Original article
General thoracic
Functional Restoration of Diaphragmatic Paralysis: An Evaluation of Phrenic Nerve Reconstruction

https://doi.org/10.1016/j.athoracsur.2013.09.052Get rights and content

Background

Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options.

Methods

An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications.

Results

In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values.

Conclusions

Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy.

Section snippets

Patients and Methods

The Jersey Shore University Medical Center (Neptune, NJ) Institutional Review Board approved the study, and informed patient consent was obtained in accordance with study approval.

PS Group

The PS group comprised 53 male and 15 female patients, with an average age of 53 years (range, 11 to 79 years) and a mean body mass index of 30.2 ± 5.3 kg/m2 (Table 1). The paralysis was left-sided in 40 patients and right-sided in 28. All patients provided a history of an episodic or recurrent iatrogenic or traumatic event or events (Table 2). The average duration between onset of respiratory symptoms and surgical treatment was 22 months (range, 8 to 72 months). The follow-up period after

Comment

Diaphragmatic paralysis is a disorder that is not readily recognized, primarily because it is unlike many other respiratory diseases in which the underlying pathophysiology affects the airways or lung parenchyma, or both. Respiratory deficits caused by dysfunction of the primary respiratory muscle are most often a direct result of injury to its innervation, the phrenic nerve. The etiology can be iatrogenic injury (ie, surgical, anesthetic blocks, chiropractic) or trauma (ie, whiplash, traction

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