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A5346 - Bilateral Phrenic Nerve Paralysis as a Complication of Decompressive Cervical Laminectomy
Author Block: M. Hafiz1, V. Maddipati2; 1East Carolina Universty, Greenville, NC, United States, 2Dept. Pulmonary and Critical Care, East Carolina University, Greenville, NC, United States.
Diaphragmatic paralysis from phrenic nerve injury is a well described entity but occurrence after cervical laminectomy is very rare and possibly under recognized. We report a case of bilateral phrenic nerve and diaphragmatic paralysis resulting from cervical laminectomy. 73-year-old male with a history of cervical stenosis, chronic obstructive pulmonary disease, coronary artery disease with remote bypass surgery, congestive heart failure with automated implantable cardioverter defibrillator, presented to the referring hospital (Outlying Hospital) after falling at a rehab facility. 2 weeks prior to that, he had an uneventful bilateral laminectomy for symptomatic cervical stenosis, C3 through C7. At the outlying hospital patient was somnolent with some concern for periodic breathing pattern. Admission CT head was negative and CT chest showed bilateral pulmonary nodules (stable for over a year), emphysematous changes and spinal lytic lesions. He was treated with antibiotics for possible aspiration pneumonia. Patient progressed to respiratory failure requiring intubation and mechanical ventilation. He also developed new left sided weakness after which a repeat CT head showed a right frontal ischemic stroke. He was then transferred to our facility for failure to wean from ventilator. On arrival, vital signs were stable and he remained intubated on the ventilator. He was drowsy but arousable, moved all his extremities but had left sided weakness. Labs showed hemoglobin of 7.5 g/dl, creatinine 2.04 mg/dl and hypocalcemia. On two consecutive days he quickly failed T-piece trial with use of accessory muscles. BNP was normal and CXR did not have infiltrates or edema. CT cervical spine showed multiple lytic lesions in cervical and thoracic vertebrae, and post-surgical changes. Bilateral phrenic nerve electrodiagnostic study was performed which did not illicit any motor response in either hemi-diaphragms, suggestive of bilateral phrenic nerve palsy. This was confirmed on diaphragmatic ultrasound as well. Multiple lytic lesions, anemia, hypercalcemia and renal failure were suggestive of multiple myeloma. Patient was eventually transitioned to comfort measures. Cervical laminectomy is a rare cause of diaphragmatic paralysis and the mechanism remains unclear. It is hypothesized that individuals undergoing cervical laminectomy can have a delayed onset central apnea due to interruption of reticulo-spinal fibers innervating phrenic nerve nuclei. We postulate that his delayed presentation maybe secondary to progressive phrenic nerve degeneration after laminectomy. Alternatively his prior bypass surgery might have compromised one phrenic nerve and spine surgery effected the other.