Complete Liberation from Mechanical Ventilation Using Diaphragm Pacing in a Patient with Traumatic Spinal Cord Injury Despite Persistent Unilateral Diaphragmatic Paralysis

We report a case of successful diaphragm pacing in a patient with severe traumatic spinal cord injury resulting in complete ventilator dependence. A 29-year-old man sustained a traumatic cervical spinal injury at the C3 level. On admission, he exhibited tetraplegia, complete sensory loss below the C6 dermatome, and acute respiratory failure. Emergency spinal decompression surgery was performed; however, neurological deficits showed no improvement. Despite intensive respiratory rehabilitation, the patient remained fully dependent on mechanical ventilation. Diaphragm pacing implantation was planned approximately 17 weeks post-injury. Intraoperative electrical stimulation revealed no responsiveness in the left diaphragm, whereas the right diaphragm demonstrated sufficient contractility. After estimating that adequate tidal volumes could be achieved through unilateral right diaphragmatic stimulation, bilateral diaphragmatic electrodes were laparoscopically implanted. Diaphragm pacing was initiated on postoperative day one, gradually increasing pacing duration daily while maintaining exertion levels below the Borg scale 4. By day 46 post-implantation, the patient achieved complete independence from mechanical ventilation despite persistent left diaphragmatic paralysis. Enhanced right diaphragmatic function was confirmed by increased diaphragmatic thickness and thickening fraction. Additionally, improved sputum clearance allowed withdrawal from cough-assist therapy and subsequent closure of tracheostomy. At 1-year follow-up, the patient maintained independent respiration without device-related complications. This case highlights the potential efficacy of early diaphragm pacing implantation in patients with high cervical spinal cord injury, demonstrating favorable respiratory outcomes even in the presence of unilateral diaphragmatic dysfunction.