la RM nella patologia della cuffia dei rotatori

LA RISONANZA MAGNETICA NELLO STUDIO DELLA PATOLOGIA DELLA CUFFIA DEI ROTATORI

La Risonanza Magnetica (RM) è considerata la metodica più completa nella valutazione delle varie patologie interessanti l’articolazione della spalla, per la possibilità di individuare con elevata sensibilità ed in modo panoramico lesioni che interessano parti molli, tendini e muscoli della cuffia dei rotatori, strutture scheletriche e fibrocartilaginee scapolo-omerali.

L’impiego della RM nello studio della patologia della spalla, sia traumatica sia degenerativa, rappresenta certamente un contributo fondamentale per un corretto approccio diagnostico e di pianificazione terapeutica.

Tratteremo oggi le due patologie che più frequentemente interessano la spalla e cioè la patologia della cuffia dei rotatori e l’instabilità gleno-omerale.

Patologia della cuffia dei rotatori

I tendini che compongono la cuffia dei rotatori sono il sottoscapolare, sovraspinoso, sottospinoso e piccolo rotondo. Essi concorrono a svolgere unitamente alle strutture ossee e capsulo-legamentoso funzione di stabilizzazione dell’articolazione gleno-omerale, permettono i movimenti di elevazione, abduzione, adduzione, intra ed extrarotazione del braccio. Fisiologicamente  tali tendini  mostrano regolarità morfologica ed omogenea intensità di segnale in tutte le sequenze. In relazione al loro decorso i tendini sovraspinoso e sottospinoso sono meglio rappresentati nelle immagini coronali oblique, mentre il sottoscapolare e piccolo rotondo nelle immagini trasversali (vedi Fig. 1).

Fig. 1: artro-RM anatomia  del tendine tipicamente rappresentato come banda omogeneamente  ipointensa.

Le lesioni della cuffia possono essere di origine traumatica, micro-traumatica o degenerativa.  Una delle cause più frequenti di danno ai tendini della cuffia dei rotatori è determinato dal conflitto dei tendini stessi con le strutture legamentose ed ossee che costituiscono l’arco funzionale coraco-acromiale. Sono molteplici i fattori che possono predisporre una spalla ad andare in contro ad una sindrome da conflitto e quindi ad una patologia della cuffia dei rotatori. Il più comune è la forma e lo spessore dell’osso che forma il tetto dell’articolazione, l’acromion. Infatti, qualora l’acromion abbia una protuberanza sulla sua estremità anteriore, allora è più facile che si verifichi un conflitto con la cuffia dei rotatori quando il braccio è elevato. Attività che implichino frequenti ed ampi sollevamenti del braccio possono esporre un individuo ad un maggior rischio di danni alla cuffia dei rotatori. Alcune volte i muscoli della spalla possono invece sbilanciarsi per effetto di traumi o non uso e lo sbilanciamento può determinare il contatto tra acromion e cuffia nell’ambito d’attività che contemplino movimenti a rischio. Quando la cuffia dei rotatori e la sovrastante borsa si infiammano e diventano dolorose per effetto del contatto ripetitivo con l’acromion, i tendini possono cominciare a sfilacciarsi in prossimità della loro inserzione sulla testa dell’omero. Dopo un certo tempo, in cui prosegue lo sfilacciamento causato dal contatto tendine-acromion e caratterizzato da importante dolore diurno e notturno dei muscoli della spalla, i tendini possono rompersi totalmente, staccandosi dalla testa omerale.

La RM offre un elevato dettaglio diagnostico nel riconoscimento della lesione del tendine, definendone gli aspetti morfologici, ispessimento od  assottigliamento, precisandone la sede e l’estensione; questa valutazione non è tuttavia sufficiente per il successivo trattamento  terapeutico poiché è necessario quantificare il danno intrastrutturale secondo la classificazione anatomo-patologica che divide le lesioni in tre categorie:

  • lesione parziale, che interessa il versante articolare o bursale del tendine;
  • lesione intraparenchimale, che si estende alla sola porzione interna del tendine;
  • lesione a tutto spessore sub-completa, che interessa almeno in una porzione l’intera sezione del tendine senza determinarne la retrazione poiché la restante porzione ne assicura la continuità (definita anche lesione focale a tutto spessore), o lesione completa, che interessa cioè l’intera sezione longitudinale e trasversale del tendine con relativa retrazione di uno dei monconi.

La RM è la metodica diagnostica di elezione per la definizione del grado di lesione del tendine che comunque  non può prescindere dall’attuazione di una corretta metodologia d’esame e da una specifica competenza del radiologo. L’accuratezza della metodica consente di ottenere immagini a sezione (spessore) sottile secondo i piani dello spazio ideali per la rappresentazione anatomica dei tendini della cuffia dei rotatori. Il  segno di lesione del tendine consiste nella perdita della sua fisiologica bassa intensità di segnale.

Nel caso di una degenerazione cronica del tendine La RM mostra un’area di alterato segnale che spesso si associa ad ispessimento della corrispondente porzione tendinea, in parte dovuto al sovvertimento strutturale ed in parte a concomitanti fenomeni peritendinitici cronici; la degenerazione parenchimale può essere caratterizzata in RM grazie all’utilizzo di opportune sequenze T2 pesate che escludono la presenza di fenomeni infiammatori acuti.

Le lesioni tendinee acute sono sempre associate ad infarcimento flogistico del tendine, sinovite reattiva e relativo versamento nel cavo articolare e nella borsa sinoviale sottoacromion-deltoidea. La comunicazione tra queste due strutture, che avviene solo nei casi in cui vi è una lesione a tutto spessore di uno dei tendini della cuffia dei rotatori, viene ottimamente visualizzata nelle immagini RM coronali (fig. 2) ove la fissurazione è dimostrata da una zona di iperintensità dovuta alla presenza di liquido sinoviale. Nei casi di dubbia interpretazione può essere indicato l’utilizzo, in corso di esame RM, dell’introduzione di una soluzione contrastografica  all’interno dell’articolazione mediante puntura per via percutanea (fig 3). Questa metodica, che viene definita artro-RM, trova tuttavia indicazione elettiva per lo studio della cuffia dei rotatori specialmente nei pazienti operati di ricostruzione della cuffia dove in condizioni basali rimane ancor oggi molto difficile la valutazione accurata della qualità della plastica tendinea (fig.2).

Fig 2. Immagine coronale T1 pesata.  Lesione completa del tendine sovraspinoso che appare retratto.

fig. 3. Immagine coronale dopo artrografia. Il liquido contrastografico iniettato in articolazione  attraversa il tendine laddove presente la lesionee distende la borsa sottoacromion-deltoidea.

Più difficile è l’identificazione con RM delle lesioni parziali specialmente quando poco estese e quando interessano il versante bursale; in alcuni casi la valutazione di questa lesione è favorita dalla presenza di fenomeni infiammatori, e variabile versamento nella relativa borsa sotto-acromion-deltoidea che “bagna” la superficie del tendine sede della lesione definendone meglio l’irregolarità che ne costituisce il segno distintivo.

Dott. Sergio De Bac, radiologo         

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