Severe asthma complicated by bilateral diaphragmatic paralysis attributed to Parsonage-Turner syndrome

Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers

OBJECTIVES

Bilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction.

METHODS

Patients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database.

RESULTS

Fourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side.

CONCLUSIONS

PR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.

Right hemidiaphragmatic paralysis after cervical transforaminal epidural steroid injection: illustrative case

BACKGROUND

Cervical radiculopathy is a common cause of neck pain, with radiation into the upper extremity in a dermatomal pattern. Corticosteroid injection is a conservative management option with a low risk of major adverse events. No reviewed literature or case reports have implicated phrenic nerve injury secondary to cervical transforaminal epidural steroid injection (CTFESI).

OBSERVATIONS

A 45-year-old man with severe right C6 radiculopathy secondary to a large right-sided C5–6 herniated intervertebral disc presented to the pain management clinic, where he received a right-sided C6 CTFESI. An hour after injection, the patient experienced shortness of breath, which was found to be caused by right diaphragmatic paralysis. The patient underwent a C5–6 anterior cervical discectomy and fusion, which provided complete relief of his radicular symptoms. However, the right hemidiaphragmatic paralysis remained at the 1-year postoperative visit.

LESSONS

Thorough literature review showed no established explanations for phrenic nerve injury after CTFESI. In this study, the authors explored the suspected mechanisms of possible injury to the phrenic nerve. Epidural corticosteroid injection is considered to be a safe option for conservative management of cervical radiculopathy. This study unveiled a unique and important adverse event that should be considered before a patient receives CTFESI.

Neuralgic amyotrophy: clinical features and diagnostic evaluation

BACKGROUND

Neuralgic amyotrophy is an uncommon neurologic syndrome of unknown etiology involving the brachial plexus, which is manifest by shoulder and arm pain, weakness, and sensory loss. Because of the diversity and variability of the initial features and similarity to other neurologic and non-neurologic disorders, patients may initially present to internists, orthopedic surgeons, or pulmonologists, and may be initially diagnosed with an alternative disorder.

REVIEW SUMMARY

Neuralgic amyotrophy occurs at an annual incidence rate of 1 to 2 cases per 100,000 population. The disorder is most common in adulthood, but patients of any age may be affected. Pain is the most common initial symptom and is followed by weakness and sensory loss in the distribution of a single nerve or diffuse regions of the brachial plexus. Although the exact etiology is unknown, many associated factors, such as immunizations, minor trauma, infectious diseases, pregnancy, and surgical procedures have been associated with the development of the disorder. Evaluation with electrodiagnostic and radiographic studies is useful in confirming the diagnosis and excluding alternative disorders. No treatment has been definitively proven to improve the course of the disorder; however, the overall prognosis is good, with approximately 90% of patients demonstrating significant improvement.

CONCLUSIONS

Neuralgic amyotrophy is an important, potentially debilitating disorder, which may present to physicians in multiple specialties. Awareness of this disorder may preclude unnecessary testing or surgical procedures and can guide toward appropriate treatment with physical therapy. Counseling patients about the overall good prognosis can help appease patients' anxiety about a more sinister diagnosis or course.

Neuralgic amyotrophy presenting with bilateral vocal cord paralysis in a child: a case report

Acute stridor and bilateral vocal cord paralysis is not uncommon in the neonate but is unusual in the older child. We report the first case of bilateral vocal cord paralysis secondary to neuralgic amyotrophy, a peripheral polyneuropathy, in a 5-year-old child. An extensive workup revealed a paralyzed right hemidiaphragm, arm weakness and an EMG pattern consistent with neuralgic amyotrophy. Neuralgic amyotrophy is an uncommon disorder in pediatric patients which may involve cranial and peripheral nerves including the phrenic nerves and rarely the recurrent laryngeal nerves. We propose that the diagnosis be considered in children who present with bilateral vocal cord paralysis and other associated neurologic findings.