A 64-year-old man was referred to the orthopaedic service with right hemidiaphragm paralysis. He had initially presented to his general practitioner reporting subjective shortness of breath after stand-up paddleboarding. His past medical history was significant for asbestos exposure and polio. Chest radiograph revealed an elevated right hemidiaphragm (Figures and ). A previous chest radiograph taken five years before showed normal diaphragmatic contours. He was subsequently referred to the respiratory physicians where workup included a chest CT scan (which revealed no intrathoracic abnormality) and dynamic fluoroscopic sniffing test (which confirmed complete right hemidiaphragm paralysis). He reported innocuous injuries to his neck in the past and intermittent neck pain for which he had previously consulted both a chiropractor and an osteopath. An MRI scan was undertaken which showed right-sided cervical foraminal stenosis (with uncovertebral and facet joint osteophytic changes at C3/4 and C4/5) (). He was therefore referred to the orthopaedic service. On examination, he had no focal cervical spine tenderness with a well-preserved range of motion. He did have some generalized right shoulder girdle and upper limb wasting and weakness compared to the left (presumed to be secondary to his postpolio syndrome). His upper limb reflexes were intact and symmetrical with the contralateral side.\nThe underlying cause for his hemidiaphragm paralysis, whether it was related to his cervical foraminal stenosis or postpolio syndrome, was indeterminant ().\nAfter obtaining multiple subspecialist opinions, a decision was made to proceed with posterior right C3/4 and C4/5 foraminotomies accepting that this may not have any effect on his shortness of breath. Surgery proceeded uneventfully as did postoperative recovery. By three months postoperatively, his hemidiaphragm paralysis had completely resolved on chest radiograph, and his shortness of breath had also improved (). Comparison of preoperative and postoperative spirometry lung function showed significant improvements in all parameters tested: increases in FVC from 3.88L to 4.86L, FEV1 from 2.44L to 3.13L, TLC from 5.11L to 7.65L, FRCpl from 2.61 to 3.63, and RV from 1.23L to 2.58L. A graphic representation of these findings is shown in . A satisfactory outcome was thus achieved.
A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.