粘连性肩关节囊炎的治疗（十一）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Redler LH, Dennis ER. Treatment of Adhesive Capsulitis of the Shoulder. J Am Acad Orthop Surg. 2019;27(12):e544-e554. 本次学习由阎芳副研究员主讲。

Complications

Complications from MUA range from fractures, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Arthroscopic capsular release, while improving outcomes in management of AC, introduces its own unique set of potential complications, including axillary nerve injury and rarely the development of complex regional pain syndrome.

并发症

手法松解的并发症包括骨折、盂唇损伤、神经失用症和肩袖病变。关节镜下关节囊松解术在改善AC治疗效果的同时，也带来了一系列独特的潜在并发症，包括腋神经损伤，以及少见的复杂性区域疼痛综合征。

In a prospective trial, arthroscopic assessment after MUA revealed multiple potential iatrogenic complications, such as superior labral tears, partial tears of the subscapularis, anterior labral detachments, and tears of the middle glenohumeral ligament. Case reports have documented glenoid and proximal humerus fractures and axillary nerve neurapraxia. These results support the use of arthroscopy to directly visualize tissues and prevent iatrogenic injury that can occur with blind MUA.

在一项前瞻性试验中，松解术后关节镜检查显示多种潜在的医源性并发症，如上唇撕裂、肩胛下肌部分撕裂、上唇前脱离和中盂肱韧带撕裂。病例报告有关节盂和肱骨近端骨折和腋神经失用的病例。这些结果支持使用关节镜直视下的松解，防止非直视下的松解可能发生的医源性损伤。

Summary

AC occurs in up to 5% of the population, more often in women and patients with diabetes, and its etiology is still unknown. The pathology of the disease seems to be related to a combination of inflammation and active fibroblastic proliferation, with transformation of myofibroblasts leading to extensive scar tissue formation. Based on the natural history of the disease, early corticosteroid injection has a role in shortening the overall duration of symptoms. Patients should be counseled that NSAIDs and corticosteroid injections do not cure the problem; they simple make the PT, which is imperative for recovery, more comfortable to endure. For patients with diabetes who may have undue metabolic disarray from corticosteroid injection, ECSWT may have a role in symptom relief. Most patients will see complete resolution of symptoms with nonsurgical management. When surgical intervention is required, the ideal technique should include both anterior and posterior capsular release as well as rotator interval release specifically including release of the CHL. When combined with a gentle MUA, circumferential capsular release is possible without risking injury to the axillary nerve. Early PT is essentially postoperatively. An interscalene block can be used to provide enhanced pain relief. To avoid complications, aggressive MUA should be avoided, care must be taken with inferior release, and all patients should have portable AP, lateral, and axillary imaging in the post-anesthesia care unit to assess for fracture.

总结

AC发生率高达5%，多见于女性和糖尿病患者，其病因尚不清楚。该病的病理学似乎与炎症以及成纤维细胞活跃增生，肌成纤维细胞的转化导致广泛的瘢痕组织形成有关。根据疾病的自然病程，早期注射皮质类固醇有缩短症状持续时间的作用。我们应告诉病人非甾体抗炎药和皮质类固醇注射不能治愈这个疾病；它们仅能使物理治疗变得更加舒适，物理治疗是疾病恢复必不可少的。对于担心注射皮质类固醇而导致代谢紊乱的糖尿病患者，体外冲击波治疗可能有缓解症状的作用。通过非手术治疗，大多数患者的症状会完全消失。当需要手术治疗时，理想的方法应该包括前囊和后囊的松解，以及肩袖间隙的松解，特别是喙肱韧带的松解。手法温和的松解，是可以松解关节囊，而不会损伤腋神经。术后应尽早开始物理治疗。肌间沟阻滞可提供较强效的镇痛。为避免并发症，应避免粗暴的手法松解，必须注意关节囊下侧的松解，所有患者应在麻醉后监护室进行便携式正位、侧位和腋窝x线成像，以评估是否有骨折的情况。