肩膀痛可能意味者上肩胛神经被压迫


  April 21, 2005 (纽奥良) - 根据一位神经外科医师发表指出,对于肩膀疼痛的患者,上肩胛神经受到压迫可能是主因;这个症状可能藉由手术而成功的减轻。
  
  研究医师为Daniel Kim,任职于加州的史丹佛大学,代表史丹佛的研究同僚们,在路易斯安那州立大学所举行的美国神经外科医师学会年会中作出发表。
  
  Kim医师表示,在史丹佛参与试验的肩痛患者有42位;最常见的抱怨,为疼痛皆集中在肩胛旁侧,或上肩胛凹迹处;患者们的第一个30度的手臂伸展及前臂向外旋转都有困难。
  
  Kim医师指出,这些都是典型的神经压迫症状,但是这种情形很少见。
  
  参与研究的患者中,19位的神经压迫是来自职业伤害,16位运动伤害,4位为直接外伤,3位则因腱鞘囊肿引起;患者平均年龄34.6岁,平均追踪期为18个月,症状期平均26个月。
  
  39位神经压迫的患者中(囊肿者除外),31位(79%)为轻度到中度的肩痛及棘肌无力;以5刻度的运动能力基准作评估,术前棘上肌及棘下肌皆为0到2分;经过神经舒放手术后,90%的患者之棘上肌指数进步到4分以上;而棘下肌的进步幅度却不如此明显,10位进步到3分以上,2至3分者有14位,1分者有7位。
  
  Kim表示,疼痛严重者有8位,其中7位因为手术而改善,他们的运动能力有些维持不变,有些则进步到4分;此外,并未发现任何并发症。
  
  Kim建议,保守治疗在经过6到8个月之后,若肌电图(ECG)研究排除颈椎根神经病变,就应该考虑进行手术。
  
  宾州大学神经外科学系的Eric Zager医师对本研究赞许有加;他表示,这是文献记载中,第二大的个案系列研究。
  
  Zager医师表示,神经压迫不易诊断,延迟诊断会导致萎缩及功能下降;诊断的进行很困难,这需要详细的神经学检查及EMG研究。
  
  Zager总结指出,在进行治疗程序之前,医师们应该对上肩胛神经复杂的解剖学作详细研究;若可能,甚至可以考虑先在大体上作解剖研究。

Shoulder Pain May Mean Suprasc

By Alicia Ault
Medscape Medical News

April 21, 2005 (New Orleans) — For patients with shoulder pain, suprascapular nerve entrapment may be responsible, according to a neurosurgeon who presented results of a study here yesterday showing that the condition can be successfully alleviated with surgery.

Daniel Kim, MD, from Stanford University in California, presented the study on behalf of colleagues at Stanford and Louisiana State University at the American Association of Neurological Surgeons annual meeting.

He said the most common complaint from the 42 patients treated and studied at Stanford was shoulder pain localized to the parascapular region or in the suprascapular notch. They also had weakness in the first 30 degrees of arm abduction and in external rotation of the forearm.

These are classic signs of entrapment, said Dr. Kim, although he noted that the condition is relatively rare.

Of the patients studied, 19 had entrapment from occupational injuries, 16 from sports-related injuries, four from direct trauma, and three from ganglion cysts. Patients' mean age was 34.6 years; there was a mean follow-up of 18 months. Patients had symptoms for an average of 26 months.

Of the 39 patients with entrapments (excluding cysts), 31 (79%) had mild to moderate shoulder pain and spinati weakness, with a grade of 0 to 2 or less on a five-point scale preoperatively for the supraspinatus, and a grade of 0 to 2 for the infraspinatus. After surgery to release the nerve, 90% of those patients improved to a grade 4 or better for the supraspinatus. Results were not as dramatic for the infraspinatus — 10 patients improved to grade 3 or above, 14 to grade 2 to 3, and seven improved to grade 1.

Seven of eight patients who had severe pain improved with the procedure, and their motor strength remained the same or improved to a grade 4, said Dr. Kim. There were no complications.

Dr. Kim recommended that surgery be considered after six to eight months of conservative treatment and careful electromyelogram studies to rule out cervical radiculopathy.

Eric Zager, MD, from the department of neurosurgery at the University of Pennsylvania in Philadelphia, praised the study, noting that it is now the second largest case series in the literature.

Suprascapular nerve entrapment is underdiagnosed, Dr. Zager said, adding that a delay in diagnosis leads to atrophy and decreased function. Making a diagnosis is difficult, requiring a careful neurologic examination and EMG studies, he said.

Before attempting a procedure, surgeons should closely study the suprascapular nerve's difficult anatomy, Dr. Zager said, adding that they might even consider dissections on a cadaver first.

AANS 2005 Annual Meeting: Abstract 765. April 20, 2005

Reviewed by Gary D. Vogin, MD

    



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