1246 - Right hemidiaphragm paralysis in patient with C2 AIS B Spinal Cord Injury

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

RE

Ray Espinosa, MD

Resident Physician
Mount Sinai Hospital
New York, New York, United States

Co-Author(s)

CB

Christopher Bo, MD

Fellow
Icahn School of Medicine at Mount Sinai
New York, New York, United States
TB

Thomas Bryce, MD

Medical Director of the Spinal Cord Injury Program
Icahn School of Medicine at Mount Sinai
new york, New York, United States

Case Diagnosis: Right hemidiaphragm paralysis

Case Description: A 57 year old male with a history of chronic C5 incomplete spinal cord injury was admitted to acute inpatient rehabilitation after developing a spinal epidural abscess leading to C2 AIS B spinal cord injury requiring ventilator support. The patient was weaned off the ventilator, but was noted to have increased work of breathing and low volume speech despite aggressive chest physiotherapy. On exam, decreased breath sounds were notable on the right side. Chest x-ray showed an elevation of the right hemidiaphragm. Bedside POCUS showed absent lung sliding on the right, and no caudal movement of the liver at the level of the diaphragm. Examination on the left showed appropriate lung sliding. Given the findings, Cardiothoracic Surgery was consulted who placed a diaphragm pacer, which led to improved phonation and work of breathing.

Discussions: We present an interesting case of right hemidiaphragm paralysis after nontraumatic C2 spinal cord injury. This patient was progressing well in the ventilator weaning process, however persistent episodes of oxygen desaturation, increased work of breathing, and low volume speech warranted further examination. It is well known that patients with spinal cord injuries at C5 and above are at increased risk of impaired diaphragm function, and we found the use of ultrasound to be highly beneficial in the diagnosis of hemidiaphragm paralysis. Pacer placement immediately led to clinical improvement in phonation and work of breathing, further confirming the diagnosis.

Conclusions: In patients with spinal cord injury at C5 or above, it is important to be mindful of diaphragm paralysis as a potential complication and cause of shortness of breath, low volume speech, or other respiratory concerns. Evaluation with ultrasound is a cheap and easy way to assess diaphragm function.