PMC8769390_01
Chest X-rays immediately after the accident (a), preoperative (b), and postoperative (c). The diaphragm on the left side was elevated preoperatively although no diaphragmatic abnormality was observed immediately after the accident. The diaphragm abnormality was also improved postoperatively.
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F1
At the time, chest X-ray showed no abnormal findings (Fig. 1a). Chest X-ray and computed tomography (CT) did not show any abnormal findings without elevation of the left diaphragm which was the contralateral side of rib fractures (Fig. 1b), thereby traumatic phrenic nerve palsy was suspected. Foraminal stenoses due to osteophyte were more severe in the left sides (Supplementary Fig. 1, left; Supplementary Fig. 1 is available online.); therefore, thorough foraminotomies were performed using a bone curette and an ultrasonic aspirator, confirming sufficient root nerve decompressions (Supplementary Fig. 1, right). Chest X-ray showed an improved hemidiaphragmatic elevation on the left side (Fig. 1c).
Preoperative and postoperative findings. Preoperatively, a remarkable spinal canal stenosis did not exist in the sagittal view of cervical CT (a), whereas foraminal stenoses were observed at C3/4 (b), C4/5 (c), and C5/6 on both sides in the axial view. The C3/4 foramen on the left side was especially narrow (white arrow). Cervical MRI revealed mild disc bulging at C3/4, C4/5, and C5/6 in the sagittal view (d) without an intramedullary high signal on T2-weighted images. It also showed no lateral disc herniations at C3/4 (e), C4/5 (f), and C5/6 in the axial view. Postoperatively, titanium-coated PEEK cages were inserted between C3/4 and C4/5 (g). Intervertebral foramens were expanded at C3/4 (h) and C4/5 (i). CT: computed tomography, MRI: magnetic resonance imaging, PEEK: polyether-ether-ketone.
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CT showed foraminal stenoses at C3/4, C4/5, and C5/6 on both sides, especially C3/4 on the left side (white arrow); however, the spinal canal was not that narrow (Fig. 2a-2c). Cervical magnetic resonance imaging (MRI) revealed mild disk bulging at C3/4, C4/5, and C5/6 without lateralities nor an intramedullary high signal on T2-weighted images (Fig. 2d-2f). Cervical CT proved expansion of each intervertebral foramen (Fig. 2g-2i).
The respiratory function changes. Both the percent FVC and FEV1.0/FVC had drastically improved since the operation. FEV1.0: forced expiratory volume percent in one second, FVC: forced vital capacity.
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F3
Postoperative spirometry also showed a gradually improving respiratory function: the %FVC became 78.9% and FEV1.0/FVC became 64.9% 1 month postoperatively (Fig. 3).