肩胛上神经损伤原因的解剖学分析

目的:探讨肩胛上神经损伤的解剖学原因。方法:观察人肩胛切迹的形态,肩胛上神经和肌肉的关系,同时测量肩胛上神经在肩胛下孔处的转折角、肩胛上、下孔的横径、肩胛上、下横韧带的长度。结果:肩胛切迹U型58.82%,弧形17.65%,V型19.12%,半封闭型2.94%,全封闭型1.47%;肩胛上神经经过肩胛上孔进入冈上窝,之后经冈盂切迹进入冈下窝,此处有1个51.18°±6.93°的转折角,即肩胛上神经转折角;肩胛上孔由肩胛切迹和肩胛上横韧带围成,肩胛上孔横径(7.81±3.29)mm,韧带长(12.23±4.89)mm;肩胛下孔是由冈盂切迹和外侧的肩胛下横韧带(冈盂韧带)围成,其横径(8.79±3.96)mm,韧带长(21.26±5.45)mm。同时肩胛上神经主干主要在肌肉和肩胛骨面之间。结论:肩胛上神经自身走行的路径是其损伤的基础,肩关节反复活动对神经的牵拉是损伤的直接原因。     

针刀微创手术治疗肩胛上神经卡压的解剖学研究

目的观测肩胛上横韧带,肩胛上动脉、肩胛上神经及其冈上肌支,为针刀治疗肩胛上神经卡压提供解剖学依据。方法解剖观测肩胛上横韧带的长度、宽度和厚度;观察肩胛上动脉和肩胛上神经以及它们的冈上肌支与肩胛上横韧带的位置关系,测量它们在肩胛切迹处的直径;以韧带内侧附着处下点的骨面为基点,确定体表穿刺点和穿刺深度。结果肩胛上横韧带下缘长(0.901±0.234)cm,韧带中间窄厚,内、外侧附着点宽薄;肩胛上神经走行于肩胛切迹内,肩胛上横韧带的下方;肩胛上动脉有16.67%走行于切迹内神经的外侧,83.33%走行在切迹外韧带外上方;肩胛上神经的冈上肌支经肩胛切迹内上角走行入冈上肌;体表穿刺定位角为(24.102±3.681)°。穿刺定位距离计算的回归方程是:Y=2.560+0.615X,穿刺深度为(4.342±0.629)cm。结论针刀切断韧带的方向应从韧带内侧部下缘切向内上,可避免损伤韧带下方的肩胛上神经和韧带外上的肩胛上动脉,且可更有效地解除对肩胛上神经及其冈上肌支的卡压;直线回归方程使穿刺的体表定位因人而异,更为准确。     

冈盂切迹的解剖形态学测量及临床意义

目的探讨干燥标本的冈盂切迹解剖形态学测量及其临床意义。方法收集282例干燥肩胛骨标本,观测冈盂切迹宽度(关节盂内侧缘至肩胛冈直线距离)、冈盂切迹厚度(冈盂切迹最低点厚度)、冈盂切迹深度、冈盂切迹转折角(肩胛切迹,冈盂切迹最低点连线与肩胛冈基底部所成的夹角)等。结果冈盂切迹宽度、深度分别为(12.75±1.06)mm、(11.65±1.89)mm,且右侧更宽更深,双侧对比P0.05有统计学差异;冈盂切迹厚度(9.93±1.57)mm,肩胛上切迹至冈盂切迹距离为(18.73±3.18)mm,且双侧对比P0.05;冈盂切迹转折角为(40.24±8.69)°,双侧对比P0.05有统计学差异。结论冈盂切迹的厚度、深度、宽度和转折角均是肩胛上神经卡压症的危险因素,且冈盂切迹越深,冈盂切迹转折角越小,发生肩胛上神经卡压的几率越大。本研究解剖数据可为临床在手术入路和内固定物植入位置选择等提供参考,降低术中神经损伤风险。     

肩袖合并肩胛上神经损伤原因的解剖学研究

目的:探讨肩袖损伤合并肩胛上神经损伤的解剖学原因及其临床意义。方法:在44侧经常规防腐处理的成人尸体上肢标本上解剖观测肩袖和肩胛上神经,观测肩胛上神经及其分支的数目、直径、起始、走行、分布以及与肩袖的解剖关系。结果:肩胛上神经行程迂曲,有起点、入肌点两个固定点,另有肩胛上孔、肩胛下孔两个约束点,在冈盂切迹处形成大约50°左右的转折角,发出冈上肌支44支、冈下肌支44支、上关节支42支、下关节支53支、感觉支37支,分布于冈上肌、冈下肌和肩关节等处。肩胛上神经分别在肩胛上、下孔处贴近肩胛上韧带、肩胛下韧带,活动余地较小,肩部外展活动时神经张力增大,肩袖和肩胛上神经干之间有筋膜相隔。结论:肩胛上神经内在的解剖因素是肩袖合并肩胛上神经损伤的基础,肩袖的牵拉是其受伤的直接原因,肩袖损伤时可合并肩胛上神经损伤。     

肩胛上神经冈下肌支卡压1例

1临床资料 患者,男,25岁,喜欢打篮球。右肩胛部疼痛3月,理疗无效,右肩部肌肉萎缩、活动乏力而就诊。查体：右肩胛部冈下肌明显萎缩,肩胛冈中外1／3交界下方压痛,压痛范围1cm×1cm。皮肤感觉正常,右肩关节各向活动范围正常,外旋肌力减弱。肌电图表现为传导速度减慢,潜伏期延长。行手术治疗,沿肩胛冈中点向外侧切开至肩峰,切断部分斜方肌、三角肌在肩胛冈上的附着部,分别将冈上、下肌自肩胛冈两侧剥离并牵开,于外侧见肩胛上神经冈下支神经血管束穿行于冈盂切迹与肩胛下韧带构成的骨纤维孔道,肩胛上神经冈下支水肿及瘢痕增生。切除肩胛下韧带及冈盂切迹内侧部分骨质,骨蜡涂抹切骨处,神经外膜松解。术后肩胛部疼痛消失。术后半年两侧肩部肌肉对称。     

肩胛上神经卡压症针刀手术入路研究

目的提供肩胛上神经卡压症针刀手术入路的解剖学基础。方法在30侧经10％福尔马林固定及灌注红色乳胶的成人上肢标本上行局部层次解剖。①观察肩胛上神经位置，行程和分布，以及与周围结构的相互毗邻关系。②测量肩胛上下孔；肩胛上下横韧带的相关数据。③设定肩胛上神经的体表测量标志，并测量相关数据。结果：①肩胛上神经由臂丛C5、6形成后，越过颈后三角向外，经肩胛上孔入冈上窝，分出冈上肌支、上关节支，其主干改名为冈下肌支穿肩胛下孔入冈下窝，分出冈下肌支、下关节支。②肩胛上孔横径7．90±3．0mm；纵径6．2±1．2mm；肩胛下孔横径9．81±1．53mm纵径7．81±2．40mm；肩胛上横韧带长13．4±0．5mm；肩胛下横韧带长25．3～3．9mm。③引用黄德清所测数值：设定肩胛上孔为A点，肩胛下孔为B点，肩胛上角为C点，肩峰外侧端为D点。肩胛冈内侧端与肩胛骨内侧缘相交处为E点。AD／AC相对值为1．26±0．47；BD／BE相对值为0．60±0．08。结论肩胛上神经卡压症的解剖学研究数据能为肩胛上神经卡压症针刀手术提供较安全的入路及定位标志。     

关节镜Bristow-Latarjet术中打内固定骨道时CT定位肩胛上神经的应用价值

文题释义： Bristow-Latarjet术：是带有联合腱的喙突骨块，穿过被横断的肩胛下肌腱后，固定于肩盂前缘，是治疗复发性肩关节前脱位的有效方法。神经损伤是该术式常见并发症。 肩胛上神经：在肩胛盂上方穿过肩胛上横韧带与肩胛切迹组成的纤维骨性通道即肩胛上孔，进入冈上窝。肩胛上神经的冈上窝段紧贴着冈上肌深面向外下走行，穿过肩胛下孔(由冈盂切迹和连于肩峰根部及肩胛骨背面的肩胛下韧带构成)并绕着冈盂切迹向内下而到冈下窝，发出分支支配冈下肌。 背景：Bristow-Latarjet术是治疗复发性肩关节前脱位的可靠方法。然而据报道，其中1.6%的患者伴有神经损伤。因此全关节镜Latarjet术式越来越受欢迎，由于外科医生不能触诊神经，神经的定位和保护变得困难。 目的：研究肩胛上神经在肩胛颈后上方的CT定位，提高对Bristow-Latarjet术临床操作安全范围的认知。 方法：选用经甲醛常规固定的成年尸体上肢标本12侧，男8侧，女4侧，实验方案符合东莞市中医院对研究的相关伦理要求。解剖并使用显影线标记12侧标本肩胛上神经的主干和分支，CT水平位上测量肩胛上孔、冈盂切迹、最外侧神经分支入肌点3个位置在肩关节内旋45°和外旋45°体位时到肩胛盂前后缘连线的距离、成角以及与肩胛盂的高度比，所得数据进行统计学处理。 结果与结论：①Pearson 相关性分析：盂的高度分别与冈盂切迹、入肌点到关节面的距离呈正相关；②内旋45°与外旋45°两个体位比较：肩胛上孔处的距离和成角度数差异无显著性(P均> 0.05)；冈盂切迹处的距离和成角差异有显著性意义(P均< 0.01)，高度比差异无显著性意义(P > 0.05)；入肌点处的距离、成角和高度比差异均有显著性意义(P均< 0.01)，表明与内旋位相比，外旋位具有更大的角度和距离的安全范围；③内外旋45°位时，冈盂切迹处与入肌点处的角度、距离、高度比差异均有显著性意义(P均< 0.01)，表明相比冈盂切迹，入肌点与关节面的角度更小、距离更短，相对盂的高度比更大；④提示关节镜下Bristow-Laterjet术打内固定骨道时建议外旋位操作，以减少神经损伤的发生概率。 ORCID: 0000-0002-6828-042X(袁胜超) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程     

小针刀治疗肩胛上神经嵌压症的应用解剖

目的为小针刀减压治疗肩胛上神经嵌压症提供形态学基础.方法在34侧常规固定的成人尸体标本上解剖出冈上孔、冈下孔和肩胛上神经及血管,观察冈上孔、冈下孔及其与肩胛上神经、血管的走行位置关系,测量有关数据.结果冈上孔位于锁骨锥状结节的后端深面,由肩胛切迹和横架于其上方的肩胛上横韧带围成,距体表(4.75±0.79)cm.冈下孔位于肩胛冈中外1/3交界处下方2cm处的深面,由冈盂切迹和连于肩峰根部及肩胛骨背面的肩胛下横韧带围成,距体表(3.93±0.95)cm.肩胛上神经起自臂丛上干,行向后外下,穿冈上孔人冈下窝,再向后穿冈下孔入冈下窝,沿途发支至冈上肌、冈下肌和肩关节.肩胛上血管经肩胛上横韧带的外上方入冈上窝与神经伴行.结论本文提出同时扩大或开放两孔进行治疗的新思路,提供的有关数据和定位方法,可提高小针刀治疗肩胛上神经嵌压症的准确性和安全性.     

肩胛上神经卡压综合征的电生理诊断

目的：探讨肩胛上神经卡压综合征电生理诊断方法。方法：对10例肩胛上神经卡压综合征的病人应用肌电图（EMG）观察自发电位,检测肩胛上神经支配肌冈上肌、冈下肌;腋神经支配肌三角肌;肩胛背神经支配肌提肩胛肌的复合肌肉动作电位（CMAP）,观察指标为潜伏期、波幅的变化。结果：10例病人冈上肌均见自发电位,募集反应减弱,CMAP潜伏期延长,波幅降低,且波形离散。结论：电生理是诊断和鉴别诊断肩胛上神经卡压综合征的重要辅助手段。     

肩胛骨解剖学研究及其临床意义

目的测量肩胛骨相关解剖学参数,为临床上肩胛上神经卡压提供解剖学依据,同时为国人解剖学数据提供资料。方法选择国人成人肩胛骨标本72例,测量其肩胛切迹上横直径、最大深度,及其肩胛骨形态长度和形态宽度,并研究它们之间的关系。结果肩胛骨的形态长度为(13.110±2.191)cm,形态宽度为(10.081±1.430)cm;肩胛切迹上横直径为(1.172±0.763)cm,最大深度为(0.783±0.582)cm。回归分析显示,肩胛切迹上横直径与肩胛骨形态宽度成正相关,肩胛切迹最大深度与肩胛骨形态长度成正相关。结论肩胛骨的形态长度、宽度与肩胛切迹最大深度、上横直径存在线性关系,而肩胛切迹狭窄时易造成肩胛上神经卡压,因此为神经卡压提供解剖学依据。     

Nerve conduction studies of suprascapular nerve for site-of-lesion diagnosis

Shoulder pain is a common symptom, resulting not only from bone and shoulder joint diseases, but also from neurogenic lesions. Entrapment neuropathy of the suprascapular nerve also causes shoulder symptoms. Conduction of the suprascapular nerve was studied in 12 healthy control subjects and 25 patients suffering from shoulder pain and/or dysfunction. Surface stimulation was performed at Erb's point, and compound muscle action potentials(M waves) were recorded from the supraspinatus and the infraspinatus muscles with concentric needle electrodes. To determine the optimal site for recording M waves from the infraspinatus muscle, simultaneous multi-channel recordings of M waves using pairs of surface electrodes were obtained from different sites over the infraspinatus muscle. In two patients, latency of the M waves to the infraspinatus muscle was prolonged, whereas that to the supraspinatus muscle was normal. These findings indicate entrapment neuropathy at the spinoglenoid notch. In three patients, the latency to the infraspinatus and supraspinatus muscles was prolonged. These findings are compatible with entrapment neuropathy at the suprascapular notch. The latency to the supraspinatus and infraspinatus muscles was prolonged in patients with brachial plexus injury and in those with suprascapular nerve injury. In patients with myopathy, those with neuralgic amyotrophy and those with cervical radiculopathy, the latency was normal. Thus, conduction studies of the suprascapular nerve using multiple-channel recordings are useful, especially for the diagnosis of entrapment neuropathy of the suprascapular nerve.     

Morphological study of the inferior transverse scapular ligament

The suprascapular nerve can be compressed by the inferior transverse scapular ligament (ITSL), also known as the spinoglenoid ligament, and this entrapment results in dysfunction of the external rotation of the upper arm owing to isolated weakness of the infraspinatus muscle. The morphology of the ITSL has not been adequately characterized. The aim of this study was to clarify the morphological characteristics of the ITSL. In total, 110 shoulders from 72 cadavers were dissected in this study. The ITSL was present in 73 (66.4%) of the 110 specimens, and comprised membrane in 40 (36.4%), ligament in 25 (22.7%), and both membrane and ligament in eight (7.3%). This structure could be classified into three types on the basis of its shape: band‐like (33.6%, type I), triangular (15.5%, type II), or irregular (17.3%, type III). In the spinoglenoid notch, the suprascapular nerve was always close to the lateral margin of the scapular spine. The length of the ligament between its origin and insertion sites ranged from 8.7 to 23.4 mm at its superior margin and from 8.9 to 17.5 mm at its inferior margin. The ligament width and thickness at its midportion ranged from 1.6 to 10.0 mm and from 0.1 to 1.2 mm, respectively. The results of this study improve understanding of the ITSL and will be helpful for successful diagnoses and treatments for selective suprascapular nerve entrapment. Clin. Anat. 27:707–711, 2014. © 2013 Wiley Periodicals, Inc.     

Proposed surgical technique to facilitate targeted reinnervation of the infraspinatus: A cadaveric feasibility study

Restoration of shoulder lateral rotation remains a significant challenge following brachial plexus injury. Transfer of the accessory nerve to suprascapular nerve (SSN) has been widely performed, although with generally poor outcomes for lateral rotation. A recent report suggested a selective infraspinatus reinnervation technique using a radial nerve branch for SSN transfer. This cadaveric study was performed in 7 specimens (14 shoulders). We present technical modifications to achieve additional length to the recipient nerve (suprascapular) that would facilitate direct repair. Key elements of the technique are (1) isolation of the SSN immediately distal to its motor branch to supraspinatus near the superior transverse scapular ligament; and (2) delivery of the transected SSN through the spinoglenoid notch and deep to the infraspinatus for emergence in the infraspinatus‐teres minor interval. Nerve overlap of at least 21 mm was observed in all 14 dissected shoulders between the harvested SSN and radial nerve branches. The mean nerve overlap between harvested branches was 26 mm (range 21–32 mm). The mean harvested SSN length was 59 mm (range 46–80 mm). The mean length of the harvested radial nerve branch was 72 mm (range 65–85 mm). No measurements were significantly different between left and right shoulders or between males and females (smallest P value = 0.1249). Nerve diameter of the two harvested branches was judged to be appropriately compatible for surgical coaptation in all 14 dissected shoulders. We present a variation on a described technique to increase recipient suprascapular nerve length. Additional length of the recipient nerve is achieved through utilization of a more proximal dissection of the suprascapular nerve near the level of the superior transverse scapular ligament and delivering the nerve through the teres minor‐infraspinatus interval. These surgical modifications are of clinical interest when selective reinnervation of the infraspinatus muscle is considered. We believe such a targeted approach can potentially increase shoulder lateral rotation function. Clin. Anat. 32:131–136, 2019. © 2018 Wiley Periodicals, Inc.     

Anatomical basis of the suprascapular nerve entrapment, and clinical relevance of the supraspinatus fascia

Introduction  

The entrapment of the suprascapular nerve (SSN) is commonly considered at the level of the suprascapular notch and more rarely in the spinoglenoid notch. Recent per-operative findings showed a compression of the SSN along its course in the supraspinatus fossa. The removal of a fascia for releasing the nerve between the suprascapular notch and spinoglenoid notch led us to purchase an anatomical study.     

基于CT三维重建的肩胛切迹解剖分型及临床意义

目的 探讨基于CT三维重建的肩胛切迹解剖形态学分型及临床意义。 方法 收集来自西南医科大学附属中医医院300例因肩部疾病就诊患者的肩胛骨,通过CT三维技术重建肩胛骨图像,并进行肩胛切迹形态学分型及几何数据测量。 结果 我们将收集的肩胛切迹分为5种类型,√-形称为Ⅰ型共138例,约占46%;U-形称为Ⅱ型共125例约占41.7%;Ⅴ-形称为Ⅲ型,共20例,约占6.7%;O-形称为Ⅳ型,共10例约占3.3%;Ω-形称为Ⅴ型,共7例约占2.3%（另外,发现W-形、双O-形各1例,因数量较少暂未纳入分型）;左侧肩胛切迹平均深度、宽度分别为（5.58±1.42、10.22±3.24）mm,右侧肩胛切迹平均深度、宽度分别为（6.02±1.87、10.81±3.35）mm,左右对比差异有统计学意义（P<0.05）;Ⅰ和Ⅱ型的切迹宽度较其他3种类型宽度更宽,分别为（12.46±3.20、9.95±2.68）mm,且P<0.05差异有统计学意义;另外,不同类型中肩胛切迹最低点到肩胛冈基底部的垂直距离长度有所不同,其中Ⅰ型最短的为（12.52±2.56）mm,Ⅲ型最长的为（14.48±4.29）mm,Ⅰ型和Ⅲ型比较差异有统计学意义（P<0.05）。 结论 基于CT三维重建结果,将肩胛切迹分为5型,分别为√-形、U-形、Ⅴ-形、O-形、Ω-形。其中Ⅴ-形和O-形发生肩胛上神经卡压症的几率较大,而√-形及U-形的卡压几率则较小。     

Bilateral suprascapular nerve entrapment

Bilateral suprascapular nerve entrapment syndrome is very rare. It presents with shoulder pain, weakness and atrophy of the supraspinatus and infraspinatus muscles. We present a twenty-year old man having a history of bilateral shoulder pain associated with weakness. Electromyographic studies revealed signs of a lesion that caused a neupraxic state of the left suprascapular nerve, moderate axonal loss of the right suprascapular nerve and denervation of the right suprascapular muscle. The patient was treated with physical and medical therapy. Due to worsening of the symptoms, a surgical operation was performed by the excision of the transverse scapular ligaments bilaterally. His pain, weakness and atrophy had diminished on examination six weeks later. Suprascapular nerve entrapment should be considered in patients with shoulder pain, particularly those with weakness and atrophy of the supraspinatus and infraspinatus muscles.     

冈上肌腱的血供特点及临床意义

目的　为肩关节疾患的防治及肩关节功能的重建提供血供解剖学基础。 方法　采用40侧常规防腐灌注红色乳胶的成人上肢标本,解剖出冈上肌观察其形态结构、起止点、血供来源、走行、分布特点并测量有关数据。 结果　冈上肌的血供主要来自肩胛上动脉和颈横动脉降支。肩胛上动脉起始处外径为(2.9±0.3) mm,主干长(4.8±0.7) cm;营养冈上肌肌支在肩胛横韧带的上方或下方分为2～3支进入肌腹。其入肌点位于肩胛横韧带的前下方(1.9±0.2) mm;冈上肌腱在移行部和扩展部动脉吻合丰富,而在实质部距肌腱止点部1 cm处毛细血管稀疏,是一个明显的乏血管区。冈上肌的神经支配主要是肩胛上神经,与血管伴行分2～3支支配冈上肌。 结论　肩袖撕裂或肩袖损伤考虑行手术修复时,不宜采取简单的断端缝合,应将断端的缺血组织切除后再行缝合或采用合适的肌腱代用材料进行修补,改善局部血供,有利于愈合。     

Ultrasonographic evaluation and morphometric measurements of the suprascapular notch

Background:  The aim of this study was to define the sonographic evaluation and morphometric measurements of the suprascapular notch. Methods  The suprascapular notch was evaluated by ultrasound on both sides in 50 volunteers (25 males, 25 females). By means of ultrasound, the notch width, the notch depth and the distance between the skin and the notch base (skin–notch base interval) were measured and imaging of the superior transverse scapular ligament was attempted. Furthermore, imaging of the suprascapular artery and vein was performed by Doppler ultrasound. Results  On the measurements performed, the notch was found to be deeper in men than in women on both the right (P = 0.022) and the left (P = 0.011) sides. Taking all volunteers into account without grouping sex, no differences were detected between the two sides with respect to the measurements of the notch width, notch depth and distance between the skin and the notch base. The superior transverse scapular ligament was demonstrated in 48 (96%) of 50 volunteers. On color Doppler ultrasound, the artery–vein complex was visualized in a total of 43 (86%) volunteers. Conclusions  Suprascapular notch measurements and the visualization of the anatomical neighborhood, which may be beneficial for the suprascapular nerve blockade procedure, can be successfully performed by the use of high-frequency ultrasound imaging.     

Morfometrical and morphological analysis of the suprascapular notch with multidetector computerized tomography

IntroductionSuprascapular notch is situated in lateral section of margo superior of scapula as adjacent to substratum of processus coracoideus. Suprascapular nerve compression is characterized with chronic localized pain spreading to shoulder posterior and/or lateral areas, to under brachion and into the neck; and with weakness in shoulder abduction, and also atrophy of supraspinatus and infraspinatus muscles. In our study, we aimed to exhibit notch suprascapularis morphology and the variations of this structure which creates an important passage for suprascapular nerve.MethodsThis study was conducted on 100 patients (35 females–65 males). Average age of individuals included into the study was 17–87 years.ResultsThe morphological study of the suprascapular notch revealed six different types of notches.DiscussionThe data we have obtained in our study are important to constitute a reference space of Turkish society. Furthermore, the fact that the differences between genders and right-left are exhibited will be helpful for surgeons who perform surgery in this region. Therefore, we conclude that the exhibited results will provide a better detail of information regarding morphometry of suprascapular notch and will aid in diagnosing and surgical treatment for shoulder pain.