Le lesioni parziali del sovraspinoso

Anatomia

Per capire e trattare le lesioni parziali di cuffia occorre conoscere l’anatomia inserzionale della cuffia in particolare del sovra e sottospinoso.

Se la si osserva dal lato articolare, l’inserzione della cuffia puo’ presentare un ispessimento arciforme che origina dal leg.coraco-omerale e si dirige posteriormente verso il sottospinoso, denominato CABLE, che delimita una mezzaluna di tendine inserito al trochite definito CRESCENT. L’ipotesi formulata da Burkhart  prevede che il cable svolga una azione protettiva nei confronti del crescent meno vascolarizzato e più esposto a fenomeni degenerativi.

Altrettanto importante è conoscere l’anatomia inserzionale del sovraspinoso, il cosiddetto foot-print : la lunghezza antero-posteriore è di 25 mm. in media, lo spessore medio di 11,5/12 mm. e la distanza cartilagine-tendine è di 1,5 mm. La conoscenza di questi parametri è indispensabile per quantificare, classificare e trattare le lesioni parziali di cuffia.

Fisiopatologia

Le lesioni parziali di cuffia possono essere causa PRIMARIA di dolore e disfunzione alla spalla oppure essere SECONDARIE ad altre condizioni patologiche (per es. instabilità) la cui identificazione e trattamento sono la base del successo.

Le FORME PRIMARIE riconoscono due meccanismi patogenetici: degenerativi e traumatici.

Le forme DEGENERATIVE sono caratterizzate dalla progressiva trasformazione metaplastica dei tenociti in condrociti sul lato articolare,  dall’evoluzione fibro-cartilaginea del tendine e  dall’assenza di processi riparativi in sede di lesione.

Caratteristica di queste lesioni degenerative è l’evolutività in senso negativo che generalmente evolvono attraverso un ampliamento della lesione  e una trasformazione in lesione completa.

Le forme TRAUMATICHE sono di più difficile identificazione e spetta a Snyder  la descrizione della avulsione articolare del sovraspinoso definita PASTA lesion e la relativa proposta di sutura transtendinea. Sono possibili anche lesioni bursali isolate o associate per esempio a fratture del trochite e caratterizzate da maggiori possibilita’ riparative come dimostrato da lavori sperimentali su topi da Hirose.

Le FORME SECONDARIE riconoscono due patologie principali: l’instabilità e il conflitto primario.

Le lesioni secondarie ad INSTABILITA’ sono prevalenti sul lato articolare, spesso in posizione eccentrica rispetto al crescent, tipiche dei giovani e atleti overhead e si possono realizzare sia nella fase di caricamento per abrasione con la rima glenoidea postero-superiore (lesioni posteriori) sia nella fase di decelerazione per fallimento tensile e abrasione con rima glenoidea antero-superiore (lesioni anteriori).

Le condizioni che predispongono gli atleti a questi contatti anomali sono la contrattura capsulare posteriore e/o la lassita’ capsulo-legamentosa antero-inferiore la cui identificazione e trattamento sono indispensabili.

Le lesioni secondarie al CONFLITTO si realizzano sul lato bursale per attrito con l’arco coraco-acromiale patologico, sono associati a fenomeni degenerativi tendinei e sono più frequenti in pazienti di età medio-avanzata e presentano elevate possibilità evolutive in senso negativo.

Questa classificazione fisiopatologia è importante perchè a parità di entità lesionale il trattamento artroscopico potrà essere diverso a seconda della patogenesi traumatica o degenerativa, primitiva o secondaria, il tutto messo in relazione con l’età e il livello di richieste funzionali.

Classificazione

Le lesioni parziali si dividono possono interessare il versante bursale, la componente intraparenchimale od il versante articolare:

Le classificazioni anatomo-morfologiche delle lesioni parziali di cuffia presenti in letteratura sono quella di Snyder che le suddivide in quattro gradi enfatizzando l’area di superfice interessata ma è poco precisa sullo spessore di inserzione tendinea residuo e quella di Ellman che pur proposta nel 1991 è estremamente precisa ed attuale in quanto basata sull’entità del foot-print residuo

Ellman individua sia per le lesioni articolari che bursali tre gradi:

Grado 1 = lesione minore di 3 mm. o inferiore a 1/3 del foot-print

Grado 2 = lesione tra i 3 e i 6 mm. o inferiore al 50% del foot-print

Grado 3 = lesione maggiore di 6 mm. o maggiore del 50% del foot-print

Questa classificazione è riproducibile perchè si basa sulla misurazione dell’area trochitica esposta dopo eventuale debridment della lesione, conoscendo lo spessore del foot-print e lo spazio tra cartilagine articolare e inserzione normale del tendine.

Diagnosi

La diagnosi clinica si basa sui dati anamnestici (età, sport di lancio, eventi traumatici) sulle caratteristiche del dolore (notturno nelle forme degenerative, durante il gesto atletico nelle secondarie…), sull’esame clinico (test di lassità e/o instabilità nelle secondarie del giovane, test di conflitto nelle bursali, test di Whipple e dolore a 30° di abduzione contro resistenza nelle articolari…).

La diagnosi strumentale riveste un ruolo fondamentale nella stadiazione della lesione parziale: con l’ecografia e la Risonanza Magnetica viene infatti definita la sede della lesione, la sua estensione ed il grado di interessamento patolocico del foot print tendineo, altrimenti non valutabile dal chirurgo in quanto non visualizzabile con la procedura artroscopica.

la lesione parziale del foot print è rappresentata dalla lineare banda iperintensa ad orientamento trasversale che interessa circa il 50% dell’area inserzionale a partire dal versante articolare; questa lesione, quando isolata,  merita di essere segnalata al chirurgo in quanto non può essere visualizzata durante l’indagine artroscopica; nell’esame artro-RM, le frecce arancioni indicano la lesione del versante articolare del tendine ancor meglio confermata dal passaggio di liquido articolare a livello della depressione di Codman  (frecce bianche).

Altra indicazione assoluta all’esecuzione di un esame RM è l’identificazione delle lesioni parziali intraparenchimali della giunzione miotendinea (fig in basso).

La diagnosi di una lacerazione della cuffia dei rotatori viene in genere effettuata mediante l’identificazione di un gap di intensità del segnale del fluido all’interno della cuffia, che appare marcatamente iperintenso su immagini pesate in T2, in particolare quando viene applicata la soppressione del grasso (figura in basso a sinistra). Tuttavia, non tutte le rotture della cuffia dei rotatori dimostrano questo aspetto classico, e in effetti alcune lesioni hanno un’intensità del segnale relativamente bassa sulle immagini pesate sul T2 a causa dello sviluppo di cicatrici e / o tessuti di granulazione che riempiono il difetto (figura in basso a destra). In tali casi, l’interpretazione accurata dell’MR è più impegnativa e il rilevamento di risultati come un brusco cambiamento nel segnale o nel contorno del tendine, retrazione delle fibre tendinee, retrazione della giunzione muscolotendinea o identificazione dell’atrofia grassa sono utili per effettuare la diagnosi .

In basso a sinistra e destra si rileva lesione parziale del versante articolare della zona crescent del tendine sovraspinoso (freccia rossa  nella figura nin basso a sinistra; punta di freccia rosse nella figura in basso a destra).

Articolo curato dal Dott. Sergio De Bac

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