Chest
Volume 119, Issue 2, February 2001, Pages 638-639
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Selected Reports
Diaphragmatic Paralysis Following Cervical Chiropractic Manipulation: Case Report and Review

https://doi.org/10.1378/chest.119.2.638Get rights and content

This case report documents an uncommon cause of bilateraldiaphragmatic paralysis resulting from phrenic nerve injury duringcervical chiropractic manipulation. Several months after the initialinjury, our patient remains short of breath and has difficultybreathing in the supine position. Other causes of diaphragmaticparalysis and phrenic nerve injury are reviewed.

Section snippets

Case Report

A previously healthy, nonsmoking, 41-year-old male producemanager sought chiropractic care for pain and stiffness in his neck andshoulders. He stated that the pain developed after sleeping on a sofawhile on vacation the previous week. After obtaining neck and chestradiographs, the chiropractor did a number of manipulations that thepatient described as forcing his shoulders downward and turning hishead laterally. His neck pain and stiffness were slightly relievedimmediately after the visit.

Discussion

When bilateral phrenic nerve paralysis occurs, it usually causessevere morbidity in adults. Most cases of either unilateral orbilateral paralysis are due to thoracic surgery or intrathoracicmalignancy, but can also stem from trauma, neuromuscular disease, orvarious inflammatory conditions,10 such as pleurisy, pneumonia, or herpes zoster infection.11 Diaphragmaticparalysis is much more common than clinicallyrecognized,12 and the etiology remains unidentified inmore than two thirds of cases.1314

References (18)

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    It is implausible that his phrenic nerve was damaged during the course of either of his 2 original surgical operations given the timing of the new onset of orthopnea. Another previously documented possibility is that a maneuver performed by his chiropractor resulted in a phrenic neuropraxia, which is more consistent with the time course of this presentation.8,9 Desire to avoid tracheostomy and associated side effects may lead to consideration of BCV during radiation therapy.

  • Diaphragmatic dysfunction as the presenting symptom in neuromuscular disorders: A retrospective longitudinal study of etiology and outcome in 30 German patients

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    Classical protagonists of the former group are neurodegenerative (i.e. familial amyotrophic lateral sclerosis, hereditary neuralgic amyotrophy) and myopathic disorders (i.e. Pompe disease, hereditary myopathy with early respiratory failure), whereas the latter group primarily relates to acquired neurodegenerative (i.e. sporadic amyotrophic lateral sclerosis), infectious (i.e. polio, neuroborreliosis), autoimmune (i.e. multifocal motor neuropathy, chronic inflammatory demyelinating neuropathy, myasthenia gravis), and (iatrogenic) traumatic diseases (i.e. insertion of central venous catheter [4]; cardiac surgery; cardiac catheter ablation [5–9]), as well as conditions in which the underlying pathophysiology is still elusive or a matter of debate (i.e. neuralgic amyotrophy, idiopathic phrenic neuropathy, critical illness neuropathy/myopathy) [1,2,10,11]. While diaphragmatic dysfunction is common in late stages of several of the abovementioned disorders, studies on its presence as the presenting or predominant symptom in patients with neuromuscular disorders are scarce and mainly consist of case reports [12–16] and case series [10,11,17–21]. To address this issue in more detail, we reviewed the medical records of patients, who had been treated at two major tertiary referral centers for patients with neuromuscular diseases in the metropolitan region of Nuremberg-Erlangen in Bavaria, Germany.

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    Common presenting symptoms in patients with diaphragm paralysis include: shortness of breath with exertion and/or when supine, increased fatigue, loss of energy, gastrointestinal reflux and bloating (left-sided paralysis), and sleep disturbances. There are several etiologies that have been described, most relating to surgical, anesthetic, or chiropractic complications in the neck and/or chest [1–8]. Traumatic events that cause a traction-type injury – when the neck is jolted in an opposite direction from the shoulder and arm – has been implicated as a cause of diaphragm paralysis, although is more commonly associated with injury to the brachial plexus [9].

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