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PubMedDate not supplied

Neuralgic amyotrophy: A rare cause of bilateral diaphragmatic paralysis.

Neuralgic amyotrophy, also known as brachial neuritis, is a well described clinical entity. Diaphragmatic dysfunction, as a result of phrenic nerve root involvement (cervical roots 3 to 5), is an uncommon, but increasingly recognized association. The case of a previously healthy 61-year-old woman who, after a prodrome of neck and shoulder discomfort, presented with severe orthopnea is described. Pulmonary function and electrophysiological studies led to a diagnosis of bilateral diaphragmatic paralysis. The patient's clinical course and the exclusion of other nerve entrapment syndromes and neurological disorders strongly favoured the diagnosis of neuralgic amyotrophy.

Brachial Plexus Neuritis↗

PubMed1996

Digital pressure during interscalene block is clinically ineffective in preventing anesthetic spread to the cervical plexus.

The application of digital pressure above the injection site during interscalene block has been advocated to prevent cephalad spread of local anesthetic. In prior studies, radiographs taken immediately after interscalene injection of radiographic contrast have supported this concept. However, the clinical efficacy of digital pressure has not been previously tested. If digital pressure were effective in inhibiting cephalad spread of local anesthetic, attenuation of both hemidiaphragmatic paresis and the resulting compromise in pulmonary function would be expected. Sensory, motor, and pulmonary effects were prospectively evaluated in 20 patients presenting for elective shoulder surgery. Patients were randomly assigned to receive interscalene block with or without digital pressure. No clinical differences were seen between groups. All 20 patients had ipsilateral hemidiaphragmatic paresis by ultrasonographic evaluation and large mean decreases in forced vital capacity, 31.2% +/- 7.8% (with digital pressure), 33.7% +/- 12.8% (without digital pressure), and forced expiratory volume at one second, 27.9% +/- 9.3% (with digital pressure), 33.7 +/- 12.8% (without digital pressure). Peak sensory level of anesthesia to pinprick was not significantly different between groups, each group having mean levels of C-2 to C-3. Digital pressure was ineffective in limiting the flow of local anesthetic into the cervical plexus. Digital pressure influenced neither the incidence of diaphragmatic paresis nor the resulting large decreases in pulmonary function that result from interscalene block.

Adolescent↗

PubMed1985

Extracorporeal membrane oxygenation and congenital diaphragmatic hernia: modification of the pulmonary vasoactive profile.

We studied the vasoactive profile of a term infant with congenital diaphragmatic hernia and intractable pulmonary hypertension who was refractory to conventional medical management despite an early stable period. Plasma prostanoid vasoconstrictor thromboxane A2 (TxB2) levels were elevated prior to ECMO at 150pg/mL, rose to 310pg/mL with the first hour of bypass and remained elevated until 72 hours by which time they fell to less than 50pg/mL. This coincided with the decreased extracorporeal circulatory support needed to maintain systemic arterial pO2 between 70 to 90 torr. Pulmonary vasodilator prostacyclin (6-keto-PGF1 alpha) was minimally elevated prior to bypass a 50pg/mL and became undetectable. Catecholamine levels were markedly elevated prior to ECMO at 4,000pg/mL with no demonstrable pulmonary extraction of norepinephrine. Though catecholamine levels remained nonspecifically elevated, pulmonary metabolism of norepinephrine improved with bypass time to 48% at 96 hours and coincided with the overall improvement of the infant's respiratory function. These data suggest pulmonary hypertension associated with congenital diaphragmatic hernia is at least partially precipitated by alterations in prostanoid homeostasis as selective activation of thromboxane synthetase pathways rather than nonspecific activation of the entire archidonate cascade. While ECMO per se may have no lasting effect on prostanoid homeostasis, ECMO can allow a period of cardiopulmonary rest during which more physiologic prostanoid levels are established. Although activation of the sympatho-adrenal axis may contribute to pulmonary hypertension, the role of catecholamines in this infant is not clear. Return of the lungs ability to clear norepinephrine may be an additional marker of biologic lung recovery.

6-Ketoprostaglandin F1 alpha↗

PubMed1988

An unexpected functional cause of upper airway obstruction.

A case of acute respiratory obstruction in the immediate postoperative period is described in a young woman who emerged from general anaesthesia after a Caesarean section for fetal distress. She had a pregnancy complicated by disabling polyhydramnios and anxiously anticipated the birth of a child with a diaphragmatic hernia, diagnosed antenatally. The cause of the airway obstruction was functional in nature as confirmed by flexible fibreoptic laryngoscopy. The diagnosis, paradoxical vocal cord motion, has to be considered as an infrequent cause of postoperative airway obstruction; its recognition and treatment are discussed. The patient did not have a history which might have indicated its possible occurrence. It is suggested that paradoxical vocal cord movement in a more mild form may be overlooked as cause for postoperative stridor and airway obstruction.

Acute Disease↗

PubMedDate not supplied

[Congenital postero-lateral right diaphragmatic hernia--case report].

OBJECTIVE: There are three types of congenital diaphragmatic hernias (DH): posterolateral (Bochdalek) diaphragmatic hernia, subcostosternal (Morgagni's) hernia and esophageal hiatal hernia. The posterolateral (Bochdalek) diaphragmatic hernia is the result of a congenital diaphragmatic defect in the posterior costal part of the diaphragm in the region of 10th and 11th ribs, which allows free communication between the thoracic and abdominal cavity. The defect is usually found at the left side (90%) but may occur on the right side, where the liver often prevents detection. CASE REPORT: We present a 9-year-old girl with persistent cough during four weeks, vomiting and loss of appetite. She was admitted in hospital after one month ambulatory treatment without success. Chest x-ray showed an infiltrative shadow in basal lobe of the right lung and multiple radiolucencies over the right hemithorax. Irrigography confirmed presence of contrast in the right hemithorax (with herniation of colon in the right lung). The child had a restrictive type of pulmonary function and was operated after establishing the diagnosis of the disease. Posterolateral diaphragmatic defect was established intraoperatively with diameter 10 x 11 cm and with ascending colon prolapse, caecum appendix and part of colon transfersum. The child was in good condition after operation. Control X-ray was normal and the child has a normal pulmonary function on routine controls. COMMENT: The posterolateral right congenital DH is a rare diaphragmatic defect. The symptoms are noncharacteristic and patients with this disease can be without symptoms for a long period. The main tool for diagnosis of congenital DH is radiography, whereas treatment is surgical.

Child↗

PubMed1984

The advantages of reconstruction of the dome of the diaphragm in congenital posterolateral diaphragmatic defects.

Repair of a congenital posterolateral diaphragmatic defect (CPLDD) by direct suture results in a flat drum-head diaphragm, which has very little function. Other harmful effects of such a repair include enlargement of the thoracic cavity, resulting in more overexpansion of the hypoplastic lungs which may contribute to pulmonary vascular obstruction, and decrease in volume of the abdominal cavity, making closure of the laparotomy difficult. Reconstruction of a diaphragmatic dome would result in a more functional diaphragm and would prevent the above complications. This was substantiated in a series of 10 babies, all severely symptomatic from birth and treated according to the proposed technique. Eight babies survived, the two deaths occurring 36 hours and 3 months after surgery, in babies with severe cardiac anomalies. It is concluded that reconstruction of the dome of the diaphragm in patients with a CPLDD is well tolerated and may result in an increased survival.

Diaphragm↗

PubMed2004

Prenatal puncture of a unilateral hydronephrosis leading to fetal urinoma and postnatal nephrectomy.

Fetal pelvicaliceal dilatation due to ureteropelvic junction obstruction is the most common cause of antenatal hydronephrosis; it rarely leads to a spontaneous rupture resulting in urinoma formation. Antenatal intervention has been recommended only in those cases of large urinomas that seem to interfere with the function of other organ systems (eg, pulmonary hypoplasia secondary to diaphragmatic elevation). We report the case of a fetal intervention (transuterine puncture) in a unilateral massive hydronephrosis leading to a perirenal urinoma and the preterm birth of a female infant. Postnatally, mechanical ventilation and oxygen were required, as was forced percutaneous urinoma drainage. Evaluation revealed a fistula formation between the perirenal space and the kidney's collecting system, possibly due to the fetal intervention. Unfortunately the kidney function was very poor, and surgery to remove the impaired kidney and the urinoma was performed. We discuss the possible effects of fetal intervention in cases of obstructive uropathy and the postnatal risks associated with it.

Adult↗

PubMed1985

Ventilatory response to fatiguing and nonfatiguing resistive loads in awake sheep.

To study the changes in ventilation induced by inspiratory flow-resistive (IFR) loads, we applied moderate and severe IFR loads in chronically instrumented and awake sheep. We measured inspired minute ventilation (VI), ventilatory pattern [inspiratory time (TI), expiratory time (TE), respiratory cycle time (TT), tidal volume (VT), mean inspiratory flow (VT/TI), and respiratory duty cycle (TI/TT)], transdiaphragmatic pressure (Pdi), functional residual capacity (FRC), blood gas tensions, and recorded diaphragmatic electromyogram. With both moderate and severe loads, Pdi, TI, and TI/TT increased, TE, TT, VT, VT/TI, and VI decreased, and hypercapnia ensued. FRC did not change significantly with moderate loads but decreased by 30-40% with severe loads. With severe loads, arterial PCO2 (PaCO2) stabilized at approximately 60 Torr within 10-15 min and rose further to levels exceeding 80 Torr when Pdi dropped. This was associated with a lengthening in TE and a decrease in breathing frequency, VI, and TI/TT. We conclude that 1) timing and volume responses to IFR loads are not sufficient to prevent alveolar hypoventilation, 2) with severe loads the considerable increase in Pdi, TI/TT, and PaCO2 may reduce respiratory muscle endurance, and 3) the changes in ventilation associated with neuromuscular fatigue occur after the drop in Pdi. We believe that these ventilatory changes are dictated by the mechanical capability of the respiratory muscles or induced by a decrease in central neural output to these muscles or both.

Airway Resistance↗

PubMed1989

Lung ventilation and perfusion scintigraphy in the follow up of repaired congenital diaphragmatic hernia.

To evaluate the effects of congenital diaphragmatic hernia (CDH) and pulmonary hypoplasia on subsequent lung function and development, we performed lung 133Xe ventilation and 99mTc perfusion scintigraphies in a group of infants who had undergone surgical repair of a severe left CDH with respiratory distress within the first 6 h of life. The initial lung scans performed in 15 children, 2-3 months of age, demonstrated a decreased ventilation in 7. In 9 children there was a trapping of 133Xe at the left lung base. Perfusion to the hernia side was reduced in 8 of the children. We re-evaluated 11 of these 15 patients after 1-2 years. The ventilation to the left lung was still decreased in 3, but perfusion remained decreased in 9. After 5 years, ventilation to the hernia side was normal in 4 of the 5 patients studied, whereas pulmonary blood flow was abnormal in 4. These results show a progressive improvement of ventilation with a persisting reduction of perfusion to the lung of the hernia side, suggesting a primary vascular pulmonary hypoplasia in CDH.

Female↗

PubMed1984

Creation and repair of diaphragmatic hernia in the fetal lamb: techniques and survival.

Diaphragmatic hernias were created in 54 fetal lambs at 72 to 82 days gestation via a left thoracotomy. The diaphragmatic hernia was repaired in 30 lambs at 106 to 123 days gestation, and 14 of these lambs subsequently aborted. The majority of those surviving to term were delivered for survival. Four lambs with an unrepaired diaphragmatic hernia were intensively resuscitated at delivery and their diaphragmatic hernias repaired; survival in these lambs ranged from 20 minutes to 89 hours. Nine lambs with repaired diaphragmatic hernia were resuscitated following delivery; survival times ranged from one hour, 45 minutes to 123 days, with three lambs surviving to be sacrificed at 43, 62, and 123 days. Three of the lambs that died before sacrifice, died of causes unrelated to their lung function. These results show that in-utero repair of the diaphragmatic hernia in the fetal lamb results in improved survival. We feel, however, that direct application of these results in humans would be premature.

Animals↗

PubMed2006

Myocardium expression of connexin 43, SERCA2a, and myosin heavy chain isoforms are preserved in nitrofen-induced congenital diaphragmatic hernia rat model.

BACKGROUND: Previous morphological studies had produced controversial results with regard to heart development in congenital diaphragmatic hernia (CDH), whereas a few publications investigated cardiac function and myocardial maturation. Myocardium maturation is associated with age-dependent increasing of gene expression of gap junction protein connexin 43 (Cx43), adenosine triphosphatase of the sarcoplasmic reticulum (SERCA2a), as well as switching of myosin heavy chains (MHCs) from beta to alpha isoforms. Our aim was to evaluate myocardium maturity in nitrofen-induced CDH rat model. METHODS: Fetuses from dated pregnant Sprague-Dawley rats were assigned to 3 experimental groups: control, nitrofen (exposed to nitrofen, without CDH), and CDH (exposed to nitrofen, with CDH). Myocardial samples collected from left ventricle free wall were processed to (i) quantification of messenger RNA (mRNA) of Cx43, SERCA2a, alpha and beta MHC isoforms, as well as beta-actin (housekeeping gene); and (ii) separation of MHC isoforms (alpha and beta isoforms) by sodium dodecyl sulfate polyacrylamide gel electrophoresis silver stained. RESULTS: We demonstrated that there is no difference in myocardial gene expression of Cx43 (control, 1.0 +/- 0.1; nitrofen, 1.1 +/- 0.2; CDH, 1.3 +/- 0.2) and SERCA2a (control, 1.0 +/- 0.1; nitrofen, 0.9 +/- 0.1; CDH, 1.0 +/- 0.2). Myocardial gene expressions of alpha and beta mRNA of MHC isoforms were slightly decreased both in nitrofen and CDH fetuses when compared with control fetuses, but evaluation of the alpha-to-beta ratios of MHC isoforms at protein level revealed no significant differences between CDH and control (control, 16.9 +/- 2.5; CDH, 17.0 +/- 2.0). CONCLUSIONS: Myocardial quantification of Cx43 and SERCA2a mRNA, as well as the expression pattern of MHC isoforms at protein levels, was similar in all studied groups. We predict, therefore, that acute heart failure commonly observed in CDH infants might be attributed predominantly to cardiac overload secondary to severe pulmonary hypertension rather than to myocardial immaturity.

Animals↗

PubMed2006

Different effects of ATP on the contractile activity of mice diaphragmatic and skeletal muscles.

Apart from acetyl-choline (Ach), adenosine-5'-trisphosphate (ATP) is thought to play a role in neuromuscular function, however little information is available on its cellular physiology. As such, effects of ATP and adenosine on contractility of mice diaphragmatic and skeletal muscles (m. extensor digitorum longa-MEDL) have been investigated in in vitro experiments. Application of carbacholine (CCh) in vitro in different concentrations led to pronounced muscle contractions, varying from 9.15+/-4.76 to 513.13+/-15.4 mg and from 44.65+/-5.01 to 101.46+/-9.11 mg for diaphragm and MEDL, respectively. Two hundred micromolars of CCh in both muscles caused the contraction with the 65% (diaphragm) to 75% (MEDL) of maximal contraction force-this concentration was thus used in further experiments. It was found that application of ATP (100 microM) increased the force of diaphragmatic contraction caused by CCh (200 microM) from 335.2+/-51.4 mg (n=21) in controls to 426.5+/-47.8 mg (n=10; P<0.05), but decreased the contractions of MEDL of CCh from 76.6+/-6.5mg (n=26) in control to 40.2+/-9.0mg (n=8; P<0.05). Application of adenosine (100 microM) had no effect on CCh-induced contractions of these muscles. Resting membrane potential (MP) measurements using sharp electrodes were done at 10, 20 and 30 min after the application of ATP and adenosine. Diaphragm showed depolarization from 75+/-0.6 down to 63.2+/-1.05, 57.2+/-0.96 and 53.6+/-1.1 mV after 10, 20 and 30 min of exposition, respectively (20 fibers from 4 muscles each, P<0.05 in all three cases). Adenosine showed no effect on diaphragmatic MP. Both agents were ineffective in case of MEDL. The effects of ATP in both tissues were abolished by suramin (100 microM), a P2-receptor antagonist, and chelerythrin (50 microM), a specific protein-kinase C (PKC) inhibitor, but were not affected by 1H-[1,2,4]-oxadiazolo-[4,3-alpha]-quinoxalin-1-one (ODQ, 1 microM), a guanylyl-cyclase inhibitor, or by adenosine-3,5-monophosphothioate (Rp-cAMP, 1 microM), a protein-kinase A (PKA) inhibitor. Besides the action on contractile activity, ATP (100 microM) led to a significant (P<0.001) depolarization of diaphragm muscle fibers from 74.5+/-2.3 down to 64+/-2.1, 58.2+/-2.2 and 54.3+/-2.4 mV after 10, 20 and 30 min of incubation, respectively. Incubation of MEDL with the same ATP concentration showed no significant change of MP. Denervation of the muscles for 28 days led to a decrease of CCh-induced contractions of diaphragm down to 171.1+/-34.5mg (n=11, P<0.05), but increased the contractile force of MEDL up to 723.9+/-82.3mg (n=9, P<0.01). Application of ATP elevated the contractility of denervated diaphragm caused by CCh up to normal values (311.1+/-79.7 mg, n=6, P>0.05 versus control), but did not significantly affect of contractility of MEDL, which became 848.1+/-62.7 mg (n=6). These results show that the effects of ATP on both diaphragmatic and skeletal muscles are mediated through P2Y receptors coupled to chelerytrin-sensitive protein-kinase C.

Adenosine Triphosphate↗

PubMed2003

Functional morphology of blind and other processes in the lymph capillary system.

"Blind" lymph capillaries of the diaphragmatic tendon center were studied in normal rabbits and after injections of India ink, yellow cadmium, chicken erythrocyte suspensions, and whole chicken blood into the abdominal cavity. Three groups of blind capillaries differing by morphological and functional signs were distinguished. Some blind capillaries can deposit foreign particles. The process of intracapillary endothelial growth is described.

Animals↗

PubMed1987

Could inspiratory apnea disturb left ventricular volume assessment by contrast angiography?

To assess the influence of postinspiratory apnea on the measurement of the left ventricular volumes, contrast ventriculography was performed on 19 patients during spontaneous breathing and then in postinspiratory apnea. Data obtained were similar for end diastolic volumes (81 +/- 29 ml/m2 vs. 83 +/- 25; NS), end systolic volumes (35 +/- 20 ml/m2 vs. 34 +/- 19; NS), systolic index (46 +/- 13 ml/m2 vs. 49 +/- 12; NS), and ejection fraction (0.57 +/- 0.11 vs. 0.59 +/- 0.12; NS). Postinspiratory apnea suppressed the overlapping of the left ventricle with abdominal viscera in 15 of 17 patients. Diaphragmatic immobility permitted the assessment of regional left ventricular function in all 19 patients. However, pressures recorded in inspiratory apnea can no longer be compared to a transmural pressure, and, to assess ventricular compliance, intrapleural pressure must be measured simultaneously. We conclude that left ventricular volume assessment by contrast ventriculography is not disturbed by inspiratory apnea. This maneuver improves the quality of the images and allows a better evaluation of left ventricular segmental function. Spontaneous breathing can be recommended to simplify left ventricular compliance study.

Adult↗

PubMed1999

Anatomic fundoplication failure after laparoscopic antireflux surgery.

OBJECTIVE: Anatomic fundoplication failure occurs after antireflux surgery and may be more common in the learning curve of laparoscopic antireflux surgery (LARS). The authors' aims were to assess the incidence, presentation, precipitating factors, and management of anatomic fundoplication failures after LARS. SUMMARY BACKGROUND DATA: The advent of LARS has increased the frequency with which antireflux surgery is performed for the treatment of gastroesophageal reflux disease. Postoperative symptoms frequently occur and may result from physiologic abnormalities or anatomic failure of the fundoplication (e.g., displacement or disruption). Few data exist on the potential causes or best treatment of anatomic fundoplication failures. METHOD: LARS was performed in 290 patients by one of the authors over a 6-year period. In the first 53 patients (group 1), the short gastric vessels were divided on a selective basis and the diaphragmatic crura were closed only when large hiatal hernias were present. In the subsequent 237 patients (group 2), the crura were always approximated posterior to the short gastric vessels and full fundic mobilization was performed. Clinical postoperative evaluation was performed on a regular basis, with detailed tests of anatomy and physiology when untoward symptoms developed. Postoperative foregut symptoms were reported by 26% of the patients, of whom 73% were found to have an intact fundoplication. In 7% of the entire group, anatomic failure of the fundoplication was demonstrated, with the majority exhibiting intrathoracic migration of the wrap with or without disruption of the fundoplication. New-onset postoperative epigastric or substernal chest pain frequently heralded fundoplication failure. Factors correlated with the development of anatomic fundoplication failure included presence in group 1, early postoperative vomiting, other diaphragm "stressors," and large hiatal hernias. Repeat operation has been performed in 8 of the 20 patients (40%), with 5 patients successfully treated using laparoscopic techniques. CONCLUSIONS: Anatomic fundoplication failure occurred in 7% of patients undergoing LARS, with the majority occurring in patients who underwent surgery during the learning curve. Anatomic failure is associated with technical shortcomings, large hiatal hernias, and early postoperative vomiting. Full esophageal mobilization and meticulous closure of the diaphragmatic crura posterior to the esophagus should minimize anatomic functional failure after LARS.

Female↗

PubMed2005

Absence of device-device interaction (DDI) in a patient with cardiac and diaphragmatic pacemakers for congenital central hypoventilation syndrome.

Autonomic control of ventilation is impaired in patients with Ondine's curse or congenital central hypoventilation syndrome (CCHS), but voluntary control remains intact. Bradyarrhythmias can be life threatening. In a patient with CCHS and long sinus pause requiring cardiac pacemaker insertion, a diaphragmatic pacemaker inserted in early childhood caused diaphragmatic pacer spikes observed during the interrogation of the cardiac pacemaker. Diaphragmatic pacing did not interfere with the cardiac pacemaker function.

Adult↗

PubMed1992

Diagnostic imaging in cancer.

Screening chest radiographs do not reduce mortality from lung cancer. Should an incidental noncalcified pulmonary parenchymal nodule be discovered, chest CT will demonstrate one third of such patients to, in fact, have the multiple nodules of metastatic disease. CT is very helpful to guide fine needle aspiration biopsy of lung lesions and to assist in evaluation for resectability. MR can be helpful in special circumstances, including the definition of the extent of paravertebral, superior sulcus, and diaphragmatic lesions. Endorectal ultrasound is not sensitive enough to function as a screening tool for prostate cancer but is used routinely to guide biopsies. CT and MR are rarely helpful in staging this disease. Given the highly characteristic trait of bone metastasis in prostate cancer, a bone scan is mandatory in all patients. Double contrast barium enema can be used as an adjunct or alternative to sigmoidoscopy for colorectal cancer screening, in the preoperative evaluation of patients, and in postoperative surveillance. CT and MR can detect macroscopic adenopathy and liver metastases; CT is generally the preferred study. Screening mammography can have a major impact in reducing breast cancer mortality. It is recommended that a baseline study be obtained at age 35. Annual or biannual examinations should commence at age 40. Any palpable lesion, whether or not it is demonstrated mammographically, must be subjected to biopsy. Ultrasound is the most useful initial imaging study for evaluating pelvic masses. MR will, on occasion, identify the origin of a mass not determinable from ultrasound scan. MR is particularly valuable to identify parametrial spread (inoperability) of cervical cancer, and has been underused for this purpose. Surgery remains the mainstay for the staging of ovarian and endometrial cancer, although CT can be helpful to identify macroscopic relapse, ascites, or liver metastases. Bone scan and liver CT remain the standard procedures for detecting metastases in these respective organ systems. MR can be invaluable in the imaging of epidural metastasis and spinal cord compression in patients with vertebral metastatic disease. Contrast-enhanced MR is more sensitive than contrast-enhanced CT for detecting brain metastases, but the latter remains a useful tool. Chest CT can improve the detection of pulmonary metastases when this is of crucial importance.

Biopsy, Needle↗

PubMed1986

[Consequences of adult brachial plexus paralysis and its surgical treatment on respiratory function].

The authors have studied 22 patients suffering from traumatic brachial plexus injuries and the consequences on respiratory function of paralysis of the diaphragm and other respiratory muscles. They have also studied the effects of some surgical treatment on respiratory function. The patients were divided into three groups: post-traumatic paralysis of the diaphragm (5 cases), patients who had had an intercostal neurotization (11 cases) and patients with paralysis of some respiratory muscles with an intact diaphragm (2 cases). Six tests were performed--vital capacity, total pulmonary capacity, residual functional capacity, airway resistance, maximum expiratory volume per second and airflow at 50 p. 100 of the vital capacity. Respiratory function was decreased by about 50 p. 100 in cases of diaphragmatic paralysis. This finding should be taken into consideration in cases of extensive lesions of the brachial plexus. The effects of intercostal neurotization were minimal when performed in cases with respiratory paralysis, but with an intact diaphragm. They were negligible in the absence of any respiratory paralysis. It is concluded that intercostal neurotization should not be performed in cases with diaphragmatic paralysis. In such cases, other types of neurotization are preferred.

Adolescent↗