BACKGROUND: Respiratory dysfunction is a leading cause of morbidity and mortality after cervical spinal cord injury (C-SCI). Respiratory impairment is exacerbated by mechanical ventilation, which is associated with higher infection rates and diaphragm atrophy. Intramuscular stimulation of the diaphragm, that is, diaphragm pacing (DP), is a potential strategy to facilitate ventilator weaning, enhance respiratory function, and reduce complications. However, its impact on respiratory recovery and neuromuscular activation remains understudied. METHODS: This prospective observational case series evaluated changes in respiratory function and diaphragm activation over two months in 11 patients with acute traumatic C-SCI who underwent DP. Outcomes included tidal volume, respiratory rate, minute ventilation, maximal inspiratory/expiratory pressure generation (MIP/MEP), forced vital capacity (FVC), and diaphragm electromyography (EMG) recorded from the implanted electrodes. RESULTS: Participants demonstrated severe respiratory impairment at baseline, with tidal volumes averaging 2.8±1.3 mL/kg and FVC at 19±14% of predicted. Despite this, 89% weaned from mechanical ventilation within 41±19.8 days post-injury. Significant weekly improvements were evident in tidal volume (+0.26 mL/kg), respiratory rate (-0.66 breaths/min), and minute ventilation (+0.35 L/min). MIP and MEP increased by 3% predicted function per week, and FVC increased by 2% of predicted function per week. Diaphragm EMG amplitudes during quiet breathing decreased over time, particularly in patients with high baseline activation (>80% of maximum) possibly reflecting improved neuromuscular efficiency. CONCLUSIONS: These findings suggest that DP may support early respiratory recovery after C-SCI improving respiratory function and diaphragm activation. Future research is needed to elucidate the underlying mechanisms and optimize clinical use of DP for respiratory recovery after C-SCI. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic Study; Level IV.
Vose et al. (Mon,) studied this question.