Vastamäki Martti, Vastamäki Heidi
Research Institute Orton, Invalid Foundation and Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland.
Clin Orthop Relat Res. 2016 Mar;474(3):799-805. doi: 10.1007/s11999-015-4614-1. Epub 2015 Oct 30.
Resection of the medial upper corner of the scapula is one option for treating patients with a painful chronic snapping scapula. However, the degree to which this procedure results in sustained relief of pain during long-term followup, and whether surgical treatment offers any compelling advantages over nonsurgical approaches at long-term followup, are not known.
QUESTIONS/PURPOSES: We asked: (1) At long-term followup after surgical treatment of a painful snapping scapula, did patients' pain decrease? (2) Did scapulocostal crepitation improve? (3) Did patients return to work?
Between 1971 and 1992, 15 patients underwent surgery by one surgeon for persistent (> 1 year) and severely painful crepitus around the superomedial scapula that did not respond to nonsurgical approaches. The procedure consisted of an open resection of the superomedial corner of the scapula and release of the levator scapulae muscle. Patients treated surgically were compared with a group of nine patients treated nonsurgically between 1975 and 1997; their treatments included temporary physiotherapy, massage, and NSAIDs. In general, the patients treated nonsurgically presented with less pain. However, during much of this study period, objective pain and functional scales were not in common use, and so baseline scores were not available. Of the 15 patients treated surgically, nine participated in a clinical and questionnaire survey at a mean of 22 years (range, 16-35 years), and 12 participated in a questionnaire survey a mean 27 years after surgery (range, 23-43 years). Of the nine patients treated nonsurgically, seven participated in a clinical followup and questionnaire survey at a mean followup of 16 years (range, 10-25 years), and all nine completed a questionnaire survey at a mean of 22 years (range, 17-33 years). Patient age at onset of symptoms was a mean of 27 years. The clinical followup and questionnaires focused on pain, crepitation, and work status.
With the numbers available, there was no difference in pain scores between patients treated surgically and those treated nonsurgically (mean VAS pain with exertion 0.8 ± 1.3 versus 1.5 ± 1.6; p = 0.357); in fact, pain scores were quite low in both groups. Pain improved promptly in seven of 12 patients treated surgically, but lasted for at least several years in all patients treated nonsurgically. Crepitus persisted variably in both groups at final followup, with no apparent difference between the groups in terms of its frequency, but it was not consistently associated with pain at final followup in either group (six of 12 patients treated surgically, all painless; and all of seven clinically examined patients treated nonsurgically, two without pain, had crepitus at latest followup; p = 0.004), whereas at initial presentation, the crepitus had been painful in all patients. All patients in both groups had returned to work after surgery or the first consultation.
Carefully selected patients who undergo this procedure appear to obtain sustained relief of painful crepitus at long term, but so do patients treated nonsurgically. Since the decision to treat these patients surgically was somewhat subjective, and since patients treated nonsurgically did so well (although the surgically treated patients improved faster), we cannot conclude that surgery is better than nonsurgical treatment. Multicenter comparative studies with carefully applied indications are needed.
Level III, therapeutic study.
切除肩胛骨内上角是治疗慢性疼痛性弹响肩胛患者的一种选择。然而，该手术在长期随访中能在多大程度上持续缓解疼痛，以及在长期随访中手术治疗相对于非手术治疗是否具有任何显著优势，目前尚不清楚。
问题/目的：我们提出以下问题：（1）在对疼痛性弹响肩胛进行手术治疗后的长期随访中，患者的疼痛是否减轻了？（2）肩胛胸壁摩擦音是否改善？（3）患者是否重返工作岗位？
1971年至1992年间，15例患者由同一位外科医生进行手术，治疗持续时间超过1年且严重疼痛的肩胛上内侧周围摩擦音，这些患者对非手术治疗无效。手术包括开放性切除肩胛骨的上内侧角并松解肩胛提肌。将接受手术治疗的患者与1975年至1997年间接受非手术治疗的9例患者进行比较；他们的治疗包括临时物理治疗、按摩和非甾体抗炎药。一般来说，接受非手术治疗的患者疼痛较轻。然而，在本研究的大部分时间里，客观疼痛和功能量表并不常用，因此无法获得基线评分。在接受手术治疗的15例患者中，9例在平均22年（范围16 - 35年）时参与了临床和问卷调查，12例在术后平均27年（范围23 - 43年）参与了问卷调查。在接受非手术治疗的9例患者中，7例在平均随访16年（范围10 - 25年）时参与了临床随访和问卷调查，所有9例在平均22年（范围，并完成了问卷调查。患者症状出现时的平均年龄为27岁。临床随访和问卷调查重点关注疼痛、摩擦音和工作状态。
就现有数据而言，接受手术治疗的患者与接受非手术治疗的患者在疼痛评分上没有差异（运动时平均视觉模拟评分疼痛分别为0.8±1.3与1.5±1.6；p = 0.357）；事实上，两组的疼痛评分都相当低。接受手术治疗的12例患者中有7例疼痛迅速改善，但所有接受非手术治疗的患者疼痛至少持续数年。在最终随访时，两组的摩擦音均有不同程度持续存在，两组在摩擦音频率方面无明显差异，但在最终随访时，两组中摩擦音均与疼痛无一致关联（接受手术治疗的12例患者中有6例无痛；接受非手术治疗且接受临床检查的7例患者中，最新随访时2例无痛但有摩擦音；p = 0.004），而在初次就诊时，所有患者的摩擦音都伴有疼痛。两组所有患者在手术后或首次就诊后均已重返工作岗位。
经过精心挑选接受该手术的患者似乎能在长期获得疼痛性摩擦音的持续缓解，但接受非手术治疗的患者也是如此。由于对这些患者进行手术治疗的决定在一定程度上是主观的，并且由于接受非手术治疗的患者效果良好（尽管接受手术治疗的患者改善更快），我们不能得出手术优于非手术治疗的结论。需要进行严格应用适应症的多中心比较研究。
三级，治疗性研究。
