Q&A with Dr. Kaufman
Q: How much of your practice is devoted to phrenic nerve surgery?
Approximately 40 percent and growing. Each case requires a lot of time. In addition to the actual procedure, there is extensive pre-surgery preparation since most of the patients are from out of town. There’s a tremendous amount of time that goes into preparing each one. To fly across the country, or from someplace else in the world, and have a unique surgery requires careful planning to maximize a successful outcome.
Q: How common is phrenic nerve injury and what are its causes?
It’s probably more common than most people think, but hard to know. For example, what percentage of those with this problem are finding us at The Institute for Advanced Reconstruction?
I think there are some standard causes. If you break it down into broad categories you have a surgical injury (i.e. damage to the nerve while being operated on for other causes), an anesthetic injury (e.g. inadvertent phrenic nerve damage by a needle passed into the neck), a manipulation injury (e.g. chiropractic), or some type of trauma (such as a fall from a horse, a car accident, or even a freak event such as twisting the wrong way).
Q: What are the various factors among those requiring this procedure?
Age is a big factor for recovery; young patients regenerate better than older ones. Among our patients, the 25-50-year-olds do much better than the 60-70+-year-olds in terms of recovery.
Two-thirds to three-four of the patients are men. Men have more injuries in general—so they undergo more surgery, as well as chiropractic, and more likely to get injured from it. Secondly, men are usually bigger and heavier—so if the neck and (big, heavy) arm twist, there is potentially more damage.
Q: What is Idiopathic Diaphragm Paralysis?
Idiopathic Diaphragm Paralysis is the diagnosis applied when the cause of the diaphragm (breathing) paralysis is not known. For example, if there is no obvious acute trauma to the neck or chest, and there has not been any procedure or intervention that may have inadvertently caused a phrenic nerve injury.
Idiopathic Diaphragm Paralysis has traditionally been thought to occur from a “mystery” virus (often termed Parsonage-Turner syndrome or viral neuritis), however from our vast experience in evaluating thousands, and treating hundreds of patients over the last fifteen years, we have clearly identified that most cases of Idiopathic Diaphragm Paralysis are actually a result of chronic peripheral nerve compression in the neck region.
Chronic nerve compression of the peripheral cervical roots and phrenic nerve is a kind of “wear and tear” phenomenon, likely related to a cumulative impact of past “mini-traumas.” Examples could include contact sports, work-related damage (e.g. manual laborers, tech-neck) or exercise injuries. Unfortunately, there is no way to accurately identify compression of these small nerve structures on an MRI. However, we do rely on cervical MRI to eliminate the possibility of spinal cord compression. We also perform complete diagnostic testing to rule out the possibility of a viral cause or a generalized neurological disorder (e.g. Amyotrophic Lateral Sclerosis, Charcot-Marie-Tooth disease).
Q: Can you treat Idiopathic Diaphragm Paralysis with surgery?
In many cases, yes. At The Institute for Advanced Reconstruction, we have pioneered phrenic nerve reconstruction for the treatment of diaphragm paralysis. We have the world’s greatest experience in this procedure to restore functional movement to the diaphragm, including successfully treating many patients with presumed “Idiopathic Diaphragm Paralysis.”
Each patient is required to go through the necessary diagnostic testing to determine if they would be a surgical candidate.
Q: How long have you been doing these surgeries, and do you consider 500 a landmark number of procedures?
I think that 500 is a lot for any procedure and that type of extensive experience helps us to continuously improve our techniques for better outcomes. I’ve been doing these surgeries since 2007, with the majority of them in the last five years. My specialty in phrenic nerve problems occurred somewhat by accident. Our website was continually attracting patients with various rare nerve problems. I was challenged to figure out if I could do something for those with phrenic nerve problems requiring surgery.
It falls within my specialties—head and neck, and plastic surgery. The phrenic nerve is not commonly dealt with, unless it is neck or chest surgery, so thoracic or otolaryngology surgeons will encounter the phrenic nerve—but basically just to try to stay away from it. Until now, no one has attempted to actually get to the phrenic nerve—unless they inadvertently harm it– to do something positive with it.
I see the procedures I’ve done as just the tip of the iceberg. Unfortunately, despite our numerous medical publications and persistence in trying to educate physicians throughout the United States and abroad, a large portion of the medical community that takes care of phrenic nerve injury patients has no idea about these phrenic nerve treatments yet, so the goal is to get the word out.
Q: How do you intend to spread the word of your work?
To date, we have both a book chapter and several peer-reviewed articles published in the medical literature, including our January 2014 landmark paper in the Annals of Thoracic Surgery, entitled, “Functional Restoration of Diaphragmatic Paralysis: an Evaluation of Phrenic Nerve Reconstruction” This article unequivocally demonstrated that phrenic nerve surgery is superior to no treatment, and at least as good as diaphragm plication surgery, with the added benefit of restoration of functional movement. . In a follow up article published in the Journal of Reconstructive Microsurgery looking at longer term results, we demonstrated (in 186 patients) a 125% increase in diaphragm muscle strength and a greater than 85% overall success rate two years after phrenic nerve surgery. These results far surpass what can be achieved with medical therapy or plication surgery.
We make it a point to lecture annually at national gatherings of pulmonary physicians and spinal cord injury treatment professionals. Our mission is to continuously evaluate and report on surgical outcomes, especially long term follow-up of greater than one to two years, in order to demonstrate the benefits of this procedure. We have also authored the UpToDate section, “Surgical treatment of phrenic nerve injury.”
Q: How is your success rate with phrenic nerve surgery?
I’ve had a 80 to 85 percent success rate, which is consistent with other nerve surgeries that have been around for years. No one has 100 percent success. We don’t know enough about the nervous system to be able to surgically achieve that kind of success rate. While we’ve had a remarkable number of positive life-changing results with phrenic nerve cases, we’ve had patients who’ve not gotten better, and those we are waiting on over time, and we don’t know what their ultimate success will be. Complete recovery can take a long time (even two to three years), and post-operative rehabilitation is a big factor in overall success.
I always want to make procedures better. You always aim for 100 percent success; obviously, no one gets that. That being said, full function (of the phrenic nerve) is the goal I hope for. But if someone gets even 50 percent improvement in diaphragm function, his or her life is going to be better.
Over time, I’ve learned a tremendous amount. I have a better understanding of how the nerve functions, and how it gets damaged. So with each case, the success rates are going to get higher.
Q: How do you determine your success rate?
Other than the patient telling you he or she feels better, there are really only a few tests you can do. One would be a study of the nerves, but not everyone wants to come back and get needles stuck into them for this purpose; another is an x-ray to look for motion in the diaphragm, and the third is breathing tests–pulmonary function tests–which don’t always coordinate with patients’ symptoms. Pulmonary rehab and diaphragm re-training therapy are also an important part of the recuperative process that can help improve outcomes.
Q: How have you been impacted by the psychological or emotional aspect of doing this procedure over time?
I’m more in tune with the emotional aspect, since previously I never fully realized the implications of this condition in someone’s life, and quality of life. Most physicians still believe phrenic nerve injury is a relatively minor problem and that most people can live with it, and that they don’t necessarily need to be treated for it. But my patients have taught me otherwise. That’s also what we’re trying to teach the medical community.
Q: What can the patient do to help his/her odds?
If patients have this surgery they have to exercise the muscle (diaphragm). There are two things that are damaged: the nerve and the muscle. We’re only treating the nerve. I can’t make the muscle better. The muscle has to rebuild itself by exercise, usually through a pulmonary rehabilitation program and/or a program of diaphragm re-training therapy administered by a physical therapist with specialty training.
Q: Is every case different both physically and psychologically?
Yes, each case is different. It’s never cookie-cutter. It’s not like gallbladder surgery. It keeps me on my toes. We always have a standard game plan going into surgery, but I never completely know what I’m going to find until I go in– for example, if a person will need an actual nerve transplant– or what the outcome is going to be. It’s hard to prepare patients; that’s why I tell them all scenarios, and proceed with cautious optimism. We also turn away a lot of people. Just last week I turned a man away. Although he is very symptomatic, he had inconsistent results on tests we require. His tests show motion in his diaphragm, so I’m not going to take a person with a functioning diaphragm into surgery. I’ve probably turned away as many patients as I’ve operated on.
Q: Do you get ‘performance anxiety’ before doing these surgeries?
I wouldn’t say anxiety, but you get your ‘game face’ on; you get into the zone. You have to plan, think, prepare. One of my mentors said, you have to do three things for surgery: study it, know what you’re going to do; envision the entire process in your head; finally, realize that process.