Long Term Experience with Diaphragm Pacing for Traumatic Spinal Cord Injury: Early Implantation Post Injury is More Beneficial
Onders R, Elmo M
University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
Purpose: Cervical spine injury (SCI) can result in catastrophic respiratory failure requiring invasive mechanical ventilation(MV) which is a leading cause of mortality and cost. Diaphragm Pacing(DP) was developed to replace/decrease mechanical ventilation. This is the largest long term analysis to be reported of a subgroup of traumatic SCI.
Methods: A retrospective review of prospective IRB approved protocols. All patients underwent laparoscopic diaphragm mapping and implantation of electrodes. DP electrodes were characterized and diaphragm strengthening with mechanical ventilator weaning was initiated immediately post op.
Results: March 2000 through June 2017 there have been a total of 486 DP implants at this single site. Within this group, 155 had spinal cord damage and 92 of those patients had SCI secondary to trauma. The manner of injury: MVA 44, Sports 22, Falls 12, GSW 7, Crush 3, Forceps Delivery 2, Assault 1, and electrocution 1. The age at time of injury ranged from birth to 74 years old with the average of 27.3 years and median age of 23 years. Time on mechanical ventilation prior to DP was an average of 47.5 months(6 days to 25 years with median of 1.58 years). Patients’ highest level of injury: 27 C1, 36 C2, 14 C3, 7 C4, 5 C5 and 3 C6. Twelve patients had internal permanent cardiac pacemakers. There was no device to device interactions between DP and cardiac pacemakers. A total of 83% of patients achieved 4 consecutive hours of pacing with fifty-six patients(60.8%) being full time and an additional 13% using DP >12 hours. DP decreased the need and risk of cuffed tracheostomy with 60% of patients going to cuffless tracheostomy and 7 decannulations. One patient with early DP implant avoided tracheostomy. Five patients were not successful in weaning off MV. Five patients had full recovery of automatic breathing with subsequent DP removal. Two pediatric patients have had growth spurts of 10 inches or greater without need of electrode replacement. There have been 23 deaths with no primary respiratory origin. Subgroup analysis showed that earlier DP implantation leads to greater 24 hour use of DP and no need for any MV. This group also had the greater proportionate recovery of breathing.
Conclusions: DP can successfully decrease need for mechanical ventilation for a significant number of SCI patients. There is a correlation of early implantation to greater weaning success, recovery of independent breathing and has the potential to obviate need for tracheostomy. Liberation from MV can substantially improve SCI rehabilitation. To minimize MV days and complications, DP should be considered early after injury even in those who may re-gain independent breathing.
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