title: Diaphragmatic reinnervation in ventilator-dependent patients with cervical spinal cord injury and concomitant phrenic nerve lesions using simultaneous nerve transfers and implantable neurostimulators.
abstract: BACKGROUND
  Patients who are ventilator dependent as a result of combined cervical spinal cord injury and phrenic nerve lesions are generally considered to be unsuitable candidates for diaphragmatic pacing due to loss of phrenic nerve integrity and denervation of the diaphragm. There is limited data regarding efficacy of simultaneous nerve transfers and diaphragmatic pacemakers in the treatment of this patient population.
  
  
  METHODS
  A retrospective review was conducted of 14 consecutive patients with combined lesions of the cervical spinal cord and phrenic nerves, and with complete ventilator dependence, who were treated with simultaneous microsurgical nerve transfer and implantation of diaphragmatic pacemakers. Parameters of interest included time to recovery of diaphragm electromyographic activity, average time pacing without the ventilator, and percent reduction in ventilator dependence.
  
  
  RESULTS
  Recovery of diaphragm electromyographic activity was demonstrated in 13 of 14 (93%) patients. Eight of these 13 (62%) patients achieved sustainable periods (> 1 h/d) of ventilator weaning (mean = 10 h/d [n = 8]). Two patients recovered voluntary control of diaphragmatic activity and regained the capacity for spontaneous respiration. The one patient who did not exhibit diaphragmatic reinnervation remains within 12 months of initial treatment. Surgical intervention resulted in a 25% reduction (p < 0.05) in ventilator dependency.
  
  
  CONCLUSIONS
  We have demonstrated that simultaneous nerve transfers and pacemaker implantation can result in reinnervation of the diaphragm and lead to successful ventilator weaning. Our favorable outcomes support consideration of this surgical method for appropriate patients who would otherwise have no alternative therapy to achieve sustained periods of ventilator independence.
authors: The Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey.
authors: Matthew R
authors: MR
authors: Kaufman
authors: The Center for Treatment of Paralysis and Reconstructive Nerve Surgery, Jersey Shore University Medical Center, Neptune, New Jersey.
authors: Andrew I
authors: AI
authors: Elkwood
authors: The Institute for Advanced Reconstruction, Shrewsbury, New Jersey.
authors: Farid
authors: F
authors: Aboharb
authors: The Institute for Advanced Reconstruction, Shrewsbury, New Jersey.
authors: John
authors: J
authors: Cece
authors: Department of Rehabilitative Medicine, JFK Johnson Rehabilitation Institute, Edison, New Jersey.
authors: David
authors: D
authors: Brown
authors: Division of Plastic and Reconstructive Surgery, David Geffen UCLA Medical Center, Los Angeles, California.
authors: Kameron
authors: K
authors: Rezzadeh
authors: Division of Plastic and Reconstructive Surgery, David Geffen UCLA Medical Center, Los Angeles, California.
authors: Reza
authors: R
authors: Jarrahy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae; D002648:Child; D003131:Combined Modality Therapy; D003964:Diaphragm / Q000294:innervation*; D005260:Female; D006801:Humans; D058542:Implantable Neurostimulators; D008297:Male; D008875:Middle Aged; D016067:Nerve Transfer; D010791:Phrenic Nerve / Q000293:injuries*; D012121:Respiration, Artificial; D012189:Retrospective Studies; D013119:Spinal Cord Injuries / Q000601:surgery*; D015300:Ventilator Weaning; D055815:Young Adult