Abstract Phrenic nerve injury resulting in diaphragmatic paralysis can occur due to trauma, infection, or malignancy. Iatrogenic causes are most frequently associated with procedures involving the thoracic cavity. Cervical interventions such as epidural steroid injections, facet joint injections, and interscalene nerve blocks are commonly performed for the management of cervicalgia. However, phrenic nerve injury secondary to these procedures remains a rare but clinically significant complication. We present a case of unilateral diaphragmatic paralysis following cervical neck injections. A 79-year-old man presented to the hospital secondary to worsening shortness of breath and severe orthopnea. A month prior, he began receiving injections for cervicalgia. Shortly thereafter, he developed worsening shortness of breath. Initial chest x-ray showed left hemidiaphragm elevation with left basilar atelectasis. Ultimately, he was treated for a COPD exacerbation. He continued to have significant dyspnea and orthopnea, and subsequently underwent a fluoroscopy sniff test, which confirmed diaphragm paralysis. Repeat pulmonary function tests showed significant, new-onset restriction. Later, he developed recurrent pneumonia believed to be secondary to atelectasis in association with the paralyzed hemidiaphragm. Ultimately, he met with a thoracic surgeon for consideration of plication, but was deemed not to be a surgical candidate. The patient is now in a trial of pulmonary rehabilitation. Acquired unilateral diaphragmatic paralysis is rare, affecting less than 0.5% of individuals and occurring more frequently on the left side. Diagnosis is most commonly achieved using the fluoroscopic sniff test, which demonstrates reduced diaphragmatic excursion with or without paradoxical motion. While most unilateral cases are asymptomatic, symptomatic patients may present with dyspnea and recurrent infections due to dependent lung atelectasis. Conservative management includes respiratory muscle training, pulmonary rehabilitation, and noninvasive ventilation for sleep-disordered breathing or hypoventilation. Spontaneous recovery may occur in fewer than 10% of cases. For patients with persistent, debilitating symptoms, surgical diaphragm plication or phrenic nerve pacing may provide functional improvement. This case underscores the importance of recognizing phrenic nerve injury as a potential cause of unexplained dyspnea after cervical interventions. Phrenic nerve injury is an uncommon, but significant complication which can lead to restrictive ventilatory impairment, recurrent atelectasis, and recurrent pulmonary complications. Prolonged diaphragmatic dysfunction may result in progressive muscular atrophy and replacement of normal muscle fibers with fibrotic tissue. Future scholarly activity is warranted to define evidence-based strategies for timely intervention and optimization of long-term respiratory outcomes. This abstract is funded by: None
Jamal et al. (Fri,) studied this question.