An Unusual Cause of Dyspnea in a 77-Year-Old Man

Daniil, Zoe; Malagari, Katerina; Zakynthinos, Epaminondas; Kapotsis, G.E.; Roussos, Charis; Papiris, Spyros A.

doi:10.1378/chest.125.2.770

Cited by 10 publications

(5 citation statements)

References 5 publications

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“…The phrenic nerve arises from the anterior rami of C3 to C5 spinal nerves. While phrenic nerve dysfunction has been previously reported following myelopathy and anterior horn cell damage from cervical spondylosis, our patient had no evidence of spinal cord damage and the phrenic neuropathy was from bilateral nerve root compression at C3 to C5 [ 2 , 3 ]. Bilateral phrenic neuropathy from cervical spondylosis is a rare cause of diaphragmatic weakness and respiratory failure with only sporadic case reports [ 4 ].…”

Section: Discussionmentioning

confidence: 68%

Osteoarthrosis causing altered mental status: a case report

Reddy

2014

J Med Case Reports

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IntroductionCervical spondylosis as a cause of diaphragmatic weakness is an uncommon entity and has been reported primarily in the setting of cervical spinal cord compression. Cervical spondylosis most often causes respiratory failure from cervical myelopathy and damage to the ventral horn cells at spinal cord segments C3 to C5 from where the phrenic nerve arises. The manifestations are variable but there may be evidence of upper motor neuron signs and neurological deficits in the lower extremities along with Lhermitte’s sign. Here we report a rare case of cervical spondylosis causing phrenic nerve root compression from foraminal narrowing at C3, C4 and C5, leading to lower motor neuron paralysis of the phrenic nerve and respiratory failure, in the absence of spinal cord involvement.Case presentationAn 87-year-old Caucasian man presented with recurrent episodes of hypercapnic respiratory failure and altered mental status requiring intubation. He was noted to have neurological deficits in his upper extremities with C5 radiculopathy deficits. An arterial blood gas showed a normal alveolar-arterial oxygen gradient with chronic respiratory acidosis, and pulmonary function testing showed restrictive lung mechanics with weakened neuromuscular apparatus and low maximum inspiratory and expiratory pressures. An extensive workup including electromyogram and magnetic resonance imaging showed evidence of phrenic neuropathy secondary to C3 to C5 neural foramina compression, from cervical spondylosis. He was treated conservatively with night-time bilevel positive airway pressure which rested his respiratory musculature with significant improvement.ConclusionsCervical spondylosis leading to phrenic nerve root compression is a rare and underreported cause of chronic respiratory acidosis and must be considered in the differential diagnosis of chronic hypoventilation, particularly in the elderly. This case illustrates how a simple arterial blood gas and calculation of the alveolar-arterial oxygen gradient can help in the workup of chronic respiratory acidosis by identifying causes of hypoventilation, which are associated with a normal diffusing lung capacity and thereby a normal alveolar-arterial oxygen gradient.

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Section: Discussionmentioning

confidence: 68%

Osteoarthrosis causing altered mental status: a case report

Reddy

2014

J Med Case Reports

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“…Dyspnea is an extremely rare symptom in cervical spondylosis, making it difficult to diagnose alone. To our best knowledge, only 10 cases of phrenic nerve palsy associated with cervical spondylotic radiculopathy exist, including the present case [2][3][4][5][6][7][8][9][10] (Table 1), with nearly the same number of case reports associated with cervical myelopathy, [11][12][13][14][15][16][17][18][19] and some case series showed a declined respiratory function in cervical myelopathy. 20,21) Diagnosis of dyspnea associated with cervical spondylotic myelopathy is relatively straightforward because canal stenosis is easy to be recognized on radiological…”

Section: Discussionmentioning

confidence: 89%

Dyspnea Associated with Cervical Spondylotic Radiculopathy: A Case Report and Review of Literatures

Takamiya

Seki

Yamazaki

et al. 2021

NMC Case Report Journal

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When a patient presents with dyspnea, most physicians immediately associate it with cardiopulmonary diseases but not with the neurologic ones. Dyspnea due to cervical spondylosis rarely occurs, making it under-recognized. We report a case of a 57-year-old man who complained of dyspnea a month after his traffic accident. Chest X-ray showed a left diaphragm elevation, and cervical computed tomography (CT) revealed foraminal stenoses at C3/4, C4/5, and C5/6 on both sides, especially C3/4 on the left side. Anterior cervical discectomy and fusion at C3/4 and C4/5 were performed via a standard anterior cervical approach. Foraminal stenoses due to osteophyte were found to be more severe in the left side; therefore, thorough foraminotomies were performed. Titanium-coated polyether-ether-ketone (PEEK) cages filled with an artificial bone graft were inserted into both intervertebral spaces. His dyspnea improved immediately after the operation. Postoperative spirometry showed a gradually improving respiratory function. Therefore, cervical spondylosis should be considered to cause dyspnea, although it is an atypical symptom. Considering previous reports, outcomes achieved with surgical treatment were better than that with conservative therapy for cervical spondylotic radiculopathy-related dyspnea.

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“…Decrements of 30-50% in FVC between supine and sitting positions are considered to be sensitive for bilateral diaphragmatic paralysis. 1 The absence of such decrements have a high negative predictive value and, therefore, should form part of a patient's routine work-up.…”

Section: Discussionmentioning

confidence: 99%

An unusual case of orthopnea

Keelan

Kidney²,

Judge

2017

Clinical Medicine

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Bilateral diaphragmatic paralysis is a known cause of respiratory failure. Diagnosis can be difficult, particularly in the acute setting. We present the case of a gentleman diagnosed with bilateral diaphragmatic paralysis secondary to phrenic neuropathy in the setting of cervical spondylosis. KEYWORDS :Cervical spondylosis , diaphragmatic paralysis , orthopnea , phrenic neuropathy Case presentationA 63-year-old man presented to the emergency department with a 2-day history of orthopnea. He reported lifting heavy iron tables 3 days prior to presentation. Bilateral shoulder and neck discomfort were described 1 day prior to the onset of orthopnea. He reported no chest pain, cough, wheeze, sputum, haemoptysis, fevers or ankle oedema. He was a nonsmoker whose past medical history included osteoarthritis, hypercholesterolaemia and hypertension.Cardiovascular and respiratory examinations were normal. Bilateral tenderness of the trapezius muscles was present, increasing with shoulder abduction. No cervical spinal tenderness was evident and neurological examination was normal. Further examination revealed significant positional orthopnea. Differential diagnosisOrthopnea is a common manifestation of pulmonary oedema secondary to left ventricular failure and in those suffering from asthma, neuromuscular disease, sleep apnoea or panic disorders. Given this patient's symptoms of neck and back pain, consideration must be given to neuromuscular pathologies. Initial managementInflammatory markers, troponin, d-dimer and N-terminal pro b-type natriuretic peptide were normal. Electrocardiogram revealed left ventricular hypertrophy, documented as long standing. Initial chest X-rays demonstrated a small left pleural ABSTRACT An unusual case of orthopnea effusion, making assessment of the left hemidiaphragm difficult. A transthoracic echocardiogram was normal. A computerised tomography pulmonary angiogram (CTPA) was performed because of the patient's ongoing symptoms. This required two attempts because of the patient's orthopnea. CTPA showed bibasal atelectasis with no evidence of pulmonary embolism. Diazepam was required to allow for completion of the CTPA and consideration was given to a panic disorder. However, the patient demonstrated no other features in keeping with this.Pulmonary function tests revealed a restrictive pathology with forced expiratory volume at first second (FEV1) of 3.01 L (57% predicted), forced vital capacity (FVC) 3.84 L (60% predicted) and a FEV1/FVC ratio of 78%. Mean inspiratory and expiratory pressures were reduced and a marked decrease in vital capacity was noted with sitting and supine values of 2.13 L and 0.9 L, respectively. Bedside thoracic ultrasonography revealed limited diaphragmatic movement bilaterally. Fluoroscopic sniff test showed reduced maximum inspiratory and expiratory pressures. Chest radiographs completed in both lying (Fig 1 ) and standing (Fig 2 ) positions demonstrated elevated bilateral hemidiaphragms while supine. DiagnosisA presumptive diagnosis of diaphragmatic paralysis was con...

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An Unusual Cause of Dyspnea in a 77-Year-Old Man

Cited by 10 publications

References 5 publications

Osteoarthrosis causing altered mental status: a case report

Osteoarthrosis causing altered mental status: a case report

Dyspnea Associated with Cervical Spondylotic Radiculopathy: A Case Report and Review of Literatures

An unusual case of orthopnea

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