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(Chest. 2001;119:638-640.)
© 2001 American College of Chest Physicians

Diaphragmatic Paralysis Following Cervical Chiropractic Manipulation*

Case Report and Review

David J. Schram, MD; William Vosik, MD and David Cantral, MD, FCCP

* From the University of Nebraska Medical Center (Dr. Schram), Omaha, NE; and Good Samaritan Hospital (Drs. Vosik and Cantral), Kearney, NE.

Correspondence to: David J. Schram, MD, Via Christi St. Joseph, 1131 South Clifton, Wichita, KS 67218; e-mail: djschram{at}hotmail.com


   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
This case report documents an uncommon cause of bilateral diaphragmatic paralysis resulting from phrenic nerve injury during cervical chiropractic manipulation. Several months after the initial injury, our patient remains short of breath and has difficulty breathing in the supine position. Other causes of diaphragmatic paralysis and phrenic nerve injury are reviewed.

Key Words: cervical chiropractic manipulation • diaphragm paralysis • phrenic nerve


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Chiropractic manipulation is the most common alternative medical practice in the United States today.1 However, as with most medical treatments, complications can occur. The most serious complications stem from neurologic or vascular compromise. Reports of ischemia or infarction to the vertebrobasilar vascular system are the most commonly reported injuries.2 There are fewer reports of meningeal hematomas,2 myelopathies, radiculopathies, atlantoaxial dislocations,3 cauda equina syndrome,4 5 long thoracic nerve injury,6 and phrenic nerve injury.3 7 8 9

We report a case of phrenic nerve injury and diaphragmatic paralysis due to chiropractic manipulation. Five other case reports of phrenic nerve injury and resultant diaphragmatic paralysis from cervical chiropractic manipulation were found after a thorough review in MEDLINE (from 1969 to 1999).3 7 8 9 While spinal manipulation is typically accepted as a risk-free procedure by the general public, phrenic nerve injury may result and should be recognized as a potential complication to cervical manipulation.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A previously healthy, nonsmoking, 41-year-old male produce manager sought chiropractic care for pain and stiffness in his neck and shoulders. He stated that the pain developed after sleeping on a sofa while on vacation the previous week. After obtaining neck and chest radiographs, the chiropractor did a number of manipulations that the patient described as forcing his shoulders downward and turning his head laterally. His neck pain and stiffness were slightly relieved immediately after the visit. However, when he went to bed that evening he was unable to breathe in the recumbent position. He was forced to sit up in a recliner in order to breathe and did not sleep the entire night. He returned to his chiropractor the next day with this complaint, and was subsequently transferred to the Good Samaritan Emergency Department for evaluation of his orthopnea.

Evaluation showed a slightly tachypneic patient with diminished breath sounds bilaterally, right more than left. In the upright position, respirations were normal. However, in the supine position, the patient immediately complained of severe dyspnea and exhibited thoracoabdominal paradoxical breathing and the use of accessory muscles of respiration. The patient did not exhibit any other abnormalities, including the results of a neurologic examination, and gave no significant medical history.

The chest radiograph demonstrated elevation of the hemidiaphragms with bilateral basilar atelectasis. There were no previous chest radiographs available for comparison. Subsequent fluoroscopy of the diaphragms demonstrated very minimal excursion of both the left and right diaphragm, with no paradoxical motion identified with the sniff test. Arterial blood gas values obtained in the sitting position at presentation were pH of 7.35; PCO2, 46 mm Hg; PO2, 60 mm Hg; and HCO3, 25.4 mEq/L. Pulmonary function tests also obtained in the sitting position showed an FVC of 1.65 L (38% of predicted), FEV1 of 1.26 (35%), and FEV1/FVC of 92% consistent with a restrictive lung process.

A cervical spine radiograph was unremarkable. CT of the chest demonstrated small lung volumes with basilar atelectasis without mediastinal or hilar masses. MRI showed bony stenosis of the right neural foramen and dural sac at C3-C4 that was not believed to be clinically significant, with no other abnormalities. Results of chemical profile, ECG, serial creatinine phosphokinase, thyroid-stimulating hormone, and echocardiogram were all normal.

The clinical and radiographic findings supported the diagnosis of bilateral diaphragmatic paralysis secondary to his recent chiropractic manipulation. The patient’s functional status remained unchanged for the remainder of his hospital stay. During hospitalization, he was administered nasal mechanical ventilation from 10 PM to 5 AM. Ten months after the initial injury, the patient continues to have difficulties with shortness of breath on exertion and breathing in the supine position. Further follow-up at another institution specializing in pulmonary medicine has not revealed any other diagnosis nor any improvement in his pulmonary function tests or clinical status.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
When bilateral phrenic nerve paralysis occurs, it usually causes severe morbidity in adults. Most cases of either unilateral or bilateral paralysis are due to thoracic surgery or intrathoracic malignancy, but can also stem from trauma, neuromuscular disease, or various inflammatory conditions,10 such as pleurisy, pneumonia, or herpes zoster infection.11 Diaphragmatic paralysis is much more common than clinically recognized,12 and the etiology remains unidentified in more than two thirds of cases.13 14

Chiropractic manipulation is a relatively uncommon cause of traumatic injury to the phrenic nerve, and the actual incidence is unknown. Other more commonly recognized causes include penetrating injury to the thorax or neck,12 blunt trauma to the chest,15 jugular or subclavian catheterization,16 or birth trauma.17 Compression or destruction of the phrenic nerves by cervical osteoarthritis, aortic aneurysm, substernal thyroid, and bronchogenic or mediastinal tumors may also cause diaphragmatic paralysis.10 All reported cases of diaphragmatic paralysis associated with chiropractic manipulation result from stretching or compression of the phrenic nerve by the manipulative force. In cervical strain, forced flexion or rotation of the occiput toward a fixed depressed shoulder can cause a stretch (traction) injury to the cervical plexus and result in phrenic nerve paralysis.12

Patients with diaphragmatic paralysis typically present as our patient did, with elevation of one or both hemidiaphragms, dyspnea, orthopnea, and pulmonary function tests that show a restrictive process.10 15 18 Patients’ symptoms with bilateral diaphragmatic paralysis universally worsen in the supine position. In the upright position, the weight of the abdominal contents tends to prevent excessive paradoxical motion and cephalad displacement of the diaphragm caused by the action of the intercostal and accessory muscles during maximal inspiration. When these patients are in the supine position, this protective mechanism is lost, and patients have a marked reduction in vital capacity.10 18

Of the five previously reported cases of diaphragmatic paralysis following chiropractic manipulation, three involved unilateral phrenic nerve injury7 9 and two involved bilateral injury.3 8 Descriptions of the manipulative maneuvers were not given. Symptoms of bilateral injury usually occur immediately after manipulation, while symptoms in unilateral paralysis develop over days to years. Our patient with bilateral paralysis did not develop symptoms immediately, but rather, several hours later.

The prognosis of bilateral diaphragmatic paralysis depends on the underlying process. When the nerve injury is not due to a progressive, generalized neuropathic disease, recovery may take place over months to years.10 12 15 Only one patient of the five published cases of phrenic nerve injury secondary to cervical manipulation was followed long enough to see a change in his condition. In 3 years, he experienced gradual improvement in his symptoms, vital capacity, and transdiaphragmatic pressures.8

Although uncommon, diaphragmatic paralysis from phrenic nerve injury can be a complication of cervical chiropractic manipulation. We publish this case and information obtained from our literature search to increase awareness of this potential complication. In all cases of idiopathic phrenic nerve paralysis, we recommend taking a careful history about previous chiropractic manipulation.

Received for publication January 31, 2000. Accepted for publication July 17, 2000.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Kaptchuck, TJ, Eisenberg, DM (1998) Chiropractic origins, controversies, and contributions. Arch Intern Med 158,2215-2224[Abstract/Free Full Text]
  2. Lee, PK, Carlini, WG, McCormick, GF, et al (1995) Neurological complications following chiropractic manipulation: a survey of California neurologists. Neurology 45,1213-1215[Abstract]
  3. Tolge, C, Iyer, V, McConnell, J (1993) Phrenic nerve palsy accompanying chiropractic manipulation of the neck. South Med J 86,688-689[CrossRef][ISI][Medline]
  4. Malmivaara, A, Pohohjola, R (1982) Cauda equina syndrome caused be chiropraxis in a patient previously free of lumbar spine symptoms. Lancet 2,986-987
  5. Gallinaro, P, Cartesegna, M (1983) Three cases of lumbar disc rupture and one of cauda equina syndrome associated with spinal manipulation (chiropraxis) [abstract]. Lancet 1,411
  6. Oware, A, Herskovitz, S, Berger, AR (1995) Long thoracic nerve palsy following cervical chiropractic manipulation [abstract]. Muscle Nerve 18,1351[ISI][Medline]
  7. Heffner, JE (1985) Diaphragmatic paralysis following chiropractic manipulation of the cervical spine. Arch Intern Med 145,562-563[Abstract]
  8. Pandit, A, Kalra, S, Woodcock, A (1992) An unusual cause of bilateral diaphragmatic paralysis. Thorax 47,201[Abstract]
  9. Sivakumaran, P, Wilsher, M (1995) Diaphragmatic palsy and chiropractic manipulation. N Z Med J 108,279-280
  10. Nadel, JF Murray, JF eds. Respiratory medicine 2nd ed. 1994,2495-2499 W.B. Saunders Philadelphia, PA.
  11. Stowasser, M, Cameron, J, Oliver, WA (1990) Diaphragmatic paralysis following cervical herpes zoster. Med J Aust 153,555-556[Medline]
  12. Iverson, LI, Mittal, A, Dugan, DJ, et al (1976) Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Am J Surg 132,263-269[CrossRef][Medline]
  13. Piehler, JM, Pairolero, PC, Bracey, DR, et al (1982) Unexplained diaphragmatic paralysis: a harbinger of malignant disease? J Thorac Cardiovasc Surg 84,861-864[Abstract]
  14. Baum, GL, Crapo, JD, Celli, BR, et al (1998) Pulmonary diseases 6th ed. ,1185-1188 Lippincott-Raven Philadelphia, PA.
  15. Sandham, JD, Shaw, DT, Buenter, CA (1977) Acute supine respiratory failure due to bilateral diaphragmatic paralysis. Chest 72,96-98[Abstract/Free Full Text]
  16. Drachler, DH, Koepke, JG, Weg, JG (1976) Phrenic nerve injury from subclavian vein catheterization: diagnosis by electromyography. JAMA 236,2880-2881[CrossRef][Medline]
  17. Aldrich, TK, Herman, JH, Rochester, DF (1980) Bilateral diaphragmatic paralysis in the newborn infant. J Pediatr 97,988-991[CrossRef][Medline]
  18. Kreitzer, SM, Feldman, NT, Saunders, NA, et al (1978) Bilateral diaphragmatic paralysis with hypercapnic respiratory failure. Am J Med 65,89-95[ISI][Medline]




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