巨大肩袖損傷并發肩關節假性癱瘓的危險因素分析

徐青鐳 李飛 韓國一

·論著·

巨大肩袖損傷并發肩關節假性癱瘓的危險因素分析

徐青鐳 李飛 韓國一

目的 研究慢性巨大肩袖損傷類型與肩關節活動范圍受限的相關性，調查假性癱瘓的危險因素。方法 自2011年3月至2015年3月青島解放軍第401醫院經影像學檢查確診2個以上慢性巨大肩袖肌腱損傷，脂肪浸潤3級以上且無骨關節炎的門診患者78例并分為五個類型。分析VAS評分與損傷分型的相關性；分析主動前屈上舉、體側外旋、外展外旋和內旋與損傷分型的相關性，確定假性癱瘓的分布規律和危險因素，為臨床治療慢性巨大肩袖損傷提供指導。結果 慢性巨大肩袖損傷可分為上前、上后和上前后三大類五個亞型，累及三個肩袖肌腱的損傷類型發生假性癱瘓的危險性顯著增大，這其中肩胛下肌腱完全損傷導致假性癱瘓的危險性尤其明顯。結論 治療慢性巨大肩袖損傷應該重視肩胛下肌腱的修復，沒有條件完全修復者可通過部分修復逆轉假性癱瘓恢復肩關節活動范圍和功能。

肩關節；巨大肩袖；損傷；活動范圍，關節；假性癱瘓；危險因素

巨大肩袖損傷是臨床上常見的肩關節疾患，以肩關節疼痛和肩關節主動活動受限為主要表現。關于巨大肩袖損傷的定義，Cofield[1]提出根據撕裂大小將肩袖撕裂>5cm者界定為巨大肩袖損傷；Gerber等[2]則將累及2個及2個以上的肩袖肌腱損傷定義為巨大肩袖損傷。

慢性的巨大肩袖損傷伴嚴重肌肉組織退變的患者，臨床表現常呈現很大的差異。一部分患者僅表現輕中度疼痛而肩關節活動度(rangeofmotion,ROM)特別是主動前屈上舉并無受限；而另一部分患者表現為肩關節中重度疼痛，并且伴有肩關節假性癱瘓，即被動ROM無受限，而主動前屈上舉<90°，嚴重影響日常生活。這為此類患者的臨床評估和治療方案選擇帶來了困難和諸多不確定性。

本研究嘗試分析累及不同肩袖肌腱的巨大肩袖損傷與肩關節主動ROM受限程度的相關性，確定導致慢性巨大肩袖損傷患者出現假性癱瘓的危險因素，為臨床治療的方案選擇提供指導。

資 料 與 方 法

一、一般資料

自2011年3月至2015年3月，分析符合本研究納入及排除標準的患者共78例，所有患者均為單側受累，其中男性38例、女性40例，平均年齡65.2(58～77)歲，優勢側受累達70.5%(55/78)。

二、納入與排除標準

納入標準：(1)病史、查體和肩關節MR檢查T2加權脂肪抑制序列確診2個及2個以上肩袖肌腱慢性損傷患者。包括：理學檢查Jobe試驗陽性、力弱伴相應MR影像表現診斷為岡上肌腱損傷；肩關節體側外旋(外展0°位)力弱或延滯試驗陽性伴相應MR影像表現診斷為岡下肌腱損傷[3]；肩關節外展外旋(外展90°位)力弱或延滯試驗陽性、吹號征陽性(hornblower′ssign)及相應MR影像表現診斷為小圓肌腱損傷[4]；Lafosse改良的壓腹試驗(bellypresstest)存在力弱或延滯試驗陽性伴相應MR影像表現診斷為肩胛下肌損傷[5]。(2)肩關節MR檢查T1加權影像顯示肩袖肌肉脂肪浸潤Goutallier分級[6]達到3級與4級者。(3) 肩關節正位X線片檢查確定盂肱關節骨性關節炎Hamada分級[7]符合0～2級。

排除標準：(1)肩關節被動ROM受限者；(2)肩關節MR檢查顯示肩袖肌肉退變Goutallier3級以下者；(3)肩關節正位X線片檢查確定盂肱關節骨性關節炎Hamada3級以上者；(4)臨床資料記錄不全者；(5)既往有肩關節周圍手術史。

二、肩關節區域劃分

根據Lafosse的肩關節區域劃分標準[8]，將岡上肌作為上方肩袖結構單元，岡下肌和小圓肌分別作為后方肩袖結構單元，肩胛下肌上2/3腱性部分和下1/3肌性部分分別作為前方肩袖的結構單元，對所有符合納入標準患者的肩袖損傷區域分布類型，根據查體和MR檢查結果，按此5個結構單元進行記錄。

三、測量指標

1.肩關節主動ROM：記錄所有患者的肩關節主動前曲上舉角度、外展0°體側外旋角度和外展90°位外展外旋角度，分析肩關節主動ROM受限與肩袖肌腱撕裂類型的相關性。

2.肩關節疼痛：采用VAS評分(0～10分)標尺記錄患者主觀的疼痛程度，并分析其與肩袖肌腱撕裂類型的相關性。

3.分析假性癱瘓和吹號征陽性患者的分布規律以及其與肩袖肌腱撕裂類型的相關性。

四、統計學分析

采用SPSS14.0軟件進行統計學分析。所有五種肩袖肌腱損傷類型的肩關節疼痛評分差異用方差分析進行兩兩比較，顯著水平設定為0.05；所有五種肩袖肌腱損傷類型的主動ROM范圍(前屈上舉、體側外旋、外展外旋、內旋)的差異采用方差分析進行兩兩比較，顯著水平設定為0.05。

結 果

表2 肩袖損傷分型與活動度比較±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、肩袖損傷類型與VAS評分的相關性

損傷類型分布方面，所有患者均有岡上肌腱受累，同時合并前方、后方和前后方肩袖肌腱損傷。岡上肌腱損傷合并前方肩胛下肌損傷，命名為上前型(superior-anterior, SA)，占25例。其中岡上肌合并肩胛下肌上2/3腱性結構損傷者，為SA-1型，占15例；岡上肌合并肩胛下肌全部損傷者，為SA-2型，占10例。岡上肌腱損傷合并后方岡下肌腱、小圓肌腱損傷，命名為上后型(superior-posterior, SP)，占39例。岡上肌腱合并岡下肌腱損傷者，為SP-1型，占27例，岡上肌腱合并岡下肌腱和小圓肌腱損傷者，為SP-2型，占12例。岡上肌腱損傷合并前方肩胛下肌上2/3腱性結構損傷以及后方岡下肌腱損傷，命名為上前后型(superior-anterior-posterior, SAP)，占14例。各個肩袖損傷類型之間肩關節疼痛的VAS評分兩兩比較差異無統計學意義(P>0.05，表1)。

表1 肩袖損傷分型與VAS評分比較±s)

二、肩袖損傷類型與肩關節主動活動范圍的相關性

本組患者肩關節主動前屈上舉活動受限以累及肩胛下肌全部的SA-2型最為明顯，其主動前屈上舉范圍(75°±27°)與SA-1型(162°±21°)、SP-1型(156°±26°) 相比較差異有統計學意義(P<0.01)；與SP-2型(133°±48°)比較差異有統計學意義(P<0.05)。另外，累及岡上肌、肩胛下肌上2/3以及岡下肌三個肌腱的SAP型主動前屈上舉活動范圍(111°±41°)與SP-1和SP-2型比較差異有統計學意義(P<0.01)，見表2。

本組患者肩關節體側外旋活動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°)最為明顯，與累及前方肩袖肌腱的SA-2型(50°±17°)和SA-1型(61°±12°) 比較差異有統計學意義(P<0.01)。

外展外旋活動受限方面，以累及后方肩袖肌腱的SP-2型(19°±4°)與累及前方肩袖肌腱的SA-1型(90°±17°) 比較差異有統計學意義(P<0.01)。

本組患者肩關節內旋活動受限以累及前方肩袖肌腱的SAP型(L3)和SA-2型(L2) 最為明顯，累及后方肩袖肌腱的SP-1型(T11)、SP-2型(T12)內旋受限不明顯。

三、肩袖損傷類型與假性癱瘓的分布

假性癱瘓分布方面，累及肩胛下肌全部的SA-2型發生假性癱瘓的比例最高，達到80%；其次是累及岡上肌、肩胛下肌上2/3以及岡下肌三個肌腱的SAP型，達到48%，見圖1。

圖1 肩袖損傷類型與肩關節假性癱瘓的分布

討 論

巨大肩袖損傷的治療目前仍然缺乏共識。究其原因，首先在于關于巨大肩袖損傷的定義和界定存在不同的標準。Cofield[1]1982年首先提出肩袖撕裂無論在前后方向還是內外方向上>5cm即可定義為巨大肩袖損傷，但是由于CT、MR斷層掃描的角度以及關節鏡檢查的視角原因很難精確測定肩袖撕裂的大小，所以本研究采用Gerber等[2]提出的至少2個以上肩袖肌腱完全斷裂才可認定為巨大肩袖損傷的標準。其次，即使是累及2個以上肩袖肌腱完全損傷的患者，臨床表現可能迥異，從輕微疼痛且無活動受限到嚴重疼痛、假性癱瘓嚴重影響生活均有可能，這提示巨大肩袖損傷的類型和活動受限的相關性尚有待于進一步研究闡明。第三，相同的巨大肩袖肌腱損傷類型采用同樣的修補方法，卻往往由于肩袖肌肉本身的脂肪浸潤程度不同而表現為完全不同的臨床療效和預后轉歸[4]，這提示在評估巨大肩袖損傷和選擇治療方案時應該考慮到肌肉退變的因素。

傳統上分析肩袖損傷時都將肩胛下肌作為一個整體單元納入評估，其作用力總量可以達到其他3個肩袖肌腱肌肉作用力的總和。解剖學研究發現，肩胛下肌上2/3作為腱性部分附著于小結節，而其下1/3則是以肌肉結構的形式附著于小結節下方的區域[9]，這與后方肩袖肌腱的岡下肌腱和小圓肌腱的排列附著方式非常相似。此外，解剖學和肌電圖研究發現肩胛下肌的上2/3和下1/3分別為肩胛下神經的上方和下方的不同分支支配[10]，而在肩胛下肌上2/3發生脂肪浸潤后其下1/3的肌性部分可以作為一個獨立的結構單元發揮類似后方小圓肌腱的作用，因此本研究把肩胛下肌的上2/3腱性部分和下1/3的肌性部分作為兩個結構單元進行分析。

本研究結果表明，如果把肩胛下肌的上2/3和下1/3作為兩個肩袖肌腱功能單元，則假性癱瘓均發生于累及三個肩袖肌腱的損傷類型，其中累及岡上肌和肩胛下肌上、下部的SA-2型比例最高(占80%)，其次為累及岡上肌、肩胛下肌上2/3和岡下肌的SAP型(占48%)，累及岡上肌、岡下肌和小圓肌的SP-2型也有1/3的患者發生假性癱瘓。這顯示累及3個肩袖肌腱以及肩胛下肌的完全損傷是巨大肩袖損傷發生肩關節假性癱瘓的危險因素。累及2個肌腱的肩袖損傷很少發生假性癱瘓。因此臨床上治療巨大肩袖損傷，要逆轉假性癱瘓首先應該重視修復肩胛下肌的損傷，其次應該盡可能地完全修復所有可修補的損傷肌腱，如果沒有條件也應該爭取通過部分修補把累及3個肌腱的肩袖損傷修補為2個或1個肌腱。

綜合上述，本研究發現對于巨大肩袖損傷應該基于查體和MR[11]、CTA和X線片影像學評估進行分型；其中累及2個肩袖肌腱者很少發生假性癱瘓，臨床治療上應該力爭修復并解除疼痛；而累及3個肌腱的巨大肩袖損傷發生假性癱瘓的危險性陡增，其中肩胛下肌完全斷裂發生假性癱瘓的概率可達80%，臨床治療此類型的巨大肩袖損傷應該重視肩胛下肌的修復，無條件完全修復的應力爭通過部分修補逆轉假性癱瘓，恢復肩關節功能和活動度。本研究的不足之處在于樣本量偏小，所提出的5種損傷分型不一定能夠涵蓋所有的巨大肩袖損傷，有待于進一步研究論證。

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(本文編輯：李靜)

徐青鐳，李飛，韓國一.巨大肩袖損傷并發肩關節假性癱瘓的危險因素分析[J/CD]. 中華肩肘外科電子雜志,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青島解放軍第401醫院骨科

徐青鐳，Email:drxuql@hotmail.com

2015-09-21)