Diaphragmatic Dysfunction, Prolonged Weaning, and Rehabilitation in High Cervical Spine Injury – A Case Series

High cervical spinal cord injury (SCI) can impair phrenic nerve function (C3–C5), leading to diaphragmatic weakness and difficult weaning from mechanical ventilation. In this context, we describe three traumatic high cervical SCI patients (C2–C6) with flaccid quadriplegia who required prolonged postoperative ventilation. To monitor respiratory recovery, diaphragmatic excursion was serially assessed bilaterally at baseline, then twice weekly and before major milestones using bedside M-mode ultrasonography (subcostal approach; mean of three quiet tidal breaths). Baseline excursions were reduced (0.60–0.97 cm) but improved during recovery (1.10–1.44 cm; 49–100% gains), although they remained below typical normal values (approximately 1.5–2.5 cm) during quiet breathing. Management strategies included early tracheostomy (days four to six), structured physiotherapy and mobilization, and a therapist-implemented patient-specific weaning approach (synchronized intermittent mandatory ventilation [SIMV], continuous positive airway pressure [CPAP] + pressure support [PS], and progressively extended T-piece trials). This was supported by meticulous control of secretion and protein intake, targeting approximately 1.2 to 1.5 g.kg−1.d−1. Ultimately, all patients were liberated from ventilation and decannulated between days 54 and 68, prior to discharge home or to a neurorehabilitation facility. Thus, serial M-mode excursion monitoring, when integrated with multidisciplinary rehabilitation and protocolized, patient-specific weaning, offers an objective means to track recovery and support successful respiratory autonomy following high cervical SCI.