Early diagnosis and treatment management with USG in a patient who developed unilateral diaphragmatic paralysis after interscalene block.

Interscalene brachial plexus block is frequently used for anesthesia and analgesia in shoulder, clavicle, and humerus surgeries. However, complications such as infection, hematoma, vascular injury, local anesthetic toxicity, nerve damage, total spinal anesthesia, diaphragmatic paralysis, and Horner syndrome may occur after an interscalene block. In this case report, a case of unilateral diaphragmatic paralysis that developed after an ultrasound-guided interscalene brachial plexus block for intraoperative and postoperative analgesia, which was rapidly diagnosed and treated bedside with ultrasound, is presented and discussed. We believe that ultrasound has become an indispensable means of monitoring anesthesia practice, both in peripheral nerve block and in the diagnosis and treatment of complications, in recent years.

Superior trunk versus interscalene brachial plexus block in humerus surgery: a randomised controlled trial.

INTRODUCTION: Ultrasound (US)-guided interscalene (IS) block is a commonly performed block for shoulder and humerus surgery. Though it provides excellent analgesia, it is associated with hemidiaphragmatic paralysis and dyspnoea. Superior trunk (ST) block has been described, wherein the local anaesthetic is deposited around the ST block (formed by fusion of C5 and C6 nerve roots). This study aimed to determine whether ST block provides similar analgesic efficacy with lower incidence of diaphragmatic paresis in patients undergoing proximal humerus surgery. MATERIAL AND METHODS: A total of 62 patients scheduled to undergo unilateral internal fixation (plating) for proximal or mid shaft humerus fracture were randomised to 2 groups. Patients in group I received US-guided ST block while those in group II received US-guided IS block. Both groups received 15 mL of 0.5% bupivacaine. Diaphragmatic excursion was noted at baseline and after 30 minutes after the block. Postoperatively, the numerical rating scale score and requirement of opioids were documented. RESULTS: The incidence of complete/incomplete paresis was statistically significantly lower in the ST group. Thirty eight percent of the patients (11) had complete paresis in the IS group, compared to none in the ST group. Partial paresis was observed in 62% of patients in the IS block group and 19% in the ST block group ( P < 0.001). The percentage reduction of movement was significantly higher in the IS group vs. the ST group ( P < 0.001). There was no difference in pain scores or the amount of opioid consumption between groups. CONCLUSIONS: ST block provides similar analgesia to IS block for proximal/mid humerus surgery with better preservation of diaphragmatic function. This could be a viable alternative in patients with compromised respiratory functions scheduled for such surgery.

Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy: a randomized controlled trial.

OBJECTIVES: The incidence of hemidiaphragmatic paresis (HDP) in superior trunk block (STB) usually depends on the dose of local anesthetic. This study aimed to further evaluate the impact of a lower volume (10 mL) of the same low concentration (0.25%) ropivacaine compared to a conventional volume (15 mL), on diaphragmatic function and analgesic efficacy under a multimodal analgesia regimen for shoulder arthroscopy. METHODS: Patients scheduled to undergo shoulder arthroscopy were randomized allocated to receive either 10 mL or 15 mL of 0.25% ropivacaine in the STB under ultrasound guidance prior to general anesthesia. The primary outcome was the percentage reduction in diaphragm excursion (ΔDE) between baseline and 30 min after block. Secondary outcomes included DE and diaphragm thickening fraction (DTF) before and after block, incidence of HDP, onset of sensory/motor block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity, pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, and adverse events post-surgery. RESULTS: Compared with 15 mL volume, 10 mL ropivacaine significantly reduced the incidence of post-block HDP (as measured by ΔDE: 39.47% vs. 64.10%; and by post-block DTF: 13.16% vs. 33.33%). There was no significant difference in onset of sensory block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity between the two groups, except that the onset of motor block was significantly slower in the 10 mL group than in the 15 mL group. Pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, or postoperative adverse events were not significantly different between the two groups. CONCLUSION: In shoulder arthroscopy, STB with 10 mL of ropivacaine can reduce the incidence of HDP with no significant difference in analgesic effects under a multimodal analgesia regimen compared with 15 mL. TRIAL REGISTRATION: We registered the study at chictr.org ( ChiCTR2200057543 , 14/03/2022. https://www.chictr.ogr.cn.

Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability.

INTRODUCTION: Subaxial cervical spine injuries (SCSI) can lead to disastrous consequences such as quadriplegia, with/without respiratory paralysis (RP) and hemodynamic instability (HDI). Till date, there is no literature available for reporting outcomes of SCSI patients specifically pertaining to those presenting with RP/HDI and ours is the first study to document the same. METHODS: Retrospective 6-year study from a tertiary trauma centre database including patients >/= 18 years of operated SCSI. Only patients with ASIA A grade with admission RP/HDI and unstable injuries (fractures, subluxations) were included. Patients with ASIA grade B and above, patients with non-osseous injuries (such as disc herniation, central cord syndrome etc.) were excluded. RESULTS: 24 cases were analysed. C5 and C6 levels were the commonest. Vertebral listhesis/subluxation was the predominant radiological finding. The mean age was 47.4 years (22-79 years) and all, except one were males. Fall from height and road traffic accident (RTA) were the most common mechanisms of injury. The most common surgery was anterior discectomy and fusion followed by corpectomy. The overall mortality rate was 22/24 (92)%. Cord edema and hemorrhage had significant association with survival. None of the grade A survivors with HDI/RP showed improvement. The mean FU duration was 18.5 months (range, 16.5-20.5 months). CONCLUSIONS: Subaxial ASIA A cervical spine injuries with pre-operative RP/HDI is an indicator for non-improvement. This is the first study documenting outcome in such patients. The mortality rate in these patients is very high and is an extremely poor prognostic factor for recovery. Hence, surgery in such patients need to be decided judiciously, especially in developing countries that has a significant financial impact on the family members.

Diaphragm-sparing efficacy of subparaneural upper trunk block for arthroscopic shoulder surgery: A randomised controlled trial.

BACKGROUND: Inter-scalene block (ISB) is associated with an inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risk of HDP, an upper trunk block (UTB) has been proposed at the brachial plexus division level. OBJECTIVE: We hypothesised that UTB would be associated with a lower incidence of HDP than ISB while providing sufficient analgesia following arthroscopic shoulder surgery. DESIGN: Randomised controlled trial. SETTING: A tertiary teaching hospital. PATIENTS: Seventy patients aged 20 to 80 years undergoing arthroscopic rotator cuff repair. INTERVENTION: Ultrasound-guided ISB or UTB was performed with 5 ml 0.75% ropivacaine. MAIN OUTCOME MEASURES: The primary outcome was the incidence of complete HDP, assessed by diaphragm excursion using ultrasound, defined as a decrease to 25% or less of baseline or occurrence of paradoxical movement. Postoperative pulmonary function change, pain scores, opioid consumption and pain-related outcomes were the secondary outcomes. RESULTS: The UTB group had a significantly lower incidence of complete HDP than the ISB group [5.9% (2/34) vs. 41.7% (15/36); absolute difference, 35.8%; 95% confidence interval (CI), 17.8 to 53.7%; P  < 0.001]. The postblockade decline in pulmonary function was more pronounced in the ISB group than that in the UTB group. The pain score at 1 h postoperatively was not significantly different between the groups (ISB vs. UTB group: median 0 vs. 1; median difference, -1; 95% CI, -2 to 0.5). No significant difference was observed in any other secondary outcomes. CONCLUSION: UTB was associated with a lower incidence of HDP compared with ISB while providing excellent analgesia in arthroscopic shoulder surgery. TRIAL REGISTRATION: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ) identifier: KCT0007002. IRB NUMBER: Chungnam National University Hospital Institutional Review Board No. 2021-12-069.

Weaning failure due to isolated residual diaphragmatic paralysis after cervical spinal cord ischemia following aortic surgery- a case report.

BACKGROUND: Bilateral diaphragmatic dysfunction can lead to dyspnea and recurrent respiratory failure. In rare cases, it may result from high cervical spinal cord ischemia (SCI) due to anterior spinal artery syndrome (ASAS). We present a case of a patient experiencing persistent isolated diaphragmatic paralysis after SCI at level C3/C4 following thoracic endovascular aortic repair (TEVAR) for Kommerell's diverticulum. This is, to our knowledge, the first documented instance of a patient fully recovering from tetraplegia due to SCI while still exhibiting ongoing bilateral diaphragmatic paralysis. CASE PRESENTATION: The patient, a 67-year-old male, presented to the Vascular Surgery Department for surgical treatment of symptomatic Kommerell's diverticulum in an aberrant right subclavian artery. After successful surgery in two stages, the patient presented with respiratory insufficiency and flaccid tetraparesis consistent with anterior spinal artery syndrome with maintained sensibility of all extremities. A computerized tomography scan (CT) revealed a high-grade origin stenosis of the left vertebral artery, which was treated by angioplasty and balloon-expandable stenting. Consecutively, the tetraparesis immediately resolved, but weaning remained unsuccessful requiring tracheostomy. Abdominal ultrasound revealed a residual bilateral diaphragmatic paralysis. A repeated magnetic resonance imaging (MRI) 14 days after vertebral artery angioplasty confirmed SCI at level C3/C4. The patient was transferred to a pulmonary clinic with weaning center for further recovery. CONCLUSIONS: This novel case highlights the need to consider diaphragmatic paralysis due to SCI as a cause of respiratory failure in patients following aortic surgery. Diaphragmatic paralysis may remain as an isolated residual in these patients.

Diaphragmatic palsy following lung transplantation.

Diaphragmatic palsy after lung transplantation has been reported infrequently. Given the role of the diaphragm in respiration, the palsy may play a significant role in the post-surgical recovery as well as morbidity and mortality. This review summarises the current literature to better understand diaphragmatic palsy in the post lung-transplant setting among adults. A thorough literature search was conducted through multiple databases and 91 publications were identified that fit the research question. The review aimed to report the burden of this problem, explore different modalities of diagnosis reported, the effect of various clinical factors and treatment modalities, as well as their effects on outcomes. Additionally, it aimed to highlight the variability, limitations of reported data, and the absence of a standardised approach. This review emphasises the crucial need for more dedicated research to better address this clinical challenge.

Management of Diaphragm Paralysis and Eventration.

An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be used to differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion). Regardless of etiology, a diaphragm plication is indicated in all symptomatic patients with an elevated diaphragm. Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication. The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm. Diaphragm plication is safe, has excellent outcomes, and is associated with symptom improvement.

[Quality of life in patients with postoperative unilateral diaphragm relaxation]. / Kachestvo zhizni patsientov s odnostoronnei relaksatsiei diafragmy posle khirurgicheskogo lecheniya.

OBJECTIVE: To evaluate the quality of life before and after video-assisted thoracoscopic plication of relaxed dome of diaphragm. MATERIAL AND METHODS: The study included 17 patients operated on for unilateral relaxation of diaphragm. We analyzed quality of life in preoperative period, 1, 3, 6 and 12 months after surgery using the SF-36 and EuroQ-5D-5L questionnaires. To assess the impact of abnormality on respiratory function, we estimated diaphragm position, spirometry data and SGRQ scores. RESULTS: FVC increased by 16.5% after 1 month, 19.5% after 6 months and 20.1% after 12 months. In addition, FEV1 significantly increased (by 12.6% after 1 month, 10.1% after 6 months and 12.7% after 12 months). Mean values of diaphragm elevation in postoperative period decreased by 25.5-25.6%. According to the SF-36 and EuroQ-5D-5L questionnaires, physical and psychological health components significantly increased within a month after surgical treatment. According to the SGRQ questionnaire, influence of disease on overall status decreased a month after surgery as evidences by lower total score (p<0.05). CONCLUSION: Objective and survey data revealed significant improvement in quality of life after surgery. A trend towards higher quality of life was demonstrated by all questionnaires in a month after surgery.

Hepatitis E and diaphragmatic dysfunction: Case series and review of the literature.

INTRODUCTION: The causes of diaphragmatic paresis are manifold. An association between neuralgic amyotrophy (NA) and hepatitis E virus (HEV) infection has been reported. We wondered about the prevalence of diaphragmatic disfunction and hepatitis E infection in our clinic. METHODS: From July 1st, 2020 to August 31st, 2023, patients presenting with diaphragmatic dysfunction and simultaneous clinical symptoms of an acute NA, or a history of NA, as well as patients with previously unexplained diaphragmatic dysfunction were examined for HEV infection. RESULTS: By August 31st, 2023, 13 patients with diaphragmatic dysfunction and HEV infection were diagnosed (4 women, 9 men). Mean age was 59 ± 10 years. Liver values were normal in all patients. The median latency to diagnosis was five months (range: 1-48 months); nine patients, 4 of them with typical symptoms of NA, presented with acute onset three patients showed bilateral diaphragmatic dysfunction. All patients had a positive IgG immunoblot. Seven patients, three with NA, had an elevated hepatitis E IgM titer and six of them also a positive IgM immunoblot. In all cases, O2C hepatitis genotype 3 was identified. In eight cases, all those with a high IgG titer >125, the O2 genotype 1 was also detected. CONCLUSION: NA that shows involvement of the phrenic nerve resulting in diaphragmatic dysfunction and dyspnoea, may be associated with HEV infection. The observation of 13 patients with diaphragmatic dysfunctions and HEV infection within a period of three years indicates a high number of undetected HEV-associated diaphragmatic dysfunction in the population, especially in the absence of NA symptoms. Therefore, even in diaphragmatic dysfunction without NA symptoms and causative damaging event, HEV infection should be considered, as it may represent a subform of NA with only phrenic nerve involvement. Therapy of HEV-associated diaphragmatic dysfunction in the acute phase is an open question. In view of the poor prognosis for recovery, antiviral therapy should be discussed. However, no relevant data are currently available.

In a porcine model of implantable pacemakers for pediatric unilateral diaphragm paralysis, the phrenic nerve is the best target.

BACKGROUND: A frequent complication of Fontan operations is unilateral diaphragmatic paresis, which leads to hemodynamic deterioration of the Fontan circulation. A potential new therapeutic option is the unilateral diaphragmatic pacemaker. In this study, we investigated the most effective stimulation location for a potential fully implantable system in a porcine model. METHODS: Five pigs (20.8 ± 0.95 kg) underwent implantation of a customized cuff electrode placed around the right phrenic nerve. A bipolar myocardial pacing electrode was sutured adjacent to the motor point and peripherally at the costophrenic angle (peripheral diaphragmatic muscle). The electrodes were stimulated 30 times per minute with a pulse duration of 200 µs and a stimulation time of 300 ms. Current intensity was the only variable changed during the experiment. RESULTS: Effective stimulation occurred at 0.26 ± 0.024 mA at the phrenic nerve and 7 ± 1.22 mA at the motor point, a significant difference in amperage (p = 0.005). Even with a maximum stimulation of 10 mA at the peripheral diaphragm muscle, however, no effective stimulation was observed. CONCLUSION: The phrenic nerve seems to be the best location for direct stimulation by a unilateral thoracic diaphragm pacemaker in terms of the required amperage level in a porcine model.

Cervical Spine Stenosis Causing Diaphragmatic Paralysis: A Case Study and Narrative Review of Clinical Presentations and Outcomes.

STUDY DESIGN: Case report and narrative review. OBJECTIVE: To explore the therapeutic role of surgical and nonsurgical treatment of diaphragmatic paralysis secondary to spinal cord and nerve root compression. SUMMARY OF BACKGROUND DATA: Phrenic nerve dysfunction due to central or neuroforaminal stenosis is a rare yet unappreciated etiology of diaphragmatic paralysis and chronic dyspnea. Surgical spine decompression, diaphragmatic pacing, and intensive physiotherapy are potential treatment options with varying degrees of evidence. METHODS: The case of a 70-year-old male with progressive dyspnea, reduced hemi-diaphragmatic excursion, and C3-C7 stenosis, who underwent a microscopic foraminotomy is discussed. Literature review (MEDLINE, PubMed, Google Scholar) identified 19 similar reports and discussed alternative treatments and outcomes. RESULTS AND CONCLUSIONS: Phrenic nerve root decompression and improvement in neuromonitoring signals were observed intraoperatively. The patient's postoperative course was uncomplicated, and after 15 months, he experienced significant symptomatic improvement and minor improvement in hemi-diaphragmatic paralysis and pulmonary function tests. All case reports of patients treated with spinal decompression showed symptomatic and/or functional improvement, while one of the 2 patients treated with physiotherapy showed improvement. More studies are needed to further describe the course and outcomes of these interventions, but early identification and spinal decompression can be an effective treatment. OCEBM LEVEL OF EVIDENCE: Level-4.

Shrinking lung syndrome mimicking diaphragmatic palsy in systemic lupus erythematosus.

A 25-year-old woman presented with 1 year of progressive orthopnoea, initially explained as bilateral diaphragmatic paresis caused by seronegative myasthenia gravis. She required assisted ventilation and received pyridostigmine and corticosteroids. She had minimal (particularly proximal) symmetrical tetraparesis with apparent bilateral diaphragmatic weakness, but had normal sensation. Further investigation suggested an overlap myositis with shrinking lung syndrome from systemic lupus erythematosus. She improved following immunosuppression with pulse corticosteroids and rituximab, and at 3 months no longer needed bilevel positive airway pressure support.

Orthopnea secondary to brachial plexitis with bilateral diaphragmatic paralysis.

BACKGROUND: Diaphragmatic paralysis can present with orthopnea. We report a unique presentation of bilateral diaphragmatic paralysis, an uncommon diagnosis secondary to an unusual cause, brachial plexitis. This report thoroughly describes the patient's presentation, workup, management, and outcome. It also reviews the literature on diaphragmatic paralysis and Parsonage-Turner syndrome. CASE PRESENTATION: A 50-year-old male patient developed insidious orthopnea associated with left shoulder and neck pain over three months with no associated symptoms. On examination, marked dyspnea was observed when the patient was asked to lie down; breath sounds were present and symmetrical, and the neurological examination was normal. The chest radiograph showed an elevated right hemidiaphragm. Echocardiogram was normal. There was a 63% positional reduction in Forced Vital Capacity and maximal inspiratory and expiratory pressures on pulmonary function testing. The electromyogram was consistent with neuromuscular weakness involving both brachial plexus and diaphragmatic muscle (Parsonage and Turner syndrome). CONCLUSIONS: Compared to unilateral, bilateral diaphragmatic paralysis may be more challenging to diagnose. On PFT, reduced maximal respiratory pressures, especially the maximal inspiratory pressure, are suggestive. Parsonage-Turner syndrome is rare, usually with unilateral diaphragmatic paralysis, but bilateral cases have been reported.

A porcine model of postoperative hemi-diaphragmatic paresis to evaluate a unilateral diaphragmatic pacemaker.

Unilateral phrenic nerve damage is a dreaded complication in congenital heart surgery. It has deleterious effects in neonates and children with uni-ventricular circulation. Diaphragmatic palsy, caused by phrenic nerve damage, impairs respiratory function, especially in new-borns, because their respiration depends on diaphragmatic contractions. Furthermore, Fontan patients with passive pulmonary perfusion are seriously affected by phrenic nerve injury, because diaphragmatic contraction augments pulmonary blood flow. Diaphragmatic plication is currently employed to ameliorate the negative effects of diaphragmatic palsy on pulmonary perfusion and respiratory mechanics. This procedure attenuates pulmonary compression by the abdominal contents. However, there is no contraction of the plicated diaphragm and consequently no contribution to the pulmonary blood flow. Hence, we developed a porcine model of unilateral diaphragmatic palsy in order to evaluate a diaphragmatic pacemaker. Our illustrated step-by-step description of the model generation enables others to replicate and use our model for future studies. Thereby, it might contribute to investigation and advancement of potential improvements for these patients.