Treatment of diaphragmatic paralysis using an expanded surgical protocol: review of the largest worldwide experience

Background: Diaphragmatic paralysis due to phrenic nerve or spinal injury may result in respiratory deficits ranging from dyspnea to ventilator dependency, yet there are limited surgical options. Aims: Evaluation of an expanded surgical protocol for diaphragmatic paralysis to determine if the following could be achieved: 1. Recovery of diaphragmatic function when feasible; 2. Options for salvage after treatment failures; and 3. Ventilator weaning in spinal cord injury, regardless of severity. Methods: A review of 436 patients with diaphragmatic paralysis treated at U.S. referral centers. Surgery included: phrenic nerve reconstruction (PN), diaphragm plication (DP), pacemaker implantation (PI), diaphragm replacement (DR), or combination therapy. Assessment parameters consisted of: spirometry, chest fluoroscopy, electrodiagnostics, and ventilator weaning (when applicable). A successful outcome required patient reported corrections corroborated by diagnostic testing, or achieving weaning in vented patients. Results: PN alone or with PI was performed in 385 patients, 89% of whom demonstrated functional recovery. Of the 30 patients who underwent DP, 90% reported improvement. PN failures were salvaged with DP in another 7 patients, whereas DP failures were not candidates for salvage. Overall success in 415 diaphragmatic paralysis patients was 92%. Of the 21 vented patients, all 4 with uncomplicated spinal injuries weaned successfully after PI alone, whereas weaning was demonstrated in 65% who underwent PI combined with PN or DR for severe loss of neuromuscular integrity. Conclusion: An expanded surgical protocol may provide optimal outcomes for diaphragmatic paralysis.