeneration had unique and varying clinical manifestations. Some patients showed only mild to moderate pain while shoulder range of motion limitation was not obvious especially that active flexion and abduction activities were not affected; some other patients had moderate to severe shoulder joint pain accompanied by pseudoparalysis of the shoulder joint, i.e., active flexion was <90° while passive ROM was not limited, seriously affecting daily life of the patients. This brings difficulties and a lot of uncertainties for clinical assessment and treatment of these patients.This study attempts to analyze the correlation between massive rotator cuff tears involving different tendons and the extent of active ROM limitation, in order to determine risk factors for pseudoparalysis in patients with chronic rotator cuff tears and provide guidance on clinical treatment options.Methods From March 2011 to March 2015, we analyzed 78 patients who met the inclusion and exclusion criteria of this study. All patients were unilateral involvement, 38 cases of male, 40 cases of female, with an average age of 65.2 years old (58-77 years old), and a dominant side involvement rate of 70.5% (55/78).Inclusion criteria: (1) medical history, physical examination, shoulder MR imaging and fat suppression T2-weighted sequences confirmed the diagnosis of chronic rotator cuff tears involving two or more tendons. This included: positive Jobe′s test by physical examination, and weak muscle force with corresponding MR imaging findings supporting the diagnosis of supraspinatus tendon injury; weak muscle force at shoulder external rotation position (0° abduction) or positive lag sign with appropriate MR imaging findings to support the diagnosis of infraspinatus tendon injury; weak muscle force at shoulder abduction and external rotation position (90° abduction) or positive lag sign, positive hornblower′s sign and appropriate diagnostic MR imaging findings of teres minor tendon damage; weak muscle force by improved Lafosse′s belly press test or positive lag sign accompanied with appropriate diagnostic MR imaging findings of subscapularis muscle injury. (2) T1-weighted MR imaging of shoulder joint showed fatty infiltration Goutallier grades of 3 and 4 in rotator cuff muscles. (3)shoulder anteroposterior X-ray examination determined glenohumeral osteoarthritis with Hamada grades of 0-2.Exclusion criteria: (1) passive ROM limitation of the shoulder joint; (2) shoulder MR examination revealed that degeneration of rotator cuff muscles was less than the Goutallier grade 3; (3) shoulder anteroposterior X-ray examination determined glenohumeral osteoarthritis with Hamada grades of 3 or more; (4) patients with incomplete clinical data records; (5) past history of surgeries around the shoulder joint.Shoulder zoning: According to Lafosse′s shoulder zoning methods, assign the supraspinatus muscle into the upper rotator cuff unit, infraspinatus and teres minor muscle into the posterior rotator cuff unit, upper 2/3 tendon and lower 1/3 muscle of subscapularis into the anterior rotator cuff unit, the rotator cuff tear units of all patients who met our inclusion criteria were categorized based on the above 5 structural units, and results of physical examination and MR imaging of all patients were recorded.Measurements: active shoulder ROM: for all patients, record the shoulder active flexion and abduction range, 0° abduction and external rotation range and 90° abduction and external rotation range, analyze the correlation between active shoulder ROM limitation and the type of rotator cuff tears. Shoulder pain: use VAS score (0-10 points) to record subjective pain scale of the patients, analyze the correlation with the type of rotator cuff tears, and analyze the distribution of pseudoparalysis and hornblower′s sign and their correlation with the type of rotator cuff tears.Statistical analysis: SPSS 14.0 software was used for statistical analysis. Difference in the shoulder pain scores of all five types of rotator cuff tears was compared by pairwise analysis of variance. Significant level was set at 0.05. Difference in active ROM of all five types of rotator cuff tears (flexion and traction, external rotation, abduction and medial rotation) was compared by pairwise analysis of variance. Significant level was set at 0.05.Results Correlation between types of rotator cuff tears and VAS scores: for the distribution of types of injuries, all patients had supraspinatus tendon involvement combined with anterior, posterior or anteroposterior rotator cuff tears at the same time. Supraspinatus tendon injury combined with anterior subscapularis muscle injury was named the superior-anterior type (SA), accounting for 25 cases, among which supraspinatus injury with upper 2/3 subscapularis tendon injury was named the SA-1 type, accounting for 15 cases, and supraspinatus combined with whole subscapularis muscle injury was named the SA-2 type, accounting for 10 cases. Supraspinatus tendon injury combined with posterior infraspinatus tendon and teres minor tendon injuries was named the superior-posterior type (SP), accounting for 39 cases. Supraspinatus tendon injury combined with infraspinatus tendon injuries were named as the SP-1 type, accounting for 27 cases. Supraspinatus tendon injury combined infraspinatus tendon and teres minor injury was named the SP-2 type, accounting for 12 cases. Supraspinatus tendon injury combined with anterior upper 2/3 subscapularis tendon injury and posterior infraspinatus tendon injury was named the superior-anterior-posterior (SAP), accounting for 14 cases. There was no statistically significant difference in shoulder pain VAS scores based on pairwise comparison among different types of rotator cuff tears.The correlation between types of shoulder rotator cuff tears and active shoulder ROM: shoulder anterior elevation ROM limitation among this group of patients was most obvious in the SA-2 type involving the entire subscapularis muscle, as their active anterior elevation range (75°±27°) had significant difference as compared with the SA-1 type (162°±21°) and SP-1-type (156°±26°) (P<0.01)aswellastheSP-2type(133°±48°) (P<0.05).Inaddition,theactiveanteriorelevationrangeofmotion(111°±41°)inSAPtypeinvolvingsupraspinatusmuscle,upper2/3subscapularisand3tendonsofinfraspinatuswassignificantlydifferentfromthatoftheSP-1andSP-2types(P<0.01).Amongthisgroupofpatients,shoulderexternalrotationlimitationwasmostseriousinSP-2type(2°±2°),SP-1type(25°±11°)andSAPtype(29°±14°)involvingposteriorrotatorcufftendons,whichhadsignificantdifferenceascomparedtotheSA-2type(50°±17°)andSA-1type(61°±12°)thatinvolvedanteriorrotatorcufftendons(P<0.01).AbductionandexternalrotationlimitationwasseenmostlyintheSP-2type(19°±4°)involvingposteriorrotatorcufftendonsandtheSA-1type(90°±17°)involvinganteriorrotatorcufftendons.Thedifferenceswithothertypeswerestatisticallysignificant(P<0.01).InternalrotationlimitationinthisgroupofpatientswasmostsevereintheSAPtype(L3)andSA-2type(L2)involvinganteriorrotatorcufftendonswhileinternalrotationwasnotobviouslylimitedintheSP-1type(T11)andSP-2type(T12)involvingposteriorrotatorcufftendons.Typesofrotatorcufftearsanddistributionofpseudoparalysis:intermofpseudo-paralysisdistribution,SA-2typeinvolvingtheentiresubscapularishadthehighestratioofpseudoparalysisthatreached80%,followedbytheSAPtypeinvolvingsupraspinatusmuscle,upper2/3ofsubscapularisandinfraspinatusmuscletendons,reaching48%.ConclusionsTreatmentofchronicmassiverotatorcufftearsshouldpayattentiontorepairthesubscapularismuscles.Inpatientsthatcompleterepairisnotpossible,partialrepairmayberesortedtoreversepseudoparalysisandrestoretheROMandfunctionoftheshoulderjoint.

Shoulder;Massiverotatorcufftear;Injury;Rangeofmotion,joint;Pseudoparalysis;Riskfactor

10.3877/cma.j.issn.2095-5790.2016.01.007

266071青岛解放军第401医院骨科

徐青镭，Email:drxuql@hotmail.com

2015-09-21)