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 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.