Phrenic nerve stimulation in complex rehabilitation for cervical spinal cord injury using modified implantable device (case report)

Abstract

Background Cervical spinal cord injury (CSCI) can result in numerous pulmonary complications and special attention to respiratory support is vital in rehabilitation of the patients. Aim To develop regimens for an implantable generator of electrical impulses to be used in phrenic nerve stimulation to liberate or wean a patient from mechanical ventilator. Material and methods Stimulation of the phrenic nerve was performed for a 9-year-old boy with a traumatic spinal cord injury and complete anatomical disruption of the spinal cord at the C2 vertebra level. Artificial and auxiliary lung ventilation was provided for the patient with the CareFusion LTV 1200 system (USA). Nerve monitor ISIS IOM (Inomed Medizintechnik GmbH, Germany) was used to control the phrenic nerve. Statistical analysis of baseline data was produced with two-tailed Student's t-test. Microsoft Excel and AtteStat program, version 13.1 were used to complete data analysis reports. Results A four-contact cylindrical electrode was inserted into the epidural space of the cervical vertebrae and placed at cervical levels C2–C4 with a minimally invasive procedure and a course of electrical stimulation was initiated. Possibility of weaning was considered with four step procedure to be involved. The first phase included the development and implementation of electric stimulation modes with breathing patterns at frequency of 12, 15 and 20 cycles per minute with auxiliary respiration breathing. The second stage consisted of electrical stimulation with audiovisual support from animated cartoon singles. No auxiliary respiration was used with the peripheral oxygen saturation monitored in the upper limb. The third stage included phrenic nerve stimulation produced four times per day for fifteen minutes each, without assisted breathing, simultaneously with audiovisual support. The fourth stage included device implantation for chronic electrical stimulation with use of program version V18.6.2. Finally, the patient could breathe independently using simultaneous stimulation produced 3 times per day for 20 minutes and develop a greater amplitude of active head turns, improved speech clarity and increased voice volume. Conclusion Electrical phrenic nerve stimulation applied to a patient with a high level of spinal cord injury using an implantable modified device, virtual environment components and appropriate exercise therapy facilitated improved range of autonomy and level of independent breathing control.

Keywords

• chronic phrenic nerve stimulation
• rehabilitation