An 82-year-old man presented to the emergency department with chief complaint of nonproductive cough, chest congestion, subjective fevers, hoarseness, and shortness of breath on ambulation for 2 days. He had chronic mild neck pain, which had been treated conservatively for the past 10 years. The patient had a history of 35 pack-years of smoking, which was discontinued 30 years prior to presentation. His medical history included hypertension, type II diabetes mellitus, and peripheral vascular disease with claudication, benign prostatic hypertrophy, colonic polyps, and multifocal osteoarthritis.\nOn examination, the patient had a grade 3/6 systolic murmur and decreased breath sounds at the bases bilaterally. Additionally the patient noted a 6-month history of unstable gait and loss of hand dexterity as well as bilateral upper extremity numbness and pain. Spine examination revealed decreased cervical range of motion. Neurologic examination revealed diffuse upper extremity weakness and hyperreflexia in the upper and lower extremities. He had negative Hoffman and Babinski signs. He then underwent an extensive metabolic workup, which revealed an elevated white blood cell count, elevated troponins, hyponatremia, and elevated blood glucose. Auxiliary tests included an abnormal electrocardiogram as well as elevated right hemidiaphragm with full inspiration on chest radiograph.\nThe patient was admitted to the hospital with persistent dyspnea. On hospital day 3, he underwent cardiac catheterization, which revealed extensive stenosis of the major coronary arteries, which was believed to be the main cause of his dyspnea. On hospital day 5, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. He continued to complain of chest discomfort as well.\nMagnetic resonance imaging (MRI) and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia (\n). The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft (\n). Lateral mass screws were utilized in the subaxial spine and pedicle screws were utilized at C2. Dome laminectomy was performed at C2. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. At 12-month follow-up, the patient was ambulating well and had improved neck pain. The dyspnea was completely resolved. His neck disability index had improved from 38% preoperatively to 30% at 1-year follow-up. The patient's chest X-rays showed that the right hemidiaphragm returned to its normal position.
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.