Hernández-López GD, Escobar-Ortiz D, Alva-Arroyo NV, Elizalde-Martínez E, Moheno-Gallardo AJ

Language: Spanish
References: 21
Page: 148-157
PDF size: 250.99 Kb.

ABSTRACT

Introduction: the diaphragm is responsible for performing from 60 to 80% of the inspiratory effort. It shows bilateral innervation from the cervical plexus through two phrenic nerves that are formed from C3 to C5 roots (C4 probably to a greater extent). Involvement of diaphragmatic muscles or the phrenic nerve can cause diaphragmatic dysfunction. Our objective is to establish the incidence of diaphragmatic dysfunction in patients with cervical spondylotic myelopathy (CSM) and to analyse the relationship between this and the degree of involvement of the disease. Material and methods: a prospective study of 35 patients with cervical spondylotic myelopathy in the first 48 hours of the immediate postoperative period. Demographic and clinical factors were recorded. A diaphragmatic ultrasound was performed for the diagnosis of diaphragmatic dysfunction by means of the thickening fraction, during normal breathing and after forced inspiration. Diaphragmatic dysfunction was considered as a thickening fraction lower than 20%. The appearance of respiratory symptoms, clinical outcomes and mortality were recorded. A bivariate and multivariate statistical analysis was designed to relate the incidence of respiratory involvement with the diagnosis of diaphragmatic dysfunction and with the main clinical determinants. Results: when comparing the lesion level with the fraction of thickening < 20%, only 3 of the 35 patients had thickening < 20%. The level of affection was: C3-C7 1 (2.8%), C3-T1 1 (2.8%), C5-C6 1 (2.8%), with a p = 0.155 without statistical significance. For the description of the variables, absolute and relative frequency expressed as a percentage was used for the qualitative variables. For quantitative variables, the mean was calculated with its standard deviation (SD) or median and the interquartile range (difference between the third and first quartile) according to its distribution. 91.4% (32 cases) of these patients did not develop symptoms of severe respiratory compromise during the study period. Conclusions: diaphragm dysfunction is probably underdiagnosed but should not be overlooked as it can be associated with important clinical consequences. Identifying its origin and treating its symptoms requires a thorough examination. Considering its potential clinical implications, studies are required to evaluate the incidence of respiratory complications in these patients, as well as the impact of respiratory rehabilitation in the clinical prognosis. Ultrasound is a simple and effective means of routinely evaluating diaphragm function.

REFERENCES

1. McCormick JR, Sama AJ, Schiller NC, Butler AJ, Donnally CJ 3rd. Cervical spondylotic myelopathy: a guide to diagnosis and management. J Am Board Fam Med. 2020; 33: 303-313.

2. Lebl DR, Bono CM. Update on the diagnosis and management of cervical spondylotic myelopathy. J Am Acad Orthop Surg. 2015; 23: 648-660.

3. Jawad ZY, Hamdan FB, Nema IS. Neurophysiologic evaluation of patients with cervical spondylotic myelopathy. Egypt J Neurol Psychiatry Neurosurg. 2022; 58: 166.

4. Park HY, Kim KW, Ryu JH, Lim CR, Han SB, Lee JS. Cervical foraminal stenosis causing unilateral diaphragmatic paralysis without neurologic manifestation: a case report and review of the literature. Medicine (Baltimore). 2020; 99: e21349.

5. Vieira Santana P, Zumpano Cardenas L, Pereira de Albuquerque AL, Ribeiro de Carvalho CR, Caruso P. Diaphragmatic ultrasound: a review of its methodological aspects and clinical uses. J Bras Pneumol. 2020; 46: e20200064.

6. Ricoy J, Rodríguez-Núñez N, Álvarez-Dobaño JM, Toubes ME, Riveiro V, Valdés L. Diaphragmatic dysfunction. Pulmonology. 2019; 25: 223-235.

7. Scarlata S, Mancini D, Laudisio A, Incalzi AR. Reproducibility of diaphragmatic thickness measured by M-mode ultrasonography in healthy volunteers. Respir Physiol Neurobiol. 2019; 260: 58-62.

8. Dubé BP, Dres M. Diaphragm dysfunction: diagnostic approaches and management strategies. J Clin Med. 2016; 5: 113.

9. Demoule A, Jung B, Prodanovic H, Molinari N, Chanques G. Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact - a prospective study. Am J Respir Crit Care Med. 2013; 188: 213-219.

10. Catalá-Ripoll JV, Monsalve-Naharro JÁ, Hernández-Fernández F. Incidence and predictive factors of diaphragmatic dysfunction in acute stroke. BMC Neurol. 2020; 20: 79.

11. McCool FD, Manzoor K, Minami T. Disorders of the diaphragm. Clin Chest Med. 2018; 39: 345-360.

12. Kokatnur L, Rudrappa M. Diaphragmatic palsy. Diseases. 2018; 6: 16.

13. Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T. Ultrasound imaging for diaphragm dysfunction: a narrative literature review. J Cardiothorac Vasc Anesth. 2019; 33: 3054-3067.

14. Ramzy EA, Mostafa MA. Diaphragm ultrasound as a new functional and morphological index of outcome, prognosis and discontinuation from mechanical ventilation in critically ill patients and evaluating the possible protective indices against VIDD. Egypt J Chest Dis Tuberc. 2017; 66: 339-351.

15. López Escárraga VM, Dubos España K, Castillo Bustos RH, Peidró L, Sastre S, Sala-Blanch X. Diaphragmatic thickness ratio (inspiratory/expiratory) as a diagnostic method of diaphragmatic palsy associated with interscalene block. Rev Esp Anestesiol Reanim. 2018; 65: 81-89.

16. Dass C, Dako F, Simpson S, Marchetti N, Steiner R, Criner G. Sonographic evaluation of diaphragmatic dysfunction: technique, interpretation, and clinical applications. J Thorac Imaging. 2019; 34: S131-S140.

17. Neto Silva I, Duarte JA, Perret A, Dousse N, Wozniak H, Bollen Pinto B, et al. Diaphragm dysfunction and peripheral muscle wasting in septic shock patients: Exploring their relationship over time using ultrasound technology (the MUSiShock protocol). PLoS ONE. 2022; 17: e0266174.

18. Molina Peña ME, Sánchez CM, Rodríguez Triviño CY. Physiopathological mechanisms of diaphragmatic dysfunction associated with mechanical ventilation. Rev Esp Anestesiol Reanim. 2020; 67: 195-203.

19. Badhiwala JH, Wilson JR. The natural history of degenerative cervical myelopathy. Neurosurg Clin N Am. 2018; 29: 21-32.

20. Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018; 360: k186.

21. Zambon M, Greco M, Bocchino S, Cabrini L, Beccaria PF, Zangrillo A. Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound: a systematic review. Intensive Care Med. 2017; 43: 29-38.