Objectives: Chronic ventilator dependency in cervical tetraplegia is associated with substantial morbidity. When non-invasive weaning methods have failed the primary surgical treatment is diaphragm pacing. Phrenic nerve integrity and diaphragm motor units are requirements for effective pacing but may need to be restored for successful weaning. A surgical algorithm that includes: 1. Diaphragm pacing, 2. Phrenic nerve reconstruction, and 3. Diaphragm muscle replacement, may provide the capability of reducing or reversing ventilator dependency in virtually all cervical tetraplegics.

Design: Prospective case series.

Setting: A university-based hospital from 2015 to 2019.

Participants: Ten patients with ventilator-dependent cervical tetraplegia.

Interventions: I. Pacemaker alone, II. Pacemaker + phrenic nerve reconstruction, or III. Pacemaker + diaphragm muscle replacement.

Outcome measures: Time from surgery to observed reduction in ventilator requirements (↓VR), ventilatory needs as of most recent follow-up [no change (NC), partial weaning (PW, 1–12 h/day), or complete weaning (CW, >12 h/day)], and complications.

Results: Both patients in Group I achieved CW at 6-month follow-up. Two patients in Group II achieved CW, and in another two patients PW was achieved, at 1.5–2-year follow-up. The remaining two patients are NC at 6 and 8-month follow-up, respectively. In group III, both patients achieved PW at 2-year follow-up. Complications included mucous plugging (n = 1) and pacemaker malfunction requiring revision (n = 3).

Conclusion: Although more investigation is necessary, phrenic nerve reconstruction or diaphragm muscle replacement performed (when indicated) with pacemaker implantation may allow virtually all ventilator-dependent cervical tetraplegics to partially or completely wean.

目的：颈椎四肢瘫痪患者的慢性呼吸机依赖与严重的发病率相关。当非侵入性撤机方法失败时，主要的手术治疗是膈肌起搏。膈神经完整性和膈肌运动单位是有效起搏的必要条件，但可能需要恢复才能成功脱机。包括：1. 膈肌起搏、2. 膈神经重建和 3. 膈肌置换的手术算法可以提供减少或逆转几乎所有颈椎四肢瘫痪患者对呼吸机依赖的能力。

设计：前瞻性案例系列。

地点： 2015 年至 2019 年的大学医院。

参与者：10 名呼吸机依赖型颈椎四肢瘫痪患者。

干预措施：I. 单独起搏器，II。起搏器+膈神经重建，或III。起搏器+膈肌置换。

结果测量：从手术到观察到呼吸机需求减少的时间（↓VR），最近一次随访时的通气需求[无变化（NC），部分脱机（PW，1-12小时/天）或完全脱机（ CW，>12 小时/天）]和并发症。

结果： I 组的两名患者在 6 个月的随访中均达到 CW。在 1.5-2 年的随访中，第 II 组的两名患者实现了 CW，另外两名患者实现了 PW。其余两名患者分别在 6 个月和 8 个月的随访中为 NC。在第 III 组中，两名患者在 2 年的随访中均实现了 PW。并发症包括粘液堵塞 ( n  = 1) 和需要修复的起搏器故障 ( n  = 3)。

结论：尽管需要进行更多调查，但在植入起搏器的情况下进行膈神经重建或膈肌置换（当有指征时）可以使几乎所有依赖呼吸机的颈椎四肢瘫痪患者部分或完全脱机。