Surgical treatment of diaphragmatic eventration caused by phrenic nerve injury in the newborn

doi:10.1016/S0022-3468(98)90325-6

Journal of Pediatric Surgery

Volume 33, Issue 4, April 1998, Pages 602-605

https://doi.org/10.1016/S0022-3468(98)90325-6 Get rights and content

Abstract

Background: Phrenic nerve palsy in infants and young children usually results from birth injury or iatrogenic damage. The newborn almost invariably presents with severe respiratory distress, diaphragmatic elevation, and paradoxical movement at the affected side.

Methods/Results: In this retrospective analysis a group of 23 patients below the age of 1 year with an obstetric or postoperative phrenic nerve injury was studied and compared with cases in the literature. All patients were admitted between 1986 and 1997 to the Pediatric Surgical Center, Amsterdam. Thirteen of 18 patients with an obstetric phrenic nerve injury underwent plication of the diaphragm after an average observation period of 100 days. In the remaining five children with an obstetric phrenic nerve injury, spontaneous recovery appeared within 1 month. Only one of five patients with a phrenic nerve palsy after a cardiac surgical procedure underwent plication of the diaphragm. Fifteen of the 34 patients described in the literature underwent plication of the diaphragm after an average of 54 days.

Conclusions: If after 1 month no spontaneous recovery of the diaphragmatic paralysis caused by a phrenic nerve injury occurs, plication of the diaphragm is indicated. This operation proved to be successful for relief of symptomatic phrenic nerve injury in all cases. If the condition of the patient clinically deteriorates during this first month of life, the patient should be operated on immediately.

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Cited by (64)

Anatomic Disorders of the Chest and Airways
2023, Avery's Diseases of the Newborn
The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working toward a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, congenital pulmonary airway malformations (CPAMs), congenital diaphragmatic hernia (CDH), and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made surgical intervention on the infant airway and chest less invasive and more tolerable.
Experimental Study of Nerve Transfer to Restore Diaphragm Function
2020, World Neurosurgery
Diaphragmatic paralysis after phrenic nerve injury is an infrequent but serious condition. The destruction of respiratory function after unilateral phrenic nerve injury has been the subject of many investigations.
In this study, we used a rat model of complete paralysis of the unilateral diaphragm to observe changes in pulmonary function.
We found in young rats with complete paralysis of the unilateral diaphragm, the vital capacity and total lung capacity show compensation after 4 weeks, and contralateral phrenic nerve transfer can enhance pulmonary function. However, in the aged rats, respiratory function parameters do not show compensation until 16 weeks after injury.
These findings suggest that contralateral phrenic nerve end-to-side anastomosis is a promising therapeutic strategy. In general, our results suggest that this surgical method may hold great potential to be a secure, feasible, and effective technique to rescue diaphragmatic function.
Diaphragmatic paralysis after phrenic nerve injury in newborns
2020, Journal of Pediatric Surgery
Citation Excerpt :
The majority of those cases (12 of 13) were performed after 30 days of life. Based on this cohort, these authors advocated observation for the first 30 days of life to ensure the baby would not spontaneously recover before an operative intervention [15]. In contrast, Stramrood et al. performed 80% of surgical plications before 30 days of life and found earlier plication yielded better respiratory outcomes than plication after 30 days [16].
Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied.
Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded.
A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7–95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6–180) and 15 (4–132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation.
Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45 days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP.
Retrospective Comparative Study.
Level III.
Delivery room emergencies due to birth injuries
2019, Seminars in Fetal and Neonatal Medicine
Delivery room emergencies due to birth injuries are serious, usually unexpected, and can be distressing situations that necessitate immediate action to reduce neonatal morbidity and prevent neonatal mortality. Birth injuries requiring immediate, urgent care in the delivery room are uncommon, hence knowledge of obstetric risk factors and prenatal conditions linked to birth injury is an important first step in the management of affected neonates. Furthermore, immediate recognition of injury and quick action upon delivery is essential in order to achieve the best possible outcomes. This chapter briefly reviews the known risk factors associated with birth injury, and then discusses the identification and management of specific injuries that may require immediate treatment in the delivery room, or hasty management within hours after birth.
Injuries of Extracranial, Cranial, Intracranial, Spinal Cord, and Peripheral Nervous System Structures
2018, Volpe's Neurology of the Newborn
This chapter is focused on injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures, with emphasis on those disorders that appear to be related primarily to mechanical trauma. Extracranial hemorrhage consists of three major lesions: caput succedaneum, subgaleal hemorrhage, and cephalhematoma. These lesions are generally not serious, except for several uncommon complications. Skull fracture, the principal bony lesion of the newborn, may be linear, be depressed, or consist of occipital osteodiastasis. Intracranial hemorrhage, not unexpectedly, may result from mechanical factors, although among all types of intracranial hemorrhage, trauma per se is a prominent pathogenetic factor principally only for epidural and some cases of subdural hemorrhage. Subdural hemorrhage is discussed in Chapter 22. Spinal cord injury is the most serious CNS parenchymal lesion related primarily to mechanical factors. Two major sites of injury are upper to mid-cervical, occurring mainly in cephalic deliveries and relating primarily to torsional factors, and lower cervical to upper thoracic, occurring mainly in breech deliveries and relating primarily to longitudinal or lateral tractional factors. MRI has proven valuable for both diagnosis and prognosis. Improvements in obstetrical practice have led to declines in incidence. Management is difficult, but new pharmacological, cellular, and rehabilitative interventions are on the horizon. Traumatic injury to peripheral nervous system structures is particularly dominated by brachial plexus injury. The mechanical forces underlying most cases are usually some combination of exogenous factors, such as downward lateral traction involving delivery of the head in a breech delivery or of the shoulder in cephalic deliveries and endogenous factors, such as very strong maternal expulsion forces. Other injuries to peripheral nervous system structures individually are uncommon but collectively are relatively common.
Congenital diaphragmatic eventration in children: 12 years' experience with 177 cases in a single institution
2015, Journal of Pediatric Surgery
Citation Excerpt :
The typical clinical manifestations may lead to the diagnosis of CDE, which is often confirmed by chest x-ray and fluoroscopy. The symptomatic CDE in children usually requires surgical treatment [5,15–18]. Indications for surgery include: (1) rapid breathing without improvement under a conservative treatment; (2) two or more recurrent ipsilateral pneumonias; (3) one life-threatening pneumonia; (4) inability to wean from mechanical ventilation; (5) respiratory distress related to paradoxical motion of the diaphragm.
This study sought to summarize the diagnostic and treatment aspects of congenital diaphragmatic eventration (CDE) in children by retrospectively analyzing their medical records to identify and understand the complications of CDE, its treatment, and to evaluate the long-term outcomes of diaphragmatic plication.
The medical records of children who received treatment for CDE from January 2000 to December 2011 at the Children's Hospital of Chongqing Medical University, China were analyzed. Data analyzed included the following: age, sex, symptom, location of eventration, associated anomalies, surgical procedures, complications, and survival and follow up details after diaphragmatic plication.
The medical records of 177 children (boys: 128, girls: 49, mean age: 10.28 ± 2.35 months) with CDE were included in this study. Specific symptoms of eventration of the diaphragm were reported for 86 cases; and the typical symptoms included rapid breathing, vomiting, and recurrent respiratory infections. Except for a bilateral case, all the other patients had unilateral CDE. Associated malformations were observed in 31 cases (17.5%), hypoplastic lung (10 cases) was the most common followed by congenital heart disease (9 cases), and cryptorchidism (3 cases). Interestingly, 91 patients were asymptomatic. Diaphragmatic plication was performed in all symptomatic patients (86 cases, 48.5%) and none had recurrence.
Clinical symptoms of CDE varied in severity, ranging from asymptomatic conditions to life-threatening respiratory distress. Timely accurate diagnosis and treatment of symptomatic CDE could effectively resolve respiratory morbidity and reduce complications. The diaphragm plication surgery provided good results among the study population with no recurrence.

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Surgical treatment of diaphragmatic eventration caused by phrenic nerve injury in the newborn

Abstract

J Pediatr

J Pediatr Surg

J Pediatr Surg

Die Relaxatio diafragmatica im Kindessalter. Angeborene und erworbene Formen

Pädiatr und Pädolog

Geburtstraumatische Parese des Nervus Phrenicus

Acta Paediatr Acad Scient Hung

Phrenic nerve trauma and cardiac surgery

Lancet

Iatrogenic injury to the phrenic nerve in infants and young children

Br J Surg

Phrenic nerve injury in infants and children undergoing cardiac surgery

Br Heart J

Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication

J Pediatr Surg

Chirurgische behandeling van enkelzijdige diafragmaverlamming bij pasgeborenen

Ned Tschr Genees

Aggressive treatment of acquired phrenic nerve paralysis in infants and small children

Ann Thorac Surg

Paralysis of the diaphragm

Am J Dis Child

Ein Falle von Erb'scher Plexuslähmung mit gleich seitiger Sympathicuslähmung

Dtsch Med Wschr