Diaphragmatic Paralysis Research Articles

Low-Volume Targeted Interscalene Brachial Plexus Block in the Emergency Department as a Safer Alternative for Pain Control for Glenohumeral Reduction: A Case Series

BackgroundAcute glenohumeral dislocation is a common emergency department (ED) presentation, however, pain control to facilitate reduction in these patients can be challenging. Although both procedural sedation and peripheral nerve blocks can provide effective analgesia, both also carry risks. Specifically, the interscalene brachial plexus block carries risk of ipsilateral hemidiaphragmatic paralysis due to inadvertent phrenic nerve involvement. There are techniques, however, that the emergency clinician can utilize to reduce these risks and optimize the interscalene brachial plexus block for specific pathologies such as glenohumeral dislocation. Case SeriesWe report three cases of patients who presented to the ED with acute anterior glenohumeral dislocation. Two of the patients had a history of pulmonary disease. In all three cases, targeted low-volume interscalene nerve blocks were performed and combined with systemic analgesia to facilitate successful closed glenohumeral reduction and reduce the risk of diaphragm paralysis. All 3 patients were monitored after the procedure and discharged from the ED. Why Should an Emergency Physician Be Aware of This?Contrary to anesthesiologists who often seek to obtain dense surgical blocks, the goal of the emergency clinician should be to tailor blocks for specific procedures, patients, and pathologies. The emergency clinician can optimize the interscalene brachial plexus block for glenohumeral dislocation by using a low volume (5–10 mL) of anesthetic targeted to specific nerve roots (C5 and C6) to provide effective analgesia and reduce the risk diaphragm involvement.

Unilateral Diaphragm Paralysis Following COVID-19 Infection: A Case Report

We report a patient case of unilateral diaphragm paralysis following COVID-19 infection. A 55-year-old healthy man was infected with SARS-CoV-2 before the availability of a vaccine. He was intubated and pronated for respiratory failure. He experienced new debilitating dyspnea and orthopnea for 6 months after recovery. Dynamic chest radiography demonstrated a new hemidiaphragm paralysis. After surgical plication of the diaphragm, the patient's symptoms resolved. This patient case demonstrates the importance of thorough evaluation for diaphragm paralysis in patients who have suffered COVID-19 infection when there is persistent dyspnea or orthopnea, as well as the neuroinvasive potential of the virus that has yet to be fully explained.

Proof of concept of an accelerometer as a trigger for unilateral diaphragmatic pacing: a porcine model

BackgroundUnilateral diaphragmatic paralysis in patients with univentricular heart is a known complication after pediatric cardiac surgery. Because diaphragmatic excursion has a significant influence on perfusion of the pulmonary arteries and hemodynamics in these patients, unilateral loss of function leads to multiple complications. The current treatment of choice, diaphragmatic plication, does not lead to a full return of function. A unilateral diaphragmatic pacemaker has shown potential as a new treatment option. In this study, we investigated an accelerometer as a trigger for a unilateral diaphragm pacemaker (closed-loop system).MethodsSeven pigs (mean weight 20.7 ± 2.25 kg) each were implanted with a customized accelerometer on the right diaphragmatic dome. Accelerometer recordings (mV) of the diaphragmatic excursion of the right diaphragm were compared with findings using established methods (fluoroscopy [mm]; ultrasound, M-mode [cm]). For detection of the amplitude of diaphragmatic excursions, the diaphragm was stimulated with increasing amperage by a cuff electrode implanted around the right phrenic nerve.ResultsResults with the different techniques for measuring diaphragmatic excursions showed correlations between accelerometer and fluoroscopy values (correlation coefficient 0.800, P < 0.001), accelerometer and ultrasound values (0.883, P < 0.001), and fluoroscopy and ultrasound values (0.816, P < 0.001).ConclusionThe accelerometer is a valid method for detecting diaphragmatic excursion and can be used as a trigger for a unilateral diaphragmatic pacemaker.

Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults.

Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test. Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups. Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity.

Unilateral Diaphragmatic Paralysis After Stereotactic Ablative Radiation Therapy to a Lung Tumor Abutting the Course of the Phrenic Nerve

We present the case of a woman with metastatic adenoid cystic carcinoma who received stereotactic ablative radiation therapy with a total dose of 50 Gy in 4 fractions to 2 lung metastases and developed symptomatic left phrenic nerve injury 2 years after radiation. The maximum dose to the approximate location of the phrenic nerve was 57.7 Gy, which corresponds to a biologically effective dose for late effects (using α/β ratio = 3) of 335.14 Gy. Here, we discuss the case, planning considerations by radiation oncologists and medical physicists, and the multidisciplinary medical management of this patient.

Management of Diaphragmatic Palsy in a Patient with Past History of Cerebrovascular Accident? Case Report

Management of Diaphragmatic Palsy in a Patient with Past History of Cerebrovascular Accident? Case Report

PO-04-060 FOUND WITH SOUND: INTRACARDIAC ECHOCARDIOGRAPHY CORRELATED WITH MEDIUM-OUTPUT PACING TO AVOID PHRENIC NERVE INJURY WITH RIGHT ATRIAL ABLATION

Catheter ablation within the right atrium can be limited by proximity to the phrenic nerve and potential for hemi diaphragmatic paralysis. High output pacing is frequently employed to map phrenic position relative to endocardium, particularly in relation to the superior vena cava and the right superior pulmonary vein. The use of intracardiac echocardiography (ICE) in correlation with lower output pacing to rigorously map the course of the right phrenic nerve along the right atrium has not been previously described. We describe a case of incessant right atrial tachycardia successfully mapped and ablated close to the phrenic nerve using a combination of ICE imaging and medium-output pacing to rigorously map the phrenic nerve. n/a An 18-year-old man with incessant atrial tachycardia was referred for repeat ablation following unsuccessful attempt at ablation at an outside institution. Prior ablation was limited by proximity to the phrenic nerve and transient phrenic nerve palsy with cryoablation at the mid crista terminalis. Epicardial access to deflect the phrenic nerve was anticipated. Atrial tachycardia was mapped endocardially prior to obtaining epicardial access. An ICE catheter was advanced to the SVC and used to identify the phrenic nerve. The course of the phrenic nerve was rigorously mapped with ICE and integrated into the CARTO navigational system (Biosense Webster). Pacing along the course of the phrenic nerve was performed at 10 mA to further refine the course of the phrenic nerve within the SVC and right atrium. Regions in close anatomic proximity to the phrenic nerve with loss of pace-capture correlated with sites of physiologic effusion, where pericardial fluid was concentrated and separation of the phrenic nerve from the visceral epicardium was noted. After mapping the phrenic nerve, endocardial ablation of atrial tachycardia was successfully performed in the absence of phrenic nerve injury without the need for epicardial access. Phrenic nerve injury may be prevented by rigorous mapping of the phrenic nerve within the right atrium using intracardiac ultrasound with medium-output pacing.

Diaphragmatic paralysis associated with IgLON5 autoimmunity (P5-5.022)

<h3>Objective:</h3> To describe a rare presentation of IgLON5 IgG mediated neurological disorder <h3>Background:</h3> IgLON5 autoimmunity was previously described with sleep disorder, rhombencephalopathy, vocal cord paresis, progressive-supranuclear-palsy-like syndrome, and recently motor-neuron-disease (MND)-like syndrome. Although diaphragmatic paralysis has been known as a presenting symptom of degenerative (MND) but has never been reported with IgLON5 autoimmunity. <h3>Design/Methods:</h3> Case report <h3>Results:</h3> A 67-year-old man with obstructive sleep apnea and history of vocal cord paralysis 11 years ago, presented with 2-year history of dream enactment behavior, progressive dyspnea and orthopnea. The symptoms became more noticeable and rapidly progressive in the past 10 months. Initially, he felt shortness of breath during the daytime when he bent over. Within a few months, he had to sleep on the recliner with a minimal tilt back at night. Neurological examination demonstrated moderate right facial weakness, mild weakness of interossei muscles of right hand, and triceps. Deep tendon reflexes were marginally brisk without Babinski sign. Sensory examination was normal. Occasional fasciculation was noted in deltoid region. Right upper extremity electromyography was normal. Diaphragmatic ultrasound showed no diaphragmatic expansion during inspiration. Ultrasound-guided electromyography of diaphragm and phrenic nerve conduction study showed no phrenic nerve response on the right, and markedly reduced amplitude of diaphragmatic compound motor action potential on the left side. Brain MRI and cervical spine was essentially unremarkable. Blood work showed normal vitamin B12, creatinine kinase and monoclonal gammopathy screen. Serological evaluation of neural specific antibodies was remarkable for IgLON5-IgG (titer 1:480). The patient was treated with high-dose methylprednisolone and is scheduled to follow up in autoimmune neurology clinic for outcome assessment. <h3>Conclusions:</h3> IgLON5 autoimmunity should be considered in patients with diaphragmatic paralysis, especially ones with sleep disorder, vocal cord paresis, and episodic respiratory disturbances. <b>Disclosure:</b> Dr. Thakolwiboon has nothing to disclose. Dr. Klein has a non-compensated relationship as a Klein with Neurology Journal that is relevant to AAN interests or activities. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for UCB. The institution of Dr. Dubey has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Astellas. The institution of Dr. Dubey has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Argenx. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for AGRIMS. Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Advances in Neurology . Dr. Dubey has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Moffit Cancer Center . Dr. Dubey has received research support from Department of Defense . Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care. Dr. Dubey has received intellectual property interests from a discovery or technology relating to health care.

A comparison of short-term outcomes following robotic-assisted vs. open transthoracic diaphragm plication.

Diaphragm paralysis and eventration are rare conditions in adults. Symptomatic patients may benefit from surgical plication of the elevated hemidiaphragm. The objective of this study was to compare short-term outcomes and length of stay following robotic-assisted vs. open diaphragm plication. A multicenter retrospective study was conducted that identified patients undergoing unilateral hemidiaphragm plication from 5/2008 to 12/2020. The first RATS plication was performed in 11/2018. Electronic medical records were reviewed, and outcomes were compared between RATS and open approach. One hundred patients underwent diaphragm plication, including thirty-nine (39.0%) RATS and sixty-one (61.0%) open cases. Patients undergoing RATS diaphragm plication were older (64years vs. 55years, p = 0.01) and carried a higher burden of comorbidities (Charlson Comorbidity Index: 2.0 vs. 1.0, p = 0.02). The RATS group had longer median operative times (146min vs. 99min, p < 0.01), but shorter median hospital length of stays (3.0days vs. 6.0days, p < 0.01). There was a non-significant trend toward a decreased rate of 30-day postoperative complications (20.5% RATS vs. 32.8% open, p = 0.18) and 30-day unplanned readmissions (7.7% RATS vs. 9.8% open, p > 0.99). RATS is a technically feasible and safe option for performing diaphragm plications. This approach increases the surgical candidacy of older patients with a higher burden of comorbid disease without increasing complication rates, while reducing length of hospital stay.

Перший досвід імплантації стимулятора діафрагмального нерва в немовляти з білатеральним парезом діафрагми

Phrenic nerve injury is not frequent, but well recognized complication of birth trauma caused by brachial plexus injury. Diaphragmatic paresis is usually unilateral, and cases of bilateral damage are rare. Diaphragmatic paralysis led to development of severe respiratory disorders, which required the prolonged intensive care, often with the applying of mechanical ventilation. Although is it possible the spontaneous restoration the function of the diaphragm, this requires the long-term of respiratory support. The general accepted guidelines of the treatment of infants with paresis/paralysis of diaphragm is absent. Diaphragmatic plication considered as the main surgical method of treatment. By that, diaphragmatic plication not always had a positive effect. The aim of the study was to present new possibility in the treatment of infants with bilateral diaphragmatic paralysis. Clinical case. We presented the first experience of transthoracic implantation of diaphragm pacemaker in infant with bilateral diaphragmatic paralysis. The newborn was hospitalized with the respiratory disorders’ syndrome. The paresis of both hemidiaphragms was reviled on chest X-ray. For 7 months child required the mechanical ventilation, due to unsuccessful attempts to transfer the child to spontaneous breathing caused the decrease of saturation. With the aim to restore spontaneous breathing, the implantation of diaphragm pacemaker, under the thoracoscopic control, was performed initially at the right side and next at the left side. The effectiveness of the treatment was confirmed by the electroneuromyography and ultrasonography. Conclusions. Implantation of the diaphragmatic pacemaker my be the method of treatment in infants with bilateral diaphragmatic paralysis. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Robotic diaphragm plication: functional and surgical outcomes of a single-center experience

BackgroundDiaphragm plication remains the only effective treatment for diaphragm paralysis. Robot-assisted thoracoscopic (RATS) diaphragm plication combines advantages of open and thoracoscopic techniques. We present our experiences focussing on lung-function improvement and surgical outcome.MethodsIn this single-center retrospective study with comparative analysis, perioperative data of all patients who underwent RATS or thoracoscopic (VATS) diaphragm plication between 2015 and 2022 at our institution were assessed. Functional outcome was analysed with pre- and postoperative pulmonary function tests in sitting and supine position.ResultsWe included 43 diaphragm plications, of which 31 were performed via RATS. Morbidity in the RATS- and VATS-cohort were 13 and 8%, respectively (p = 0.64), without any major complication (Clavien-Dindo ≥ III, 0%). Surgical time for RATS diaphragm plication was reduced drastically with a median operating time for the first 16 patients of 136 min (range 84–185) and 84 min (range 56–122) for the most recent 15 patients (p < 0.0001). Pulmonary function testing after RATS-plication showed a mean increase in vital capacity (VC) of 9% (SD 8, p < 0.0001) and of 7% (SD 9, p = 0.0009) in forced expiratory volume in 1 s (FEV1) when sitting and 9% (SD 8, p < 0.0001) for VC as well as 10% (SD 8, p = 0.0001) for FEV1 when in supine position.ConclusionRATS diaphragm plication is a very safe and feasible approach, yielding good results in improving patients’ pulmonary function. Further studies are required to elucidate possible advantages over VATS or open approaches.Graphical abstract

Parsonage-Turner Syndrome Following SARS-CoV-2 Infection: A Systematic Review.

Parsonage-Turner syndrome (PTS) is an inflammatory disorder of the brachial plexus. Hypothesized underlying causes focus on immune-mediated processes, as more than half of patients present some antecedent event or possible predisposing condition, such as infection, vaccination, exercise, or surgery. Recently, PTS was reported following the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to investigate data on PTS triggered by SARS-CoV-2 infection to provide an extensive perspective on this pathology and to reveal what other, more specific, research questions can be further addressed. In addition, we aimed to highlight research gaps requiring further attention. We systematically reviewed two databases (LitCOVID and the World Health Organization database on COVID-19) to January 2023. We found 26 cases of PTS in patients with previous SARS-CoV-2 infection. The clinical and paraclinical spectrum was heterogeneous, ranging from classical PTS to pure sensory neuropathy, extended neuropathy, spinal accessory nerve involvement, and diaphragmatic palsy. Also, two familial cases were reported. Among them, 93.8% of patients had severe pain, 80.8% were reported to present a motor deficit, and 53.8% of patients presented muscle wasting. Paresthesia was noted in 46.2% of PTS individuals and a sensory loss was reported in 34.6% of patients. The present systematic review highlights the necessity of having a high index of suspicion of PTS in patients with previous SARS-CoV-2 infection, as the clinical manifestations can be variable. Also, there is a need for a standardized approach to investigation and reporting on PTS. Future studies should aim for a comprehensive assessment of patients. Factors including the baseline characteristics of the patients, evolution, and treatments should be consistently assessed across studies. In addition, a thorough differential diagnosis should be employed.

Plication for diaphragm paralysis after paediatric cardiac surgery: a single-centre experience.

Diaphragm paralysis is a well-known complication following surgery for CHDs, which increases morbidity, mortality, and length of hospital stay as well as costs. Herein, we present our experience with diaphragm plication following paralysis of the phrenic nerve encountered after paediatric cardiac surgery. This study retrospectively reviewed the medical records of 23 diaphragm plications in 20 patients who underwent paediatric cardiac surgery between January 2012 and January 2022. The patients were carefully selected based on aetiology and a combination of clinical manifestation and chest imaging characteristics including chest X-ray, ultrasonography, and fluoroscopy. Twenty-three successful plications were performed in 20 patients (15 males and 5 females) out of a total of 1938 operations performed in our centre. Mean age and body weight were 18.2 ± 17.1 months and 8.3 ± 3.7 kg, respectively. The period between the cardiac surgery and diaphragmatic plication was 18.7 ± 15.1 days. The highest incidence of diaphragm paralysis was encountered in systemic to pulmonary artery shunt patients with 7 out of 152 patients (4.6%). Any mortality was not encountered during a mean follow-up period of 4.3 ± 2.6 years. Early results of plication of the diaphragm following phrenic nerve palsy in symptomatic patients who underwent paediatric cardiac surgery are encouraging. Evaluation of the diaphragmatic function should be a routine part of post-operative echocardiography. Diaphragm paralysis may be a consequence of dissection, contusion, stretching, and thermal injury both in terms of hypothermia and hyperthermia.

Contemporary Outcomes of Tracheostomy in Patients With Single Ventricle Heart Lesions.

Approximately 0.2% to 2.7% of children with congenital heart disease require a tracheostomy after cardiac surgery with the majority having single ventricle (SV) type heart lesions. Tracheostomy in SV patients is reported to be associated with high mortality. We hypothesized that short- and long-term survival of patients with SV heart disease would vary according to tracheostomy indication. This is a single center, 20-year, retrospective review of all patients with SV heart disease who underwent tracheostomy. Demographic, cardiac anatomy, surgical, intensive care unit, and hospital course data were collected. The primary outcome was survival following tracheostomy. Secondary outcome was the completion of staged palliation to Fontan. In total, 25 patients with SV heart disease who underwent tracheostomy were included. Indications for tracheostomy included one or more of the following: tracheobronchomalacia (n = 8), vocal cord paralysis (n = 7), tracheal/subglottic stenosis (n = 6), primary respiratory insufficiency (n = 4), diaphragm paralysis (n = 3), suboptimal hemodynamics (n = 2), and other upper airway issues (n = 1). Survival at six months, one year, five years, and ten years was 76%, 68%, 63%, and 49%, respectively. Most patients completed Fontan palliation (64%). Patients who underwent tracheostomy for suboptimal hemodynamics and/or respiratory insufficiency had a higher mortality risk compared to those with indications of upper airway obstruction or diaphragm paralysis (hazard ratio 4.1, 95% confidence interval 1.2-13.7; P = .02). Mortality risk varies according to tracheostomy indication in patients with SV heart disease. Tracheostomy may allow staged surgical palliation to proceed with acceptable risk if it was indicated for anatomic or functional airway dysfunction.

Phrenic nerve neurorrhaphy with a sural nerve graft in unilateral diaphragmatic paralysis

Unilateral diaphragmatic paralysis can present following damage or impairment to a phrenic nerve. In cases where current treatment methods are not feasible, the use of a double phrenic nerve neurorrhaphy with an autologous sural nerve graft should be investigated. In preserved rats, the feasibility of this technique was explored. The sural nerve was excised from the left thigh. Entering into the thoracic cavity bilaterally through the fifth intercostal spaces, the right and left phrenic nerves were identified. The right phrenic nerve was cut to create a distal nerve stump. The sural nerve was grafted onto the distal stump of the right phrenic nerve and the side of the left phrenic nerve. Using six preserved rat cadavers, the end-to-side graft was successfully explored and performed. It was determined that approximately 2.5–3 cm of the sural nerve will be required to be harvested for the graft. The sural nerve was an appropriate size for grafting onto the phrenic nerves. Four 10–0 Nylon sutures were sufficient for each neurorrhaphy. A double phrenic nerve neurorrhaphy with an autologous sural nerve graft is potentially feasible in rat models.

Small-Molecule Inhibition of MuRF1 Prevents Early Disuse-Induced Diaphragmatic Dysfunction and Atrophy.

In clinical conditions such as diaphragm paralysis or mechanical ventilation, disuse-induced diaphragmatic dysfunction (DIDD) is a condition that poses a threat to life. MuRF1 is a key E3-ligase involved in regulating skeletal muscle mass, function, and metabolism, which contributes to the onset of DIDD. We investigated if the small-molecule mediated inhibition of MuRF1 activity (MyoMed-205) protects against early DIDD after 12 h of unilateral diaphragm denervation. Wistar rats were used in this study to determine the compound's acute toxicity and optimal dosage. For potential DIDD treatment efficacy, diaphragm contractile function and fiber cross-sectional area (CSA) were evaluated. Western blotting investigated potential mechanisms underlying MyoMed-205's effects in early DIDD. Our results indicate 50 mg/kg bw MyoMed-205 as a suitable dosage to prevent early diaphragmatic contractile dysfunction and atrophy following 12 h of denervation without detectable signs of acute toxicity. Mechanistically, treatment did not affect disuse-induced oxidative stress (4-HNE) increase, whereas phosphorylation of (ser632) HDAC4 was normalized. MyoMed-205 also mitigated FoxO1 activation, inhibited MuRF2, and increased phospho (ser473) Akt protein levels. These findings may suggest that MuRF1 activity significantly contributes to early DIDD pathophysiology. Novel strategies targeting MuRF1 (e.g., MyoMed-205) have potential therapeutic applications for treating early DIDD.

Retrospective evaluation of the effects of traditional interscalene block alone versus combined with superior truncus block-associated diaphragm paralysis during arthroscopic shoulder surgery.

The aim of this study was to investigate the effects of traditional interscalene block (ISB) alone and ISB combined with superior truncus block (STB)-associated diaphragm paralysis evaluated by ultrasound, duration of analgesia, and rate of complication in patients undergoing arthroscopic shoulder surgery. Between January 2020 and December 2022, a total of 285 patients (158 males, 127 females; mean age: 48.0±15.1 years; range, 18 to 80 years) who underwent arthroscopic shoulder surgery under ISB, either alone or combined with STB, were retrospectively analyzed. The patients were operated under ISB alone using 30 mL 0.5% bupivacaine (n=140) or ISB using 10 mL (n=67) or 5 mL 0.5% bupivacaine (n=78) combined with STB using 20 mL 0.5% bupivacaine. Ultrasound reports of all patients' diaphragm function were also retrieved. Duration of analgesia, need for additional analgesics, and the type of analgesic drugs, and evaluations of patient and surgeon satisfactions were evaluated. Degree of diaphragm paralysis considered as complete (≥75%), partial (25.1 to 74.9%) and no paralysis (≤25%) were evaluated for comparison between the block types. The patients underwent operation due to rotator cuff rupture (n=218) or Bankart (n=67). Duration of analgesia, need for additional analgesia, and the type of analgesic drugs used were comparable between the block types. The most common complication was Horner syndrome (n=96, 33.68%) which was significantly lower in ISB (5 mL) +STB (20 mL) than the others (17.9% vs. 41.4% and 37.3%, p=0.002). The ISB (5 mL bupivacaine 0.5%) + STB (20 mL bupivacaine 0.5%) resulted in less complete diaphragm paralysis with adequate surgical anesthesia not requiring general anesthesia. The ISB using 5 mL of 0.5% bupivacaine + STB instead of traditional ISB alone can be preferred due to the low rate of complete hemi-diaphragm paralysis with adequate surgical anesthesia/analgesia and high patient and surgeon satisfaction.

Hepatitis E virus-associated brachial neuritis presenting with orthopnoea as a result of bilateral diaphragmatic weakness

British Journal of Hospital MedicineVol. 84, No. 2 Case ReportHepatitis E virus-associated brachial neuritis presenting with orthopnoea as a result of bilateral diaphragmatic weaknessSamuel Mackrill, Prithwiraj Chakrabarti, Richard Butterworth, Veeresh PatilSamuel MackrillCorrespondence to: Samuel Mackrill; E-mail Address: [email protected]Department of Medicine, Milton Keynes University Hospital, Milton Keynes, UKSearch for more papers by this author, Prithwiraj ChakrabartiDepartment of Medicine, Milton Keynes University Hospital, Milton Keynes, UKSearch for more papers by this author, Richard ButterworthDepartment of Medicine, Milton Keynes University Hospital, Milton Keynes, UKSearch for more papers by this author, Veeresh PatilDepartment of Medicine, Milton Keynes University Hospital, Milton Keynes, UKSearch for more papers by this authorSamuel Mackrill; Prithwiraj Chakrabarti; Richard Butterworth; Veeresh PatilPublished Online:9 Feb 2023https://doi.org/10.12968/hmed.2022.0280AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References McLean BN, Gulliver J, Dalton HR. Hepatitis E virus and neurological disorders. Pract Neurol. 2017;17(4):282–288. https://doi.org/10.1136/PRACTNEUROL-2016-001588 Crossref, Medline, Google ScholarNoushad MA, Limnatitou D, Bhattacharjee S, Mohd Nor A. Diaphragmatic paralysis resulting in respiratory failure as a feature of hepatitis E virus-associated neuralgic amyotrophy. BMJ Case Rep. 2021;14(4):e242113. https://doi.org/10.1136/BCR-2021-242113 Crossref, Medline, Google ScholarShinder N, Polson A, Pringle E, O'Donnell DE. Neuralgic amyotrophy: a rare cause of bilateral diaphragmatic paralysis. Can Respir J. 1998;5(2):139–142. https://doi.org/10.1155/1998/926375 Crossref, Medline, Google Scholarvan Eijk JJJ, Dalton HR, Ripellino P et al.. Clinical phenotype and outcome of hepatitis E virus-associated neuralgic amyotrophy. Neurology. 2017;89(9):909–917. https://doi.org/10.1212/WNL.0000000000004297 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 February 2023Volume 84Issue 2ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 9 February 2023 Published in print 2 February 2023 Information© MA Healthcare LimitedPDF download

Woman with dyspnea after skin rash.

Woman with dyspnea after skin rash.

Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block or interscalene brachial plexus block in clavicle surgery: a single-centre, double-blind, randomized controlled trial

The sensory innervation of the clavicle is complex, and the best regional block technology for clavicular surgery has yet to be determined. The purpose of this study was to compare the application of ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block verses interscalene brachial plexus block in clavicular surgery. Fifty patients undergoing internal fixation surgery for elective clavicle fractures were randomly divided into two groups (n = 25 for each group): group I and group II. Superficial cervical plexus block combined with clavipectoral fascial plane block was used in group I, and superficial cervical plexus block combined with interscalene brachial plexus block was used in group II. The primary outcome measure was the duration of analgesia. The duration of analgesia in group I was significantly longer than that in group II (P < 0.05). The modified Bromage scale function score in group II was lower than that in group I (P < 0.01). There was no significant difference in the skin acupuncture pain score 30 min after block and visual analog scale (VAS) scores at 6 and 12 h after surgery. However, the 24 h VAS score in group I was lower than that in group II (P < 0.05). The incidence of diaphragmatic paralysis was significantly increased in group II (P < 0.01). Ultrasound-guided superficial cervical plexus block combined with clavipectoral fascial plane block can be used for clavicular surgery. It has a long postoperative analgesia time, can retain the motor function of the involved upper limb and does not cause hemidiaphragmatic paresis.Clinical trial number and registry URL: Clinical Trials.gov; Trial registration number: ChiCTR2000039383; Date of registration: 25 October 2020.