Phrenic paresis—a possible additional spinal cord dysfunction induced by neck manipulation in cervical spondylotic myelopathy (CSM): A report of two cases with anatomical and clinical considerations

Abstract

The clinical records of two male subjects with severe cervical spondylotic myelopathy (CSM) who developed respiratory insufficiency after the cervical manipulation involved in preoperative anesthetic intubation were examined. Their cervical imaging was analyzed with respect to the known anatomic relationships of the spinal phrenic nerve nuclei to the spondylotic compressive lesions in an attempt to provide the anatomic and pathologic rationales that may explain this phrenic paresis as a possible traumatic complication of severe CSM. Perusal of extant literature revealed extensive descriptions of CSM symptoms, but none had previously reported an associated neuromuscular weakness of the diaphragm. Magnetic resonance imaging analyses indicated that the existing degree of upper cervical cord compression, when reinforced by the additional posterior and anterior pressures consequent to cervical spinal extension and flexion, could readily account for the functional impairment of phrenic nerve neuron cells and/or their efferent fibers. Thus, the anatomic relations of the phrenic nerve nuclear columns and their efferent tracts predispose them to interference by compressive lesions found in CSM, and undue manipulation of the cervical spine when advanced stenosis is known to be present should be recognized as a possible cause of cervical spondylotic myelopathic-phrenic paresis.

Iatrogenic spinal cord injury: an observational study

“…20 Physical therapy: manipulation. 21 Our working hypothesis focuses on the perception that lately, there has been an increase in the incidence of SCI due to iatrogenic causes.…”

Dyspnea as the Presenting Symptom of Cervical Spondylotic Myelopathy

“…Parke and Whalen described two patients with severe CSM who developed respiratory insufficiency related to phrenic paresis after undue cervical manipulation. 6 Merino-Ramírez et al also reported two asthmatic patients who developed unilateral diaphragmatic paralysis from phrenic nerve injury, in one case after cervical chiropractic manipulation and in the second after a motorcycle incident. 7 …”

Resolution of Right Hemidiaphragm Paralysis following Cervical Foraminotomies

“…Acute dyspnoea secondary to diaphragmatic paralysis can also occur following minor cervical trauma. Parke and Whalen described two patients with severe cervical myelopathy who developed respiratory insufficiency related to phrenic nerve palsy after cervical manipulation [ 2 ]. Merino-Ramirez et al also reported on two patients who developed hemidiaphragm paralysis, one after chiropractic cervical manipulation and the other following a motorcycle accident [ 3 ].…”