Paralabral Cyst: An Unusual Cause of Quadrilateral Space Syndrome

doi:10.1053/ar.1999.v15.015063

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 15, Issue 6, September 1999, Pages 632-637

https://doi.org/10.1053/ar.1999.v15.015063 Get rights and content

Abstract

Summary: A paralabral cyst arising from a detached inferior glenoid labral tear was shown by magnetic resonance imaging (MRI) to dissect into the quadrilateral space, resulting in a compressive neuropathy of the axillary nerve. Three consecutive MRI examinations were performed over a 5-year period in a 47-year-old man with a long history of worsening shoulder pain. The MRI examinations revealed a slowly enlarging paralabral cyst extending into the quadrilateral space with progressive atrophy of the teres minor muscle.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 6 (July), 1999: pp 632–637

Section snippets

CASE REPORT

A 47-year-old man had a long history of right shoulder pain. He was a former professional football player who had suffered a third degree fracture dislocation of the distal right clavicle. In 1990, he underwent an open reduction and internal fixation with excision of bone fragments, scar tissue, and debris. Fixation of an acromioclavicular separation using a Bosworth screw and reconstruction of the coracoclavicular ligament was also performed. In 1993, he began complaining of increasing

DISCUSSION

Juxta-articular cysts are a well-described entity commonly occurring adjacent to large joints such as the hip, knee, or shoulder.9, 10, 11, 12, 13, 14, 15 Parameniscal cysts of the knee are associated with meniscal tears.⁹ Around the hip or shoulder, the presence of a paralabral cyst is frequently associated with a labral tear.15, 16 In the shoulder, labral cysts occur most commonly in the superior or posterior regions, and only rarely occur anteriorly.¹⁵ It has been well documented that labral

References (19)

BR Cahill et al.
Quadrilateral space syndrome
J Hand Surg Am
(1983)
FX Mendoza et al.
Peripheral nerve injuries of the shoulder in the athlete
Clin Sports Med
(1990)
KR Schulte et al.
Uncommon causes of shoulder pain in the athlete
Orthop Clin North Am
(1995)
CS Linker et al.
Quadrilateral space syndrome: Findings at MR imaging
Radiology
(1993)
J Beltran et al.
Diagnosis of compressive and entrapment neuropathies of the upper extremity: Value of MR imaging
AJR Am J Roentgenol
(1994)
HC McKowan et al.
Axillary nerve entrapment in the quadrilateral space
J Neurosurg
(1987)
JF Silliman et al.
Neurovascular injuries to the shoulder complex
J Orthop Sports Phys Ther
(1993)
PJ Cormier et al.
Quadrilateral space syndrome: A rare cause of shoulder pain
Radiology
(1988)
S Shankman et al.
MRI of the shoulder
Curr Probl Diagn Radiol
(1995)

There are more references available in the full text version of this article.

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Quadrilateral space syndrome induced by a large degenerative osteophyte
2021, Radiology Case Reports
A 41-year-old gentleman presented with decreased range of motion. Initial radiographs demonstrated extensive osteoarthritic changes involving the glenohumeral joint with a large inferior oriented osteophyte. Subsequent MRI of the shoulder was obtained which demonstrated isolated fatty atrophy of the teres minor and, to a lesser extent, deltoid muscles. The axillary nerve was visualized entering the quadrilateral space which, although, was severely narrowed secondary to the large osteophyte. The patient's clinical symptoms and MRI findings were consistent with quadrilateral space syndrome. The patient wanted to attempt conservative therapy first; and therefore, subsequently underwent physical therapy with improvement of shoulder strength and range of motion.
Quadrangular Space Syndrome: A Narrative Overview
2021, Journal of Chiropractic Medicine
Citation Excerpt :
In cases where QSS is secondary to acute peripheral artery occlusion with subsequent ischemia, emergent surgical intervention is warranted.58 Spontaneous resolution has been noted in 1 case report, where QSS was secondary to a paralabral cyst.73,84 In summary, people with a diagnosis of QSS are recommended to undergo up to a 6-month trial of care of physical therapy before surgical intervention.
The purpose of this narrative review of the literature is to provide an overview of quadrangular space syndrome with special attention to its clinical presentation, differential diagnosis, and treatment.
A narrative review of the English-language, peer-reviewed literature was performed using the key words “axillary nerve,” “quadrangular space,” “quadrilateral space,” and “posterior humeral circumflex artery.” Databases searched were Medline Complete, Cumulative Index to Nursing and Allied Health Literatures, and Index to Chiropractic Literature. The search period was from 1983 through January 2020.
There were 85 articles selected for this review. A summary and overview are provided.
Quadrangular space syndrome is an uncommon cause of shoulder pain. Clinicians should consider it as a diagnosis after ruling out more common shoulder conditions and examining other concurrent diseases.
Clinico-radiological review of peripheral entrapment neuropathies – Part 1 upper limb
2020, European Journal of Radiology
Citation Excerpt :
QSS is commonly caused by trauma or dislocation of the humerus, scapula, fibrous bands and muscular hypertrophy [45]. Other causes include labral cysts, hematomas, osteochondromas, lipomas, and posterior circumflex humeral artery aneurysms [46–49]. Axillary nerve entrapment is rarely caused by abnormal origin of radial collateral artery from posterior circumflex humeral artery, accessory subscapularis muscle, and thoracic surgeries [50–52].
This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies.
The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies.
Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies.
It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.
Antero-inferior paralabral cyst of the shoulder: An atypical cause of rapidly evolving axillary and musculocutaneous nerve palsy
2020, Journal of Clinical Orthopaedics and Trauma
Paralabral cysts of the shoulder are a rare cause of shoulder pain. Their association with neurological symptoms is uncommon. This case report presents an antero-inferior paralabral cyst in a painful atraumatic shoulder causing axillary and musculocutaneous nerve palsy.
The patient in the present study showed a rapidly worsening active shoulder function with dull pain in the posterior shoulder and hypoesthesia over the deltoid. Magnetic resonance imaging revealed an antero-inferior paralabral cyst. Electromyography showed a profuse denervation of the deltoid, teres minor and biceps brachii muscles.
The patient was diagnosed with a axillary and musculocutaneous nerve compression neuropathy caused by the cyst. Shoulder arthroscopy was performed with the goal of decompressing the cyst and explore the terminal branches of the brachial plexus. During surgery a partial labral tear was detected and anatomically repaired after cyst resection. Exploration of the terminal roots of the plexus brachialis showed the presence of dense fibrotic tissue that was released. Shoulder function recovered completely after surgery.
Paralabral cysts are rare and surgical management consists of cyst removal and labral repair. In presence of neurological symptoms exploring the retrocoracoid plexus may be a useful option to check for fibrosis around the nerves that could limit or slow down nerve recovery.
Quadrilateral space syndrome: a review
2018, Journal of Shoulder and Elbow Surgery
Quadrilateral space (QS) syndrome (QSS) is a relatively rare condition in which the axillary nerve and the posterior humeral circumflex artery are compressed within the QS. Fibrous bands are most commonly implicated as the cause, with true space-occupying lesions being less common. QSS is characterized by poorly localized shoulder pain and paresthesia over the lateral aspect of the shoulder and arm in a nondermatomal pattern. These symptoms are aggravated by shoulder abduction and external rotation. Point tenderness is typically present over the QS; however, diagnosis on physical examination can be difficult. Pain relief after lidocaine block of the axillary nerve within the QS is a useful finding in the evaluation of patients with suspected QSS. No definitive diagnostic imaging exists, making diagnosis difficult, although radiographs and magnetic resonance imaging are recommended to rule out other pathology. Nonoperative treatment, including nonsteroidal anti-inflammatory drugs, activity modification, and physical therapy, for at least 6 months is recommended before pursuing operative intervention. Small case series have shown that surgical decompression of the QS has good outcomes, with resolution of pain and return to sport.
Imaging Injuries in Throwing Sports Beyond the Typical Shoulder and Elbow Pathologies
2016, Radiologic Clinics of North America

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^*: Address correspondence and reprint requests to Timothy G. Sanders, M.D., Department of Radiology, Wilford Hall Medical Center, 759th MDTS/MTRD, 2200 Bergquist Dr, STE 1, Lackland AFB, TX 78236-5300, U.S.A. E-mail: [email protected]

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Paralabral Cyst: An Unusual Cause of Quadrilateral Space Syndrome*

Abstract

Section snippets

CASE REPORT

DISCUSSION

J Hand Surg Am

Clin Sports Med

Orthop Clin North Am

Quadrilateral space syndrome: Findings at MR imaging

Radiology

Diagnosis of compressive and entrapment neuropathies of the upper extremity: Value of MR imaging

AJR Am J Roentgenol

Axillary nerve entrapment in the quadrilateral space

J Neurosurg

Neurovascular injuries to the shoulder complex

J Orthop Sports Phys Ther

Quadrilateral space syndrome: A rare cause of shoulder pain

Radiology

MRI of the shoulder

Curr Probl Diagn Radiol