PURPOSE: Unilateral phrenic nerve injury often results in symptomatic hemi-diaphragm paralysis and currently few treatment options exist. Reported etiologies include: cardiac surgery, neck surgery, chiropractic manipulation, and interscalene nerve blocks. Although diaphragmatic plication has been an option for treatment, the ideal treatment would be restoration of function to the paralyzed hemi-diaphragm. The application of peripheral nerve surgery techniques for phrenic nerve injuries has not been adequately evaluated.
METHODS: Twelve patients presenting with chronic, symptomatic unilateral phrenic nerve injuries following surgery, chiropractic manipulation, trauma and/or anesthetic blocks underwent a comprehensive evaluation, including radiographic and electrophysiologic assessments. Surgical treatment was offered following a minimum of six months of conservative management. Operative planning was based upon pre/intra-operative testing, using one or more established nerve reconstruction techniques (neurolysis, interpositional grafting, and/or neurotization). Measures of post-operative improvement included: pulmonary function testing, fluoroscopic “sniff” testing, and a standardized quality-of-life survey.
RESULTS: The mean pre-operative FEV1 and FVC for all twelve patients was 62 ± 29% and 65 ± 32%, respectively. In the nine patients that underwent both pre- and post-operative spirometry, FEV1 and FVC improved following treatment by an average of 12 ± 13% and 12 ± 17%, respectively. Nine of ten patients (90%) evaluated with the MOS 36-Item Short Form Survey Instrument demonstrated clinical respiratory improvements, eight of whom could be confirmed with PFT and/or sniff testing. Comparative fluoroscopic sniff testing demonstrated an unequivocal improvement in diaphragm motion in eight of nine tested (89%).
CONCLUSIONS: Based on the favorable results in this small series we suggest expanding nerve reconstruction techniques to phrenic nerve injury treatment and propose an algorithm for treatment of unilateral phrenic nerve injury that may expand the current limitations in therapy.
CLINICAL IMPLICATIONS: The clinical implications are significant. Many patients suffer from unresolved diaphragm paralysis, mostly from surgical or anesthetic injuries, and very few can be treated. Diaphragm plication can help some, but our manuscript details an innovation that can actually restore function to the diaphragm itself, a therapeutic option that could provide a more physiologic functional improvement to many patients.
DISCLOSURE: The following authors have nothing to disclose: Matthew Kaufman, Andrew Elkwood, Michael Rose, Tushar Patel, Russell Ashinoff, Adam Saad, Robert Caccavale, Jean Bocage, Jeffrey Cole, Aida Soriano, Edward Fein, Edward Fein
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