Dyspnea as the Presenting Symptom of Cervical Spondylotic Myelopathy

Abstract

Background A case report of acute unilateral hemidiaphragm paralysis and resultant dyspnea due to cervical spondylotic myelopathy (CSM) is described.

Case Report An 82-year-old man presented with a nonproductive cough, chest congestion, hoarseness, and shortness of breath on ambulation. The patient underwent cardiac catheterization, which revealed extensive stenosis of the major cardiac arteries. Subsequently, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. Magnetic resonance and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia. The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. The dyspnea completely resolved.

Conclusion The diagnosis of CSM as the cause of dyspnea is difficult to make. When unrelated cardiac or pulmonary disease coexists, the presenting symptoms of CSM may be subtle and must be actively sought. Signs and symptoms can vary widely and may include symptoms of intermittent neck pain or headache. Dyspnea may be related to unilateral diaphragm paralysis caused by CSM. This etiology of dyspnea should be considered in elderly patients who have other comorbidities that often obscure the diagnosis.

Keywords

cervical cord compression - cervical myelopathy - cervical stenosis - diaphragmatic paralysis - dyspnea

• References

• 1 Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am 1992; 23 (03) 381-394
• 2 McCormack BM, Weinstein PR. Cervical spondylosis. An update. West J Med 1996; 165 (1–2): 43-51
• 3 Lin HY, Chen CC, Lee YK, Su YC. Dyspnea caused by atlantoaxial subluxation in a patient with rheumatoid arthritis. Case Rep Emerg Med 2012; 2012: 1-2 . Doi: 10.1155/2012/170956
• 4 Chan CK, Loke J, Virgulto JA, Mohsenin V, Ferranti R, Lammertse T. Bilateral diaphragmatic paralysis: clinical spectrum, prognosis, and diagnostic approach. Arch Phys Med Rehabil 1988; 69 (11) 976-979
• 5 Jin Y. An aged patient with 11-year untreated progressive atlantoaxial subluxation manifesting with dyspnea due to unilateral diaphragmatic paralysis: a case report and literature review. Aging Clin Exp Res 2014; 26 (06) 677-680
• 6 Parke WW, Whalen JL. Phrenic paresis—a possible additional spinal cord dysfunction induced by neck manipulation in cervical spondylotic myelopathy (CSM): a report of two cases with anatomical and clinical considerations. Clin Anat 2001; 14 (03) 173-178
• 7 Merino-Ramírez MA, Juan G, Ramón M, Cortijo J, Morcillo EJ. Diaphragmatic paralysis following minor cervical trauma. Muscle Nerve 2007; 36 (02) 267-270
• 8 Buszek MC, Szymke TE, Honet JC. , et al. Hemidiaphragmatic paralysis: an unusual complication of cervical spondylosis. Arch Phys Med Rehabil 1983; 64 (12) 601-603
• 9 Hayashi H, Kihara S, Hoshimaru M, Hashimoto N. Diaphragmatic paralysis caused by cervical spondylosis. Case report. J Neurosurg Spine 2005; 2 (05) 604-607
• 10 Fregni F, Conceição Souza GE, Taricco MA, Mutarelli EG. Phrenic paresis and respiratory insufficiency associated with cervical spondylotic myelopathy. Acta Neurochir (Wien) 2004; 146 (03) 309-312 , discussion 312
• 11 Daniil ZD, Malagari K, Zakynthinos EG, Kapotsis GE, Roussos C, Papiris SA. An unusual cause of dyspnea in a 77-year-old man. Chest 2004; 125 (02) 770-774
• 12 Reines HD, Harris RC. Pulmonary complications of acute spinal cord injuries. Neurosurgery 1987; 21 (02) 193-196
• 13 Ishibe T, Takahashi S. Respiratory dysfunction in patients with chronic-onset cervical myelopathy. Spine 2002; 27 (20) 2234-2239
• 14 Toyoda H, Nakamura H, Konishi S, Terai H, Takaoka K. Does chronic cervical myelopathy affect respiratory function?. J Neurosurg Spine 2004; 1 (02) 175-178
• 15 Yanaka K, Noguchi S, Asakawa H, Nose T. Laminoplasty improves respiratory function in elderly patients with cervical spondylotic myelopathy. Neurol Med Chir (Tokyo) 2001; 41 (10) 488-492 , discussion 493
• 16 Kawaguchi Y, Kitagawa H, Nakamura H, Gejo R, Kimura T. Neurophysiological tests of respiratory function by compound muscle action potentials from the diaphragm. Detection of lesions in the higher cervical cord. J Bone Joint Surg Br 2000; 82 (05) 695-701
• 17 Vengust R, Mihalic R, Turel M. Two different causes of acute respiratory failure in a patient with diffuse idiopathic skeletal hyperostosis and ankylosed cervical spine. Eur Spine J 2010; 19 (Suppl. 02) S130-S134
• 18 Woischneck D, Eder A, Holstege A. , et al. [Severe dyspnea by combination of cervical spondylosis and struma]. Dtsch Med Wochenschr 2015; 140 (11) 824-826
• 19 Cloward RB. Diaphragm paralysis from cervical disc lesions. Br J Neurosurg 1988; 2 (03) 395-399
• 20 Fujibayashi S, Shikata J, Yoshitomi H, Tanaka C, Nakamura K, Nakamura T. Bilateral phrenic nerve palsy as a complication of anterior decompression and fusion for cervical ossification of the posterior longitudinal ligament. Spine 2001; 26 (12) E281-E286