title: Intramuscular diaphragmatic stimulation for patients with traumatic high cervical injuries and ventilator dependent respiratory failure: A systematic review of safety and effectiveness.
abstract: BACKGROUND
  Intramuscular diaphragmatic stimulation using an abdominal laparoscopic approach has been proposed as a safer alternative to traditional phrenic nerve stimulation. It has also been suggested that early implementation of diaphragmatic pacing may prevent diaphragm atrophy and lead to earlier ventilator independence. The aim of this study was therefore to systematically review the safety and effectiveness of intramuscular diaphragmatic stimulators in the treatment of patients with traumatic high cervical injuries resulting in long-term ventilator dependence, with particular emphasis on the affect of timing of insertion of such stimulators.
  
  
  METHODS
  The Cochrane database and PubMed were searched between January 2000 and June 2015. Reference lists of selected papers were also reviewed. The inclusion criteria used to select from the pool of eligible studies were: (1) reported on adult patients with traumatic high cervical injury, who were ventilator-dependant, (2) patients underwent intramuscular diaphragmatic stimulation, and (3) commented on safety and/or effectiveness.
  
  
  RESULTS
  12 articles were included in the review. Reported safety issues post insertion of intramuscular electrodes included pneumothorax, infection, and interaction with pre-existing cardiac pacemaker. Only one procedural failure was reported. The percentage of patients reported as independent of ventilatory support post procedure ranged between 40% and 72.2%. The mean delay of insertion ranged from 40 days to 9.7 years; of note the study with the average shortest delay in insertion reported the greatest percentage of fully weaned patients.
  
  
  CONCLUSIONS
  Although evidence for intramuscular diaphragmatic stimulation in patients with high cervical injuries and ventilator dependent respiratory failure is currently limited, the technique appears to be safe and effective. Earlier implantation of such devices does not appear to be associated with greater surgical risk, and may be more effective. Further high quality studies are warranted to investigate the impact of delay of insertion on ventilator weaning.
authors.affiliation: Department of General Surgery, Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Bhavin
authors.initials: B
authors.lastname: Garara
authors.affiliation: Department of General Surgery, Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Alasdair
authors.initials: A
authors.lastname: Wood
authors.affiliation: Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Hani J
authors.initials: HJ
authors.lastname: Marcus
authors.affiliation: Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Kevin
authors.initials: K
authors.lastname: Tsang
authors.affiliation: Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Wilson
authors.affiliation: Department of General Surgery, Imperial College Healthcare NHS Trust, London, UK. Electronic address: mansoor.khan@imperial.nhs.uk.
authors.forename: Mansoor
authors.initials: M
authors.lastname: Khan
mesh_terms: D003131:Combined Modality Therapy; D003964:Diaphragm / Q000294:innervation* / Q000502:physiology* / Q000503:physiopathology; D004599:Electric Stimulation Therapy / Q000379:methods; D006801:Humans; D010791:Phrenic Nerve / Q000293:injuries*; D017410:Practice Guidelines as Topic; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy; D013119:Spinal Cord Injuries / Q000503:physiopathology* / Q000628:therapy*; D015300:Ventilator Weaning
keywords: Cervical spine injury; Diaphragmatic stimulation; Quadriplegia; Respiratory insufficiency; Review; Spinal injuries