Working Diagnosis:
Degenerative disc disease and cervical disc herniation resulted in compression of the C5 nerve root, a component of the phrenic nerve. Pressure on the phrenic nerve resulted in paroxysmal diaphragmatic paralysis. The patient's upper extremity aching was most likely secondary to C4, C5, C6 nerve radiculopathy and central canal narrowing.

Treatment:
The patient was advised against participating in activities where she could incur trauma to her head and neck. She was allowed to perform yoga, but discouraged from practicing axial loading maneuvers. The patient was prescribed traction physical therapy and aggressive strengthening of her neck musculature.

Outcome:
Conservative treatment with traction physical therapy, avoidance of axial loading and strengthening of neck musculature was effective for the patient. She did not suffer further episodes of difficulty breathing. Years later, she reported that she could perform a modified headstand pose, where her weight was supported by her shoulders and forearms, not her cervical spine. Case Photo #1 The patient did not reported any return of symptoms.

Author's Comments:
I would like to thank Nicholas J. Meyer M.D., Carl W. Nissen M.D. and Jeff Eckleberry for their help.

Editor's Comments:
I would add musculoskeletal causes, such as intercostal muscle spasm or inflammation, to the differential diagnosis of pain and shallow breathing in this patient. Considering the normal neuro exam (I presume that the remainder of the upper extremity strength testing was normal) I would have probably obtained a chest x-ray before proceeding with a cervical spine MRI. Isolated phrenic nerve dysfunction is a very unusual presentation for a cervical disc herniation. Evidence of diaphragm dysfunction, as may be noted on the chest x-ray, would present a more convincing case. I also wonder if it is wise for this patient to continue to do headstands in light of the cervical spine degeneration.

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