Coimbatore (Tamil Nadu): Pacemaker for an ailing heart is well known in India. But a pacemaker for artificial and ventilator free breathing in a spinal cord injury patient is mostly unheard of in the country. Now doctors at Kovai Medical Centre and Hospital (KMCH), Coimbatore claim to have performed just that under the leadership of senior consultant spine-neurosurgeon Dr J K B C Parthiban.
“Diaphragm is a large fan shaped prominent muscle that is responsible for our breathing and is situated between the chest that harbour the lungs and the abdominal cavity. When diaphragm contracts we inhale air (oxygen) and the lungs get inflated with oxygen that is essential for living. When the diaphragm muscle relaxes, air in the lungs containing unwanted carbon dioxide is exhaled,” explained Dr Parthiban.
“We can appreciate the function of this muscle when we breathe, by looking at the chest and abdomen. This process of breathing is controlled by brain stem (vital part in the brain), through the spinal cord that passes through the spinal canal of cervical bones (vertebrae) in the neck,” said Dr Parthiban.
“The nerves (Phrenic Nerves) that supply the diaphragm originate from cells of spinal cord in the neck. Hence injuries in this portion of the spinal cord and above, paralyses (stops) the breathing process apart from leaving the limbs ineffective. This dreaded condition is called ‘Quadriplegia or Tetraplegia with diaphragm paralysis’,” he said.
According to Dr Parthiban, recovery from such neurological deficit is very slow and sometimes not possible. Patients who suffer from cervical spine and spinal cord injury sometimes do not breathe and become ventilator dependent for life. “This is a great challenge in medicine at present,” he said.
In a freak accident while trying to help unload a heavy object, 65-year-old Mohan (name changed) sustained a severe injury to the neck and instantly became Quadriplegic (paralysis of both arms and legs below the neck) and was referred to Kovai Medical Centre and Hospital, Coimbatore for spinal surgery and critical care management.
Life saving support was immediately given to the patient and he was put on ventilator for artificial respiration, since his respiration (breathing) was inadequate for living. Investigations CT and MRI scan revealed a severely broken second cervical vertebra (Axis-C2, Neck bone) and crushed spinal cord (contusion).
The injury was graded grievous and needed long term treatment. The fracture neck bone was then fixed (stabilized) with a screw by a unique spine surgery and aggressive intensive care and physiotherapy was provided to the patient in the ICU (intensive care unit).
The patient was on artificial ventilation since then for three long months and there were no signs of spontaneous breathing efforts emerging, though he was conscious, alert and communicable with everyone. It was then that the neurosurgeon decided to provide a pacemaker for breathing, aiming to relieve the patient from ventilator dependency.
Dr Parthiban implanted the pacemaker – Phrenic Nerve Stimulator – on the patient with the help of a team of experts — Dr Arul Selvan V (neurologist), Dr Balasundaram S (cardiothoracic surgeon), Dr Rajendran K (anaesthesiologist) and Dr M N Sivakumar (intensivist).
Electrodes were placed around the phrenic nerve (that supplies the diaphragm) in the neck on both sides and the battery (pacemaker) on the chest wall. The pacemaker was then activated, which in turn stimulated the phrenic nerves to start the process of breathing. Like in normal breathing the stimulation was set in standard rate and rhythm.
“Since then the pacemaker slowly and steadily took over the process of breathing, alternating with ventilator support. By four weeks time the patient started breathing with the help of the pacemaker for more than 12 hours during daytime. This is a very significant and good result in this patient due to the fact that the ventilator was on standby. In due course, the patient can be mobilized freely without the dependency of a mechanical ventilator,” said Dr Parthiban.
“The most famous and excitable case in the history of medicine was of Christopher Reeve – The Superman, who underwent a diaphragm pacing system in 2003. However, the system was implanted on him seven years after the injury, when the diaphragm muscle was weak and atrophic. Mr Mohan’s diaphragm is strong and bulky and hence we expect a good result,” added Dr Parthiban.
“Bilateral stimulation of the nerve is very effective. This pacemaker is adjustable and can be tailored to the patient’s need. Even in developed countries these procedures are done only in few centres,” said Dr Selvan.
Dr Nalla G Palaniswami, chairman and managing director, KMCH, lauded his medical fraternities for performing this innovative technique on such a difficult case.
He said, “The infrastructure and economy of civil population should be geared up to take care of these patients with pacemakers at their home. It needs a lot of commitment and patience to nurse these patients. Mr Reeve lived for more than nine years with ventilator support in USA.”
“Medical facilities in India have grown to a new height in recent years to support and facilitate doctors to perform most challenging medical and surgical treatments,” added Dr Palaniswami.