Review Question - QID 214116

This patient has a labral tear with a concomitant paralabral cyst compressing the suprascapular nerve at the spinoglenoid notch. The most appropriate treatment would have to address the labral tear, with cyst decompression also being reasonable.

Posterior labral tears are usually due to repetitive microtrauma in the overhead athlete. Symptoms may include mechanical catching and pain with axial load or overhead movements. These labral tears can also act as a one-way valve for fluid to flow and create a cyst. Paralabral cysts can cause mass effect on surrounding structures, most notably on the suprascapular nerve. If the cyst is within the suprascapular notch, compression of the supra- and infraspinatus muscles will be seen, whereas spinoglenoid cysts will only affect the infraspinatus. A great deal of debate and research has been conducted on whether cyst decompression must be performed in conjunction with addressing labral pathology.

Kim et al. performed a nonrandomized, prospective cohort study of individuals with SLAP tears who either underwent SLAP repair alone or with additional cyst decompression. At an average follow-up of 2.5 years, they noted similar improvement in both groups in patient-reported outcomes, infraspinatus atrophy resolution, and cyst size between the two groups. This indirectly supports the one-way valve mechanism for para-labral cysts and that additional cyst decompression yields no appreciable benefit.

Schroeder et al. conducted a systemic review of all studies of patients with SLAP tears and spinoglenoid cysts who either underwent labral repair with or without cyst decompression. They showed that both groups had excellent outcomes without significant differences. This provides further evidence that addressing the primary labral pathology will lead to improved outcomes.

Figure A is an axial T1 image with a posterior labral tear and a spinoglenoid cyst. Figure B is a sagittal T1 sequence demonstrating the cyst in the spinoglenoid notch and distal to the supraspinatus muscle. Figures C-E are T2 coronal sequences showing the posterior labral tear with fluid extending directly to the cyst.
Illustration A depicts the course of the suprascapular nerve traversing within the suprascapular notch proximally and the spinoglenoid notch distally.

Incorrect Answers:
Answer 1: The biceps tendon is intact on these images and her exam is not consistent with biceps pathology
Answers 2 and 3: The images do not show a Bennett's lesion or a partial articular sided supraspinatus tear.
Answer 5: Cyst decompression should not be done in isolation when concomitant labral tears are present. This would be a reasonable adjunctive procedure.