Comprehensive surgical management of the paralyzed diaphragm

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Comprehensive surgical management of the paralyzed diaphragm

  1. 1. Comprehensive Surgical Management of the Paralyzed Diaphragm Matthew R. Kaufman, MD, FACS Plastic & Reconstructive Surgery The Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  2. 2. Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  3. 3. Surgical Management of the Paralyzed Diaphragm <ul><li>No financial disclosures </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  4. 4. Phrenic Nerve Anatomy <ul><li>Originates from C3-C5 </li></ul><ul><ul><li>Primarily C4 </li></ul></ul><ul><li>Motor innervation to diaphragm </li></ul><ul><li>Sensory fibers </li></ul><ul><ul><li>Pleura </li></ul></ul><ul><ul><li>Pericardium </li></ul></ul><ul><ul><li>Abdominal components </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  5. 5. Phrenic Nerve Anatomy Accessory Phrenic Nerve <ul><li>Occurs in 15-25% of people </li></ul><ul><li>A branch of C5 which would otherwise pass to subclavius </li></ul><ul><li>Begins lateral to the phrenic nerve in the neck </li></ul><ul><li>Obliquely traverses scalenus anterior </li></ul><ul><li>Joins the phrenic nerve at the root of the neck </li></ul><ul><li>Also supplies diaphragm with efferent fibers </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  6. 6. Phrenic Nerve Anatomy Accessory Phrenic Nerve Accessory Phrenic Nerve Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  7. 7. Respiratory Physiology <ul><li>Volitional (day time) breathing controlled by respiratory control center </li></ul><ul><li>Night breathing regulated by CO2 levels measured in brain </li></ul><ul><li>Signals go down nerves in the neck, chest to diaphragm </li></ul><ul><li>Phrenic nerve branches out into the diaphragm muscles </li></ul><ul><li>The diaphragm muscles contract drawing in air </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  8. 8. Diaphragm Paralysis Etiology <ul><li>Peripheral </li></ul><ul><li>(Phrenic Nerve Injury) </li></ul><ul><ul><li>Iatrogenic </li></ul></ul><ul><ul><ul><li>Surgery </li></ul></ul></ul><ul><ul><ul><li>Anesthetic Blocks </li></ul></ul></ul><ul><ul><ul><li>Chiropractic </li></ul></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><ul><li>Blunt </li></ul></ul></ul><ul><ul><ul><li>Penetrating </li></ul></ul></ul><ul><ul><li>Neuropathy / Neuritis </li></ul></ul><ul><ul><li>Viral </li></ul></ul><ul><li>Central </li></ul><ul><ul><li>Spinal Cord Injury </li></ul></ul><ul><ul><li>Cord Compression </li></ul></ul><ul><ul><li>Central Hypoventilation Syndrome </li></ul></ul><ul><ul><ul><li>Ondine’s Curse </li></ul></ul></ul><ul><ul><li>Tumors </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  9. 9. Diaphragm Paralysis Phrenic Nerve Injury <ul><li>Demographics </li></ul><ul><ul><li>Usually unilateral </li></ul></ul><ul><ul><li>Rarely ventilator or oxygen dependent </li></ul></ul><ul><ul><li>Severe limitations in physical functioning </li></ul></ul><ul><ul><li>Association with sleep-disordered breathing </li></ul></ul><ul><ul><li>PFTs often normal or near-normal </li></ul></ul><ul><ul><li>Abnormal Sniff Test </li></ul></ul><ul><ul><li>Told by MD: “…just learn to live with it…” </li></ul></ul><ul><ul><li>Some are offered diaphragm plication </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  10. 10. Phrenic Nerve Injury Etiology <ul><li>Iatrogenic </li></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><ul><li>Interscalene Block </li></ul></ul></ul><ul><ul><ul><li>Cervical Epidural </li></ul></ul></ul><ul><ul><ul><li>Neck Dissection </li></ul></ul></ul><ul><ul><ul><li>Carotid Bypass </li></ul></ul></ul><ul><ul><ul><li>Chiropractic Manipulation </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  11. 11. Phrenic Nerve Injury Etiology <ul><li>Iatrogenic </li></ul><ul><ul><li>Mediastinal / Chest </li></ul></ul><ul><ul><ul><li>Carotid-Subclavian Bypass </li></ul></ul></ul><ul><ul><ul><li>Aortic Surgery </li></ul></ul></ul><ul><ul><ul><li>Thymectomy </li></ul></ul></ul><ul><ul><ul><li>Coronary Bypass </li></ul></ul></ul><ul><ul><ul><li>Thoracic Outlet Release </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  12. 12. Phrenic Nerve Injury Mediastinal Surgery <ul><li>Thymectomy </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  13. 13. Ventilator Dependency Diaphragm Paralysis <ul><li>Spinal Cord Injury </li></ul><ul><ul><li>Usually C3 or higher (rarely C4-C5) </li></ul></ul><ul><ul><li>Ventilator Dependent </li></ul></ul><ul><ul><li>Tracheostomy Dependent </li></ul></ul><ul><li>Central Hypoventilation Syndrome </li></ul><ul><ul><li>Ondine’s curse </li></ul></ul><ul><ul><li>Oxygen dependent </li></ul></ul><ul><ul><li>Ventilator/ Bi-Pap at night </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  14. 14. Ventilator Dependency Diaphragm Paralysis <ul><li>Spinal Cord Injury (SCI) </li></ul><ul><ul><li>11,000 new cases/year </li></ul></ul><ul><ul><li>>50% cervical level </li></ul></ul><ul><ul><li>Interruption of descending bulbospinal respiratory pathways </li></ul></ul><ul><ul><ul><li>Respiratory paresis or paralysis </li></ul></ul></ul><ul><ul><li>Primary cause of death after SCI, regardless of level – Respiratory * </li></ul></ul>* National Spinal Cord Injury Statistical Center, 2006 Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  15. 15. Ventilator Dependency Spinal Cord Injury <ul><li>Effect of SCI on Respiration </li></ul><ul><ul><li>Paralysis of respiratory muscles </li></ul></ul><ul><ul><ul><li>Diaphragm </li></ul></ul></ul><ul><ul><ul><ul><li>Major inspiratory muscle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Innervated by phrenic motoneurons C3-5 </li></ul></ul></ul></ul><ul><ul><ul><li>Accessory respiratory muscles </li></ul></ul></ul><ul><ul><ul><ul><li>Intercostals </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thoracic/Abdominal muscles </li></ul></ul></ul></ul><ul><ul><li>Reduction in tidal volume </li></ul></ul><ul><ul><li>Blunted response to hypercapnia </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  16. 16. Ventilator Dependency Spinal Cord Injury <ul><li>SCI is among the most expensive condition among all causes for hospitalization. </li></ul><ul><ul><li>Yet a 20 year old tetraplegic on MV has their life expectancy drop by ~18 yrs vs. non-depenadent 1 </li></ul></ul>National Spinal Cord Injury Statistical Center, Birmingham, Alabama January 2008 Treatment of Pulmonary Disease Following Cervical Spinal Cord Injury, Evidence Report/Technology Assessment, Number 27 Center for Treatment of Paralysis and Reconstructive Nerve Surgery Severity of Injury Avg Yearly Expenses 1 st Yr Avg. Yearly Expenses Subsequent Estimated Lifetime Costs 25 yrs old Estimated Lifetime Cost 50 yrs old High (C1-C4) Tetraplegia $775,567 $138,923 $3,059,184 $1,800,958 Low (C5-C8) Tetraplegia $500,829 $56,905 $1,729,754 $1,095,411
  17. 17. Ventilator Dependency Impact On the Diaphragm <ul><li>Compared 14 brain dead donors on PPV to 8 controls </li></ul><ul><li>18 hours of PPV causes marked atrophy </li></ul><ul><li>57% decrease Type 1 slow twitch </li></ul><ul><li>Active muscles atrophy faster </li></ul><ul><li>Inactivity leads to oxidative stress </li></ul><ul><li>Increased proteolysis </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  18. 18. Ventilator Dependency Diaphragm Paralysis <ul><li>A CNS problem with no clinical CNS solution </li></ul><ul><li>Peripheral nerve solution(s) </li></ul><ul><ul><li>Electrical stimulation </li></ul></ul><ul><ul><li>Nerve transfer </li></ul></ul><ul><ul><li>Electrical stimulation + Nerve transfer </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  19. 19. Ventilator Dependency Spinal Cord Injury <ul><li>Above level of injury </li></ul><ul><ul><li>Functioning nerves </li></ul></ul><ul><li>At level of injury </li></ul><ul><ul><li>Inability to propagate a nerve stimulus </li></ul></ul><ul><ul><li>Cannot respond to externally applied electrical stimulus </li></ul></ul><ul><li>Below level of injury </li></ul><ul><ul><li>Inability to propagate a nerve stimulus </li></ul></ul><ul><ul><li>May respond to externally applied electrical stimulus </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  20. 20. Ventilator Dependency Congenital Central Hypoventilation Syndrome (Ondine’s Curse) <ul><li>Demographics </li></ul><ul><ul><li>Rare disorder (1 in 200,000/U.S.) </li></ul></ul><ul><ul><li>No known cure </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>Problem integrating chemoreceptor input to central ventilatory controllers </li></ul></ul><ul><ul><li>Genetic mutation identified </li></ul></ul><ul><ul><li>Association with Hirschprung’s disease </li></ul></ul><ul><li>Characteristics </li></ul><ul><ul><li>Breathe reasonably well while awake </li></ul></ul><ul><ul><li>Apneic during sleep - require ventilatory support </li></ul></ul><ul><ul><li>A third require ventilatory support 24h/day </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  21. 21. Ventilator Dependency Diaphragm Pacing <ul><li>Purpose </li></ul><ul><ul><li>Electrically pulse phrenic nerves (or nerve/muscle interface), causing diaphragmatic excursion </li></ul></ul><ul><li>Goal </li></ul><ul><ul><li>Reduce or eliminate ventilator dependency </li></ul></ul><ul><li>Experience </li></ul><ul><ul><li>Avery </li></ul></ul><ul><ul><ul><li>25 years </li></ul></ul></ul><ul><ul><ul><li>82% rate of permanent diaphragmatically-paced breathing </li></ul></ul></ul><ul><ul><li>Synapse </li></ul></ul><ul><ul><ul><li>Recently FDA approved </li></ul></ul></ul><ul><ul><ul><li>SCI trial (100% paced with intact nerves) </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  22. 22. Ventilator Dependency Diaphragm Pacing <ul><li>Criteria </li></ul><ul><ul><li>Chronic respiratory failure </li></ul></ul><ul><ul><li>Central neurological disorder or High Spinal injury </li></ul></ul><ul><ul><li>Preserved phrenic nerve integrity </li></ul></ul><ul><ul><li>Acceptable pulmonary function </li></ul></ul><ul><ul><li>Normal level of consciousness </li></ul></ul><ul><ul><li>Appropriate care and support </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  23. 23. Ventilator Dependency Diaphragm Pacing <ul><li>Procedure (Avery) </li></ul><ul><ul><li>Small incisions </li></ul></ul><ul><ul><li>Intraoperative neurophysiological testing </li></ul></ul><ul><ul><li>Implantation of electrodes and receiver </li></ul></ul><ul><li>Diaphragm conditioning </li></ul><ul><li>Long-term pacing </li></ul>Case Western University Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  24. 24. Diaphragm Pacemaker Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  25. 25. Diaphragm Pacemaker Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  26. 26. Diaphragm Pacemaker Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  27. 27. Diaphragm Pacemaker Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  28. 28. Diaphragm Pacemaker Avery Biolabs Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  29. 29. NeuRx Diaphragm Pacing System™ <ul><li>External Pulse Generator “Paces” Diaphragm </li></ul><ul><li>Home based conditioning replaces Mechanical Ventilation </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  30. 30. Diaphragm Pacemaker <ul><li>NeuRx Diaphragm Pacing Device (Synapse) </li></ul><ul><ul><li>Laparoscopic placement </li></ul></ul><ul><ul><li>Electrodes (4) applied to nerve/muscle junction </li></ul></ul><ul><ul><li>Avoid nerve manipulation </li></ul></ul><ul><ul><li>Application for neurodegnerative conditions (ALS) </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  31. 31. Ventilator Dependency Diaphragm Pacing <ul><li>Benefits </li></ul><ul><ul><li>Lower rate of pulmonary complications </li></ul></ul><ul><ul><li>Improved venous return </li></ul></ul><ul><ul><li>Normal breathing and speech </li></ul></ul><ul><ul><li>Ease of eating and drinking </li></ul></ul><ul><ul><li>Increased patient mobility </li></ul></ul><ul><ul><li>Cost-effective </li></ul></ul><ul><li>Risks </li></ul><ul><ul><li>Phrenic nerve injury </li></ul></ul><ul><ul><li>Wire displacement </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  32. 32. Ventilator Dependency Diaphragm Pacing <ul><li>Limitations </li></ul><ul><ul><li>Lack of voluntary control of breathing </li></ul></ul><ul><ul><li>Only inspiration is triggered, thus cough may be weak </li></ul></ul><ul><ul><li>Inability to time spontaneous inspiratory efforts </li></ul></ul><ul><ul><li>No benefit for unilateral injuries* </li></ul></ul><ul><ul><li>C3-5 injuries may not be candidates due to Wallerian degeneration* </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  33. 33. Diaphragm Paralysis Neurotization <ul><li>Nerve transfers (Neurotization) </li></ul><ul><ul><li>Definition </li></ul></ul><ul><ul><ul><li>Transferring intact, functioning nerves to phrenic nerves in order to restore function to the diaphragm </li></ul></ul></ul><ul><ul><li>Advantages </li></ul></ul><ul><ul><ul><li>Tremendous experience with this technique for brachial plexus, extremities, facial nerve </li></ul></ul></ul><ul><ul><ul><li>A reconstructive option for patients not candidates for pacing </li></ul></ul></ul><ul><ul><ul><li>Or, perhaps to enhance results of pacing </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  34. 34. Diaphragm Paralysis Neurotization <ul><li>Krieger & Krieger (2000) </li></ul><ul><ul><li>6 patients </li></ul></ul><ul><ul><li>C3-5 injuries </li></ul></ul><ul><ul><li>Intercostal to phrenic + pacemaker </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  35. 35. Diaphragm Paralysis Neurotization Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  36. 36. Diaphragm Paralysis Neurotization Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  37. 37. Diaphragm Paralysis Spinal Accessory Neurotization <ul><li>Potential Advantages </li></ul><ul><ul><li>Tremendous experience in brachial plexus reconstruction </li></ul></ul><ul><ul><li>Higher axonal density in the donor nerve </li></ul></ul><ul><ul><ul><li>Intercostal: 1093 </li></ul></ul></ul><ul><ul><ul><li>Spinal Accessory : 2145 </li></ul></ul></ul><ul><ul><ul><li>[Phrenic: 800] </li></ul></ul></ul><ul><ul><li>Functionally linked to phrenic </li></ul></ul><ul><ul><li>Performed through neck incisions </li></ul></ul><ul><ul><li>Lower morbidity (no thoracotomy) </li></ul></ul><ul><li>Disadvantage </li></ul><ul><ul><ul><li>Longer distance for axonal regrowth </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  38. 38. Diaphragm Paralysis Spinal Accessory Nerve Brainstem Spinal Cord Dual Origins Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  39. 39. Diaphragm Re-innervation Spinal Accessory Neurotization <ul><li>Goal </li></ul><ul><ul><li>To provide ventilator-dependent patients the ability for voluntary respiratory control +/- a diaphragm pacemaker </li></ul></ul><ul><li>Techniques </li></ul><ul><ul><li>Transfer a branch of functioning Cr XI to nonfunctioning phrenic bilaterally </li></ul></ul><ul><li>Status </li></ul><ul><ul><li>Ongoing protocol </li></ul></ul><ul><ul><li>IRB Approval </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  40. 40. Diaphragm Paralysis Spinal Accessory Neurotization <ul><li>Phrenic Nerve </li></ul><ul><li>Spinal Accessory Nerve </li></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  41. 41. Diaphragm Paralysis Spinal Accessory Neurotization <ul><li>Anticipated outcomes </li></ul><ul><ul><li>Spontaneous diaphragm function </li></ul></ul><ul><ul><li>Improve pacemaker results </li></ul></ul><ul><ul><li>Low morbidity </li></ul></ul><ul><ul><li>Another treatment for diaphragm paralysis </li></ul></ul><ul><ul><li>REDUCED COST </li></ul></ul><ul><ul><ul><li>Medicare/Medicaid reimbursed? </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  42. 42. Ventilator Dependency Summary of Potential Treatment Options <ul><li>Diaphragm Pacemaker </li></ul><ul><ul><li>C-spine (C3 or higher) or Central abnormality </li></ul></ul><ul><li>Neurotization </li></ul><ul><ul><li>C3 or higher, OR Central </li></ul></ul><ul><ul><li>Functioning donors </li></ul></ul><ul><ul><li>Poor pacemaker candidate </li></ul></ul><ul><li>Neurotization +/- Pacemaker </li></ul><ul><ul><li>C3-5 </li></ul></ul><ul><ul><li>Extensive direct injury to nerve </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  43. 43. Unilateral Diaphragm Paralysis Phrenic Nerve Injury Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  44. 44. Phrenic Nerve Grafting Nerve Interposition Graft or Nerve “Bypass” Neck Chest Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  45. 45. Phrenic Nerve Grafting Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  46. 46. Phrenic Nerve Grafting Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  47. 47. Diaphragm Re-Innervation <ul><li>“ Re-Innervation of the Paralyzed Diaphragm: Application of Nerve Surgery Techniques following Unilateral Phrenic Nerve Injury”. Kaufman et al.* </li></ul><ul><ul><li>N=12 </li></ul></ul><ul><ul><li>Unilateral, symptomatic diaphragm paralysis </li></ul></ul><ul><ul><li>Minimum 6 months </li></ul></ul><ul><ul><li>No spontaneous improvement </li></ul></ul>*Submitted for publication to CHEST journal 10/10 Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  48. 48. Diaphragm Re-Innervation <ul><li>Evaluations </li></ul><ul><ul><li>Sniff Test </li></ul></ul><ul><ul><li>Phrenic Nerve Conduction Study </li></ul></ul><ul><ul><li>Diaphragm EMG </li></ul></ul><ul><ul><li>PFTs </li></ul></ul><ul><ul><li>Standardized Quality of Life Survey </li></ul></ul><ul><ul><ul><li>Assess Physical Functioning </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  49. 49. Diaphragm Re-Innervation <ul><li>Results </li></ul><ul><ul><li>8 males, 4 females </li></ul></ul><ul><ul><li>Mean age 54 (range 40-68) </li></ul></ul><ul><ul><li>Etiology </li></ul></ul><ul><ul><ul><li>Anesthetic Blocks (2) </li></ul></ul></ul><ul><ul><ul><li>Surgery (6) </li></ul></ul></ul><ul><ul><ul><li>Chiropractic Manipulation (2) </li></ul></ul></ul><ul><ul><ul><li>Traumatic Event (2) </li></ul></ul></ul><ul><ul><li>Right (3), Left (9) </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  50. 50. Diaphragm Re-Innervation <ul><li>Results </li></ul><ul><ul><li>Treatment offered </li></ul></ul><ul><ul><ul><li>Neurolysis (12) </li></ul></ul></ul><ul><ul><ul><li>Interposition nerve graft (7) </li></ul></ul></ul><ul><ul><ul><li>Neurotization (2) </li></ul></ul></ul><ul><ul><li>Operative time </li></ul></ul><ul><ul><ul><li>Mean= 165 minutes (range 50-250) </li></ul></ul></ul><ul><ul><li>Hospital stay </li></ul></ul><ul><ul><ul><li>Mean= 2 days (range 1 to 4) </li></ul></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  51. 51. Diaphragm Re-Innervation Quality of Life Improvements Normal function = 100
  52. 52. Diaphragm Re-Innervation Improvements in PFTs
  53. 53. Diaphragm Re-Innervation Phrenic Nerve Grafting Return of Diaphragmatic Function 10 months following grafting Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  54. 54. Diaphragm Re-Innervation <ul><li>Sniff test </li></ul><ul><ul><li>8/9 improved </li></ul></ul><ul><li>Incomplete assessments in 4/12 </li></ul><ul><ul><li>(2) too early to be tested </li></ul></ul><ul><ul><li>(1) expired from unrelated cardiac event 8 months later </li></ul></ul><ul><ul><li>(1) no improvement at 8 months* </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>(1) infection at sural nerve harvest site </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  55. 55. Diaphragm Re-Innervation Conclusions <ul><li>Documentation of diaphragm re-innervation following nerve grafting </li></ul><ul><ul><li>67% objective improvements in diaphragm function </li></ul></ul><ul><li>A problem with almost no other treatment options </li></ul><ul><ul><li>Diaphragm plication </li></ul></ul><ul><ul><ul><li>Restoring physiologic function always superior to “piggybacking” dead muscle </li></ul></ul></ul><ul><li>Additional investigation </li></ul><ul><ul><li>Standard of care for diaphragm paralysis? </li></ul></ul>Center for Treatment of Paralysis and Reconstructive Nerve Surgery
  56. 56. Thank You! Center for Treatment of Paralysis and Reconstructive Nerve Surgery

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