Functional Restoration of Diaphragmatic Paralysis: An Evaluation of Phrenic Nerve Reconstruction

• Published in: The Annals of thoracic surgery Vol. 97; no. 1; pp. 260 - 266
• Main Authors: Kaufman, Matthew R., MD, Elkwood, Andrew I., MD, Colicchio, Alan R., MD, CeCe, John, BS, Jarrahy, Reza, MD, Willekes, Lourens J., MD, Rose, Michael I., MD, Brown, David, DO
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 2014
• Subjects: Adult; Aged; Aged, 80 and over; Cardiothoracic Surgery; Diaphragm - innervation; Diaphragm - physiopathology; Diaphragm - surgery; Electromyography - methods; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neurosurgical Procedures - methods; Phrenic Nerve - pathology; Phrenic Nerve - surgery; Reconstructive Surgical Procedures - methods; Respiratory Paralysis - diagnosis; Respiratory Paralysis - surgery; Retrospective Studies; Risk Assessment; Severity of Illness Index; Spirometry - methods; Surgery; Time Factors; Treatment Outcome; 6
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2013.09.052

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.