Objective: To report the use of implantable diaphragm pacer (IDP) in a patient with high cervical spinal cord injury(HCSCI). Methods: A 14-year-old male patient, who suffered from a HCSCI at C2 neurological level and had been on a ventilator for 2 years, received IDP in August 2017 at China Rehabilitation Research Center. A systematic literature review was performed on IDP in patients with HCSCI in Pubmed, CNKI, and Wanfang databases, using the keywords: phrenic nerve and electrical stimulation and spinal cord injury; IDP and spinal cord injury; breathing pacemaker system and spinal cord injury. All fields were covered from 1970/01/01 to 2018/01/01 in Pubmed, from 1981/01/01 to 2018/01/01 in CNKI, and from 1900/01/01to 2018/01/01 in Wanfang. Results: No spontaneous breathing was observed preoperatively in the patient. The electrical response of phrenic nerves was intact on the right, but unresponsive on the left. We got started with the IDP at 4 weeks after surgery. The threshold voltage of the right hemidiaphragm pacing was 0.1 V and at the level of 0.7 V with an optimal effect. No significant diaphragmatic contraction was found at left side with the extent up till 0.7 V. The maximum tidal volume was 840 ml when electrical stimulation was given at an intensity of 0.7 V bilaterally. The bilateral stimulation voltage at 0.1-0.2 V, pacing frequencies at 9 beats/min in bed, or at 12 beats/min on wheelchair, were set to maintain the tidal volume at the level of (435±32) ml. After 2-week adaptive training, the patient could wean from the ventilator for 12 hours and had a normal blood gas analysis. At 6 week after surgery, with the aid of IDP, the patient could get out in wheelchair for outdoor activities. By literature review, we found 78 English papers, including 6 clinical trials, 10 reviews, and 11 Chinese papers, consisting of 8 reviews, 1 study in animal, and 2 news reports. Extensive contents, such as preoperative evaluation, preoperative preparation, surgical procedures, complications, surgical outcomes, and animal model studies of IDP were involved. The indications of IDP reported by literature were: (1) central alveolar hypoventilation; (2) Sleep apnea syndrome (Biot's respiration); (3) Respiratory failure induced by brainstem injury or disease; (4) Respiratory failure induced by spinal cord injury or disease above C3 level. Conclusion: Our case study confirmed the therapeutic effect of IDP on patients with respiratory failure caused by HCSCI.
目的：总结植入式膈肌起搏器在高位颈髓损伤患者的临床应用经验。 方法：患者男，14岁。2015年因脊髓炎导致颈2脊髓损伤，无自主呼吸，依赖呼吸机维持生命2年。2017年8月，在中国康复研究中心接受膈肌起搏器植入手术。以phrenic nerve和electrical stimulation和spinal cord injury，或implantable diaphragm pacer和spinal cord injury,或breathing pacemaker system和spinal cord injury等为关键词检索PubMed，范围为所有领域，时间在1970年1月1日到2018年1月1日；以膈神经和电刺激和脊髓损伤，或膈肌起搏器和脊髓损伤，或呼吸起搏器和脊髓损伤等为关键词，在CNKI和万方数据进行中文检索。检索CNKI时间范围为1981年1月1日至2018年1月1日，万方数据时间范围为1900年1月1日至2018年1月1日。 结果：术前患者无自主呼吸。经皮电刺激膈神经可见右侧膈肌收缩有力，左侧未见明显收缩。术后4周测试记录右侧起搏电压阈值为0.1 V，最大化效应起搏电压为0.7 V；左侧给予0.7 V起搏电压，未观察到明显膈肌收缩。给予双侧0.7 V电压起搏，最大潮气量840 ml。起搏模式为双侧起搏电压0.1～0.2 V，起搏频率9次/min(卧床)或12次/min(轮椅活动模式)，潮气量为(435±32) ml。适应性训练2周后，患者连续12 h脱机，血气分析结果正常。手术后6周，可乘坐轮椅外出活动。与膈肌起搏器和脊髓损伤相关的英文文献共78篇，其中临床实验6篇，综述10篇。内容涉及膈肌起搏器手术前准备、膈神经功能评估方法、外科手术、并发症、手术效果及动物模型研究等。中文文献11篇，其中8篇为综述，1篇为动物研究，2篇为新闻报道。文献报道的IDP适应证为中枢性肺通气不足、睡眠呼吸暂停综合征、脑干损伤或疾病导致呼吸衰竭、C3以上脊髓损伤或疾病失去自主呼吸。 结论：植入式膈肌起搏器对部分有适应证的因高位颈髓损伤失去自主呼吸的患者疗效可靠。.
Keywords: Cervical spinal cord injury; Electrical stimulation; Implantable diaphragm pacemaker; Respiratory failure; Ventilator.