Meyer Lucy E, Blevins Kier M, Long Jason S, Lau Brian C
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
Video J Sports Med. 2022 Apr 7;2(2):26350254211071085. doi: 10.1177/26350254211071085. eCollection 2022 Mar-Apr.
The quadrangular (or quadrilateral) space is defined by its anatomical borders and is the passageway for the axillary nerve and posterior circumflex humeral artery (PCHA). Quadrangular space syndrome (QSS) can present due to various compressive pathologies but is commonly seen in overhead athletes. Quadrangular space syndrome can present with neurogenic symptoms including pain and paresthesias, as well as vascular complications from compression of the PCHA including thrombosis, aneurysm formation, and distal emboli.
Surgical decompression of the quadrangular space is indicated for severe neurogenic or vascular compromise in the case of QSS refractory to nonoperative treatment.
After appropriate preoperative physical examination findings and trial of nonoperative treatment, including physical therapy and injections, surgical decompression was indicated. The posterior border of the deltoid was marked, and an incision centered over the posterior border of the deltoid lateral to the axillary fold was made. Posterior border of deltoid was identified and retracted, revealing the interval of the teres minor and major. The nerve to the teres minor was identified, protected, and fibrous bands compressing the nerve were released. The nerve to the teres minor was tracked deep to find the axillary nerve. This was identified and fibrous bands around the nerve were decompressed. The circumflex vessels were protected throughout. Following decompression of the nerves, there was free movement of the nerves indicating adequate surgical decompression.
Adequate surgical decompression of the axillary nerve and PCHA achieved with resolution of neurogenic symptoms of pain and paresthesias at first postoperative visit.
DISCUSSION/CONCLUSION: Quadrangular space syndrome is a rare disorder, can be difficult to diagnose, and is the cause of significant morbidity, particularly in overhead athletes. If symptoms persist after nonoperative treatment, operative decompression of the quadrangular space may be indicated. Adequate surgical decompression results in relief of neurogenic and vascular symptoms.
四边形间隙由其解剖边界所界定，是腋神经和旋肱后动脉（PCHA）的通道。四边形间隙综合征（QSS）可因各种压迫性病变而出现，但在过头运动的运动员中较为常见。四边形间隙综合征可表现为神经源性症状，包括疼痛和感觉异常，以及因PCHA受压引起的血管并发症，如血栓形成、动脉瘤形成和远端栓子。
对于非手术治疗无效的QSS病例，若出现严重神经源性或血管性损害，则需对四边形间隙进行手术减压。
在进行适当的术前体格检查并尝试非手术治疗（包括物理治疗和注射）后，决定进行手术减压。标记三角肌后缘，在腋皱襞外侧、以三角肌后缘为中心做切口。识别并牵开三角肌后缘，显露小圆肌和大圆肌之间的间隙。识别并保护小圆肌神经，松解压迫该神经的纤维束带。追踪小圆肌神经向深部走行以找到腋神经。识别腋神经并松解其周围的纤维束带。全程保护旋肱血管。神经减压后，神经可自由活动，表明手术减压充分。
术后首次就诊时，腋神经和PCHA得到充分手术减压，疼痛和感觉异常等神经源性症状消失。
讨论/结论：四边形间隙综合征是一种罕见疾病，诊断可能困难，是严重发病的原因，特别是在过头运动的运动员中。如果非手术治疗后症状持续存在，可能需要对四边形间隙进行手术减压。充分的手术减压可缓解神经源性和血管性症状。
