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.
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.