Diaphragmatic Reinnervation in Ventilator-Dependent Patients with Cervical Spinal Cord Injury and Concomitant Phrenic Nerve Lesions Using Simultaneous Nerve Transfers and Implantable Neurostimulators

Abstract

Background Patients who are ventilator dependent as a result of combined cervical spinal cord injury and phrenic nerve lesions are generally considered to be unsuitable candidates for diaphragmatic pacing due to loss of phrenic nerve integrity and denervation of the diaphragm. There is limited data regarding efficacy of simultaneous nerve transfers and diaphragmatic pacemakers in the treatment of this patient population.

Methods A retrospective review was conducted of 14 consecutive patients with combined lesions of the cervical spinal cord and phrenic nerves, and with complete ventilator dependence, who were treated with simultaneous microsurgical nerve transfer and implantation of diaphragmatic pacemakers. Parameters of interest included time to recovery of diaphragm electromyographic activity, average time pacing without the ventilator, and percent reduction in ventilator dependence.

Results Recovery of diaphragm electromyographic activity was demonstrated in 13 of 14 (93%) patients. Eight of these 13 (62%) patients achieved sustainable periods (>1 h/d) of ventilator weaning (mean = 10 h/d [n = 8]). Two patients recovered voluntary control of diaphragmatic activity and regained the capacity for spontaneous respiration. The one patient who did not exhibit diaphragmatic reinnervation remains within 12 months of initial treatment. Surgical intervention resulted in a 25% reduction (p < 0.05) in ventilator dependency.

Conclusion We have demonstrated that simultaneous nerve transfers and pacemaker implantation can result in reinnervation of the diaphragm and lead to successful ventilator weaning. Our favorable outcomes support consideration of this surgical method for appropriate patients who would otherwise have no alternative therapy to achieve sustained periods of ventilator independence.

Keywords

diaphragmatic paralysis - implantable neurostimulator - phrenic nerve - quadriplegia - ventilator weaning

• References

• 1 van den Berg ME, Castellote JM, de Pedro-Cuesta J, Mahillo-Fernandez I. Survival after spinal cord injury: a systematic review. J Neurotrauma 2010; 27 (8) 1517-1528
• 2 Berkowitz M. Spinal Cord Injury: An Analysis of Medical and Social Costs. New York: Demos Medical Publishing; 1998
• 3 Fodstad H, Blom S, Linderholm H. Artificial respiration by phrenic nerve stimulation (diaphragm pacing) in patients with cervical cord and brain stem lesions. Scand J Rehabil Med 1983; 15 (4) 173-181
• 4 Adler D, Gonzalez-Bermejo J, Duguet A , et al. Diaphragm pacing restores olfaction in tetraplegia. Eur Respir J 2009; 34 (2) 365-370
• 5 Krieger LM, Krieger AJ. The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury. Plast Reconstr Surg 2000; 105 (4) 1255-1261
• 6 Auerbach AA, Dobelle WH. Transtelephonic monitoring of patients with implanted neurostimulators. Lancet 1987; 1 (8526) 224-225
• 7 Girard TD, Kress JP, Fuchs BD , et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371 (9607) 126-134
• 8 Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999; 159 (2) 439-446
• 9 Sandra Stuban R. The latest facts about the diaphragm pacing stimulation (DPS) system. Ventilator-Assisted Living. 2006; 20 (3) 2-3
• 10 Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg Am 2001; 26 (2) 303-314
• 11 Ducko CT. Clinical advances in diaphragm pacing. Innovations (Phila) 2011; 6 (5) 289-297
• 12 Tung TH, Mackinnon SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am 2010; 35 (2) 332-341
• 13 Midha R. Nerve transfers for severe brachial plexus injuries: a review. Neurosurg Focus 2004; 16 (5) E5
• 14 Mackinnon SE, Novak CB. Nerve transfers. New options for reconstruction following nerve injury. Hand Clin 1999; 15 (4) 643-666 , ix
• 15 Tung TH, Mackinnon SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am 2010; 35 (2) 332-341
• 16 Gu YD, Chen DS, Zhang GM , et al. Long-term functional results of contralateral C7 transfer. J Reconstr Microsurg 1998; 14 (1) 57-59
• 17 Ozkan T, Ozer K, Gülgönen A. Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases. J Hand Surg Am 2001; 26 (1) 44-51
• 18 Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 1999; 104 (5) 1221-1240
• 19 Levine S, Nguyen T, Taylor N , et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358 (13) 1327-1335
• 20 Al-Majed AA, Neumann CM, Brushart TM, Gordon T. Brief electrical stimulation promotes the speed and accuracy of motor axonal regeneration. J Neurosci 2000; 20 (7) 2602-2608
• 21 Gordon T, Brushart TM, Amirjani N, Chan KM. The potential of electrical stimulation to promote functional recovery after peripheral nerve injury—comparisons between rats and humans. In: Millesi H, Schmidhammer R, , eds. How to Improve the Results of Peripheral Nerve Surgery. Vienna: Springer; 2007: 3-11