血管破裂导致冈盂窝血性囊肿形成一例

doi:10.3877/cma.j.issn.2095-5790.2022.03.013

肩胛上神经卡压常常导致肩部疼痛及肩袖肌肉的萎缩^[1]，而引起肩胛上神经卡压最常见的病因是冈盂窝囊肿形成^[2]。核磁共振能够很好地检测是否存在冈盂囊肿及确认冈盂囊肿的大小和位置，而肌电图可以明确有无肩胛上神经的损害^[3，4]。对于无明显症状的冈盂窝囊肿可采用保守治疗。而对于引起症状的冈盂窝囊肿通常需要手术干预^[5，6]。随着肩关节微创技术的发展，目前更加倾向于在关节镜下对囊肿进行处理^[7]。一部分观点认为对囊肿进行充分的引流及缝合损伤的盂唇即可以起到良好的治疗效果^[8，9]；而另一部分观点认为需要同时行肩胛上神经的松解，才能够达到满意的疗效^{[10，11，12]}。对于大部分患者，冈盂窝囊肿常因盂唇损伤造成，关节液通过盂唇的单向阀门作用，使得关节液通过撕裂口单向流动并逐渐聚集形成囊肿^[13]。然而并非所有冈盂窝囊肿都是通过此机制形成，局部的外伤也可能通过另一种机制造成冈盂窝囊肿，在手术处理时需要格外注意，不能因为未发现盂唇损伤而漏诊。本文报道了1例因血管破裂导致冈盂窝血性囊肿形成，从而出现肩关节疼痛及肌力减弱的患者，行关节镜下囊肿清除、肩胛上神经松解后，肩关节疼痛及力弱迅速缓解。

图1 术前患者肩关节功能照　图A：肩关节前屈上举；图B：肩关节外旋；图C：肩关节内旋；图D：Jobe试验阳性提示患侧冈上肌肌力减弱；图E：Hug-up试验阳性提示患侧冈上肌肌力减弱；图F：外旋抗阻试验阳性提示患侧冈下肌肌力减弱

图2 术前肩关节MRI　图A-B：肩关节冠状位MRI提示囊肿位于肩峰下，肩盂内侧，呈现多房性；图C-D：肩关节矢状位MRI提示囊肿位于肩盂后上方；图E-F：肩关节水平位MRI提示囊肿位于冈盂窝内

图3 肩关节镜检未发现后上方盂唇明显损伤及通道　图A：关节镜检提示后上盂唇完整；图B：探针探查后上盂唇未见撕裂；图C：后上盂唇内侧关节囊未见撕裂

图4 发现冈盂窝内血性囊肿及清理　图A-B：镜检确认冈盂窝囊肿；图C-D：镜下剪刀剪开囊肿外壁发现囊肿呈血性；图E-F：刨刀清理囊肿外壁发现囊肿呈现多房分隔；图G-H：使用篮钳清理囊肿壁直到完全清除

图5 松解肩胛上神经　图A：探查肩胛上神经位于囊肿深面，邻近处见一破裂动脉；图B：破裂动脉仍呈活动性出血状态；图C：松解肩胛上神经

图6 术后6个月肩关节功能照　图A：肩关节前屈上举；图B：肩关节外展；图C：肩关节内旋；图D：肩关节外旋

图7 术后6个月MRI未见囊肿复发　图A-B：肩关节冠状位MRI未见囊肿复发；图C-D：肩关节矢状位MRI未见囊肿复发；图E-F：肩关节水平位MRI未见囊肿复发

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