A 59-year-old man presented with exertional dyspnea that started 1 month earlier. He had undergone wide excision for tongue cancer 6 years ago and no evidence of recurrence was observed.\nA chest radiograph revealed a marked elevation of the right diaphragm compared with the left diaphragm (Fig. A). Chest computed tomography (CT) showed no abnormalities of the mediastinal and chest thorax. In pulmonary function tests using a spirometer, his vital capacity was 3.02 L (68% of predicted), forced vital capacity was 3.17 L (71% of predicted), and forced expiratory volume-1 second was 2.17 L (61% of predicted).\nThe differential diagnosis of unilateral phrenic nerve palsy included thoracic evaluation for lung and mediastinal tumors or infections. Neurologic evaluation for neurodegenerative diseases and imaging studies for recurrent tongue cancer failed to identify the underlying cause. After excluding all possible causes, he was referred for cervical spondylosis evaluation for diaphragmatic paralysis. He did not complain of radiating pain. Motor weakness, sensory changes, and hyperactive deep tendon reflexes were also not observed on neurological examination.\nCervical CT revealed C3–4 and C4–5 foraminal space narrowing due to osteophyte formation (Fig. A) and magnetic resonance imaging (MRI) showed that the C4 root was compressed by a bony spur at the right C3–4 foraminal space (Fig. B). However, spinal cord compression was not prominent on CT and MRI.\nDespite conservative treatment for 1 month, the patient was admitted to the hospital for recurrent fever and dyspnea. Under the diagnosis of hemidiaphragmatic paralysis due to cervical foraminal stenosis, the patient underwent foraminotomies at C3–4 and C4–5 on the right side and the operative findings revealed right C4 root severe compression caused by a bony spur. Foraminal decompression was done until the root passed without resistance.\nThe chest radiograph demonstrated no interval change at 1 postoperative month (Fig. B). At 3 months postoperatively, the chest radiograph revealed a remarkable descent of the right diaphragm compared with the initial radiograph (Fig. A and B). The postoperative CT showed a widening of the foraminal canal compared with the preoperative CT (Fig. ). No dyspnea or pneumonia was observed at the surgical follow-up. The patient has provided informed consent for the publication of this case report and accompanying images.
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.