Poster 69 Waiting to Inhale: Electrodiagnosis of A Left Phrenic Nerve Palsy After Chiropractic Cervical Manipulation: A Case Report

Abstract

Disclosures: C. M. Roque-Dang, none. Patients or Programs: A 50-year-old man. Program Description: The patient had presented with the chief complaint of dyspnea for several months. He reported that he had chiropractic treatment for cervicalgia and, on the day after cervical manipulation, developed unexplained dyspnea with mild exertional activities. Due to his worsening symptoms, he terminated his chiropractic visits and was evaluated by his primary care physician and a neurologist. Pertinent radiographic imaging included a SNIFF fluoroscopic examination, which revealed left hemidiaphragmatic paralysis and a chest radiograph that demonstrated an elevated left hemidiaphragm. Based on the patient’s history and radiographic imaging a electrodiagnostic testing was then performed to rule out a left phrenic nerve palsy. Setting: Outpatient private practice office. Results: On motor nerve conduction studies, he was found to have delayed distal latencies of the left phrenic nerve. Electromyography revealed reduced recruitment throughout the left hemidiaphragm, rare spontaneous denervation potentials in the left lateral diaphragm, and complex and nascent polyphasic single motor unit potentials in the left anterior diaphragm. The electrodiagnostic findings were consistent a left phrenic nerve segmental demyelinated injury. We referred the patient to a plastic surgeon, who performed a left phrenic nerve reconstruction. After surgery, the patient had improved respiratory function and activity tolerance. Discussion: A phrenic nerve injury that resulted in symptomatic diaphragmatic paralysis is most commonly associated with cardiothoracic surgery or malignancy. There are only a few cases that report phrenic nerve palsies sustained from chiropractic cervical manipulation. In these isolated reports, electrodiagnosis was not routinely used to detect these lesions. Conclusions: Reported is an unusual case of unilateral phrenic nerve palsy sustained after chiropractic manipulation. Before receiving cervical spine manipulation, patients should be counseled of this possible and serious complication. Electrodiagnostic studies are useful in phrenic nerve injury diagnosis and treatment determination.