Damage to the phrenic nerve causes. Phrenic nerve. Syndromes of cranial nerve damage. Pathology of the cervical plexus

Cervical plexus(plexus cervicalis) is a paired part of the peripheral nervous system, which is formed by the anterior branches of the four upper cervical spinal nerves (C I -C IV) connected by arcuate loops. Located on the side of the transverse processes of the cervical vertebrae between the prevertebral and vertebral muscles. Nerves Sh. s. emerge in a fan-shaped manner from the posterior edge of the sternocleidomastoid muscle, spreading downwards, forwards and upwards.

Cutaneous branches of Sh. s. innervate the skin of the lateral part of the occipital region (lesser occipital nerve), the auricle and external auditory canal (greater auricular nerve), the anterior part of the neck (transverse nerve of the neck), the posteroinferior part of the neck, the clavicle area, the upper anterior part of the chest (supraclavicular nerves). Muscle branches innervate the anterior and lateral rectus capitis muscles, long muscles head and neck, scalene muscles, levator scapulae muscles, anterior intertransverse muscles. Lower root of Sh. s. and the upper root of the hypoglossal nerve, connecting, form a cervical loop, which innervates the scapulohyoid, sternohyoid and sternothyroid muscles.

The mixed branch of the cervical plexus is the phrenic nerve, which descends along the anterior scalene muscle to chest cavity and approaching the diaphragm in front of the root of the lung. The phrenic nerve innervates the muscles of the diaphragm, pleura, pericardium, and gives branches to the diaphragmatic peritoneum. The connections between the phrenic nerve and the celiac plexus explain the occurrence of the phrenicus symptom in liver diseases.

The diagnosis is based on characteristic clinical manifestations. Chest fluoroscopy may reveal paradoxical movements and unusual position of the diaphragm on the affected side. Informative research methods are computer

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The cervical plexus is formed by overlying nerve fibers spinal cord. The nerve tissues that make up this plexus innervate:

• cervical skin;
• neck skin;
• in partial order sternocleidomastoid type muscle fiber(Musculus sternocleidomastoideus);
• trapezius myofibers.

The cervical plexuses make up the following types of nerves:

• lesser occipital;
• large ear;
• supraclavicular;
• phrenic nerve.

This is a sensitive species nerve tissue. It innervates the outer skin of the back of the head and partially the concha of the ear.

When this nerve is damaged, the sensitivity of this area, which is innervated by it, is disrupted. Also, when exposed to an irritant, sharp pain will occur. This is the occipital type of neuralgic manifestations. Palpation effect on m. sternocleidomastoideus will reveal its painful areas.

Nervus auricularis magnus

It is also a sensitive type of nervous tissue that innervates the skin of the osteochondral canal belonging to the outer ear, which connects it to the middle ear (external auditory canal, in Latin: meatus acusticus externus).

Another large auricular nerve innervates the area under the lower jaw and, partially, the skin of the ear.

When it is exposed to damaging factors, the sensitivity of these areas with pain in the mandibular region is impaired, and the meatus acusticus externus will still hurt.

Nervi supraclaviculares

These sensory nerve tissues innervate:

• sub- and supraclavicular fossa structures;
• upper scapular zone;
• shoulder.

Impaired sensitivity is manifested by pain, which indicates that the supraclavicular neurofibers are affected.

Nervus phrenicus

Sensory branches with motor types make up the phrenic nerve, which is the largest neurofiber of the cervical plexus.

Diaphragmatic myofibers are innervated by motor nerve branches.

And the sensitive ones are innervated by:

• pleural, pericardial membranes;
• the diaphragmatic region with the peritoneum that is adjacent to it.

When the nervus phrenicus is affected, paralysis develops. Symptoms are expressed by difficulty breathing with the addition of cough.

When this nerve is irritated, the following is observed:

• impaired respiratory function associated with a feeling of lack of air;
• the patient will hiccup and feel the urge to vomit;
• he will feel pain in the chest, cervical area, supraclavicular fossa.

About occipital neuralgia

This pathology is considered a symptom complex, including symptoms of affected nerve fibers that form the cervical plexus.

About the reasons

This type of neuralgic manifestations can develop due to various circumstances. These include:

• infectious pathology;
• intoxication effects;
• disorders of water-salt metabolism in the form of spondylosis, spondyloarthrosis manifestations, spondylitis pathology of a tuberculous nature;
• oncological neoplasms of the cervical and collar zone;
• heartfelt, vascular diseases in the form of hypertension, aneurysmal conditions of the vertebral arterial vessels, as well as disturbances of vertebrobasilar blood flow.

About symptoms

The most basic symptomatic manifestation is pain in the area innervated by these nerves. This pain occurs constantly. As a rule, the large, rarely - the small occipital nerve fiber is affected.

The nervus auricularis magnus is also often involved in the clinic. Therefore, a person will feel pain in the area of ​​the concha and external auditory canal.

This soreness will increase when the patient:

• turns his head;
• coughs;
• sneezes.

Painful irradiation spreads to the sub- and supraclavicular areas, sometimes to the facial and scapular areas.

Palpation influence determines impaired sensitivity in the form of hyperesthesia, where the affected nerve tissues pass, pain sensitivity is expressed.

Therapeutic measures are reduced to the use of drugs that eliminate symptoms and treat the underlying pathology.

Clinical picture of phrenic nerve damage

Compression with an ischemic damaging effect on this nerve was observed in five patients with aneurysmal conditions of an atherosclerotic nature of the subclavian arterial vessel, the aortic arch, a pathology described by scientist Takayasu.

The clinical picture was manifested by pain in the left thoracic region (imitation of angina manifestations, “dry pleurisy”), which was not relieved by nitroglycerin and validol drugs. Irradiation of painful sensations manifested itself in the cervical and shoulder areas, aggravated when the patient swallowed, coughed, and breathed deeply.

During fluoroscopy, in order to identify the paresis of the diaphragmatic half, a weakened lower diaphragmatic breathing patient (the abdomen will not rise during inhalation).

In a patient with a neuroma on the right passing N. phrenicus at the entrance to the chest area, the clinical picture resembled chronic paroxysms of the hepatic type of colic. The patient also hiccupped for a long time.

After surgery, when the nerve fiber was crossed, the symptoms went away, the diaphragmatic part remained paralyzed.

The clinical picture of paroxysms of the diaphragmatic nervous tissue with its damaged sensory fiber structures indicates an intermittent type of ischemic manifestations affecting this nerve.

Also, in three patients who had an aneurysmal condition of the subclavian arterial vessel, the aortic arch, after reconstructive surgical intervention of the vessels was performed, the symptoms of the affected phrenic nerve completely disappeared, since compression phenomena were eliminated.

The diaphragm is a thin muscle-tendon plate that separates the thoracic and abdominal cavities. Since in the abdominal cavity the pressure is higher than in the chest, therefore the dome of the diaphragm is directed upward (this is why, with diaphragm defects, the abdominal organs are usually displaced into the chest, and not vice versa).

The diaphragm has a tendon center and a muscular part at the edges. In the muscular part there are sections adjacent to the sternum, ribs, lumbar muscles. The diaphragm has natural openings for the esophagus, aorta, and inferior vena cava. Between the sections of the muscular part of the diaphragm there are “ weak spots» - lumbocostal triangle (Bochdalek) and costosternal triangle (Larrey's fissure). Hernias, which I call diaphragmatic hernias, can emerge through natural openings and weak points of the diaphragm.

The diaphragm is covered above by the intrathoracic fascia, pleura, and in the central part by the pericardium, below by the intra-abdominal fascia and peritoneum. Adjacent to the retroperitoneal part of the diaphragm are the pancreas, duodenum, kidneys and adrenal glands, surrounded by a fatty capsule. The liver is adjacent to the right dome of the diaphragm, the spleen, the fundus of the stomach, and the left lobe of the liver are adjacent to the left. There are corresponding ligaments between these organs and the diaphragm. The right dome of the diaphragm is located higher (fourth intercostal space) than the left (fifth intercostal space). The height of the diaphragm depends on the constitution, age, and the presence of pathological processes in the chest and abdominal cavities.

The diaphragm is the main inspiratory muscle; in embryogenesis it develops from the transverse septum and pleuroperitoneal membranes. Motor innervation of the diaphragm is carried out by the phrenic nerve (C3-C5), and afferent innervation is carried out by the phrenic and lower intercostal nerves. When the diaphragm contracts, intrathoracic pressure decreases and intra-abdominal pressure increases. In this case, the diaphragm has a kind of suction effect on the lungs (intrathoracic pressure decreases) and straightens the chest (intra-abdominal pressure increases), which leads to an increase in lung volume.

There are static and dynamic functions of the diaphragm. Static consists of maintaining the difference in pressure in the chest and abdominal cavities and normal relationships between their organs. Dynamic is manifested by the effect of the diaphragm moving during breathing on the lungs, heart and abdominal organs. The movements of the diaphragm promote the expansion of the lungs during inspiration, facilitate the flow of venous blood into the right atrium, promote the outflow of venous blood from the liver, spleen and abdominal organs, the movement of gases in the digestive tract, the act of defecation, and lymph circulation.

Let us consider the main pathological processes occurring directly in the diaphragm and the pathological processes associated with its participation.

ACUTE PRIMARY DIAPHRAGMATITIS

Acute primary diaphragmatitis or Hedblom syndrome (Joannides-Hedblom syndrome) is extremely rare and is characterized by the formation of infiltrates in the diaphragm. The etiology of diaphragmatitis is unclear. With this disease, concomitant inflammation of the lung and diaphragmatic pleurisy are always diagnosed. It is believed that inflammation of adjacent organs is a secondary process.

Primary myositis of the diaphragm is another form of diaphragmatitis that can occur with infection caused by the Coxsackie virus. such diaphragmatitis is described under different names: Bornholm disease, pleurodenia, epidemic myalgia.

The clinical picture of both forms of diaphragmatitis is the same. There is pain in the subscapular region and shoulder. The pain is especially pronounced along the costal arch. Which becomes unbearable during coughing, yawning and deep breathing, also painful top part abdomen, the sound of thorny pleura may be heard. The high position of the diaphragm and the immobility of its dome are noted. There is no pleural effusion. In cases of viral nature of diaphragmatitis, skeletal muscles are involved in the pathological process.

Diaphragmatitis is differentiated from dry diaphragmatic pleurisy, gastric ulcer, pancreatitis. Diagnostic errors occur frequently with dry pleurisy.

No less rare than acute primary diaphragmatitis are tuberculous, syphilitic, eosinophilic and fungal granulomas, which cause local deformation of the diaphragm, its thickening in this area and blurred outlines. A casuistry is the development of pneumocele of the diaphragm when artificial pneumoperitoneum is applied. In the area of ​​gas protrusion into the fibromuscular elements of the diaphragm, a clearing appears in the form of a bubble.

TUMORS OF THE DIAPHRAGM

Benign tumors of the diaphragm originate from muscle, fibrous, adipose or nervous tissue. Adenomas from embryonic ectopic tissue of the liver and adrenal gland have also been described. It is often asymptomatic, and with radiation examination it must be distinguished from tumors of supra- and subdiaphragmatic localization. recognition of cysts of a dermoid or other nature (post-traumatic, mesothelial) is based on sonography or computed tomography data.

Primary malignant tumors, as a rule, represent a variety of variants of sarcomas. Their growth is accompanied by pain due to damage to the pleura and peritoneum. The tumor is detected by radiation examination, but must be distinguished from a neoplasm growing into the diaphragm from a neighboring organ. When effusion appears in the pleural cavity, it can be difficult to distinguish it from lung cancer or pleural mesothelioma.

As for metastases of a malignant tumor in the diaphragm, they form plaques or hemispherical formations that are not easy to distinguish from metastases in the adjacent pleura or peritoneum.

DIAPHRAGMAL HERNIA

Diaphragmatic hernias can be congenital or acquired. Through congenital or traumatic defects in the diaphragm, the peritoneum with the omentum, or less often with a loop of intestine, can protrude into the pleural cavity. In traumatic hernias, the organs of the abdominal wall prolapse without the peritoneum (false hernia). Very rarely, a lung protrudes into the abdominal cavity. This occurs when the abdominal organs fuse with the lung and then pull it through the hernial opening. Most often, hernias form in the esophageal opening of the diaphragm. According to Evans, diaphragmatic hernias occur in 3.4% of people undergoing X-ray examination.

N.S. Pilipchuk, G.A. Podlesnykh, V.N. Pilipchuk (1993) observed patient K., 36 years old, who was admitted to the clinic with a diagnosis of a lung cyst, which was discovered during a routine examination. I made no complaints. Blood tests are normal. An X-ray examination revealed that the cyst was localized in the anteromedial pleurodiaphragmatic sinus. Preliminary diagnosis: lung cyst or tumor. The patient was offered surgery, to which he agreed. After thoracotomy and separation of the lower lobe from the diaphragm, a diaphragmatic hernia was discovered. The hernial sac is isolated and opened. There was an oil seal in it. It was reduced, and a purse-string silk suture was placed on the hernial orifice. After the operation, the patient's general condition was satisfactory and recovery occurred.

Large hernias may be accompanied by symptoms of respiratory and cardiac problems. Dysfunction of the stomach and intestines most often occurs with left-sided hernias. A dull pain appears in the epigastric region, intensifying after physical activity. Pain may radiate to the subscapular region. In addition, when the stomach is bent, appetite may be disrupted, nausea, dysphagia or belching with hiccups may appear. If the large intestine enters the hernial sac, this leads to constipation, shortness of breath and palpitations.

The most dangerous complication of diaphragmatic hernias is their strangulation. A clinical picture of an acute abdomen develops, which depends on the strangulated organ. When the stomach or intestines are pinched, obstruction occurs. X-ray diagnosis is decisive.

Diaphragmatic hernia should be distinguished from relaxation of the diaphragm. A hernia is characterized by a protrusion above the dome of the diaphragm. The outline of the hernia may change with changes in body position.

DIAPHRAGM RELAXATION

Relaxation of the diaphragm - the term was proposed by Wieting; Currently, it is accepted by most authors to designate a one-sided persistent high standing of an extremely thinned, but preserving the continuity of the diaphragm in the presence of its attachments in its usual place.

Relaxation of the diaphragm is less common than diaphragmatic hernia. As a rule, relaxation of the left dome of the diaphragm is observed, and extremely rarely - the right one. Unlike a hernia, during relaxation the entire dome of the diaphragm protrudes. The muscle elements in the diaphragm are preserved, but they are sharply atrophied. Relaxation can be congenital or acquired (in case of damage to the phrenic and sympathetic nerves).

The dome of the diaphragm rises and sometimes reaches the level of the third rib in front, compresses the lung, and can displace the heart. Shortness of breath, palpitations, arrhythmia, angina pectoris, dysphagia, pain in the epigastric region, and gastric bleeding appear. In addition to physical data, X-ray examination and computed tomography are important in diagnosing relaxation. When the diaphragm relaxes, the dome of the diaphragm is rounded, and with pneumoperitoneum, the air is evenly distributed between the diaphragm and the stomach or liver. The diagnosis is also made based on the presence of symptoms of movement of the abdominal organs into the corresponding half of the chest, compression of the lung, and displacement of the mediastinal organs. Due to the absence of a hernial orifice, strangulation is impossible. Errors in the differential diagnosis of these two conditions are very rare and indicate the doctor’s inattention. Limited right-sided relaxation is differentiated from tumors and cysts of the lung, pericardium, and liver.

Treatment. In the presence of severe clinical symptoms, it is indicated surgery. The operation consists of reducing the displaced abdominal organs to a normal position and forming a duplicate of the thinned diaphragm or plastically strengthening it with a mesh made of synthetic non-absorbable materials.

DYSTOPIA, DICHSCINESIA AND DIAPHRAGM DYSTONIA

Dystopia of the diaphragm expressed in the high or low position of the entire diaphragm, one half of the diaphragm or any part of it. Congenital bilateral high position of the diaphragm is extremely rare. Under physiological conditions, elevation of the diaphragm develops during pregnancy; a high position of the diaphragm occurs in a number of pathological conditions - ascites, severe flatulence, intestinal obstruction, general peritonitis, hepatosplenomegaly. Radiologically, an increase in the area of ​​​​adjacent to the diaphragm of the heart and a sharpening of the costophrenic angles are noted.

There are just as many reasons for the high position of one of the halves of the diaphragm. It can be caused by a decrease in lung volume on the same side as a result of atelectasis, collapse, cirrhosis, thromboembolism, hypoplasia. It can be caused by diaphragmatitis, a subdiaphragmatic abscess, a large cyst or tumor in the subdiaphragmatic region, a severely distended stomach, and a distended splenic curvature. And, of course, the rise of one half of the diaphragm is clearly pronounced when the phrenic nerve is damaged. Some of the listed conditions need to be considered in more detail.

Limited peritonitis in the upper abdominal cavity is accompanied by the development of secondary acute diaphragmatitis. Its signs: deformation and high position of the corresponding half of the diaphragm, limitation of its mobility, uneven and blurred outlines, thickening and blurring of the contours of the intermediate leg of the diaphragm, accumulation of fluid in the costophrenic sinus, foci of atelectasis and infiltration at the base of the lung. These symptoms indicate possible abscess formation in the subphrenic space and upper liver. The formation of an abscess is recognized using sonography, CT or MRI, and if it contains gas, then radiographs.

Damage to the phrenic nerve, regardless of its nature (birth trauma, injury, poliomyelitis, intoxication, compression by an aneurysm, tumor invasion, surgical intervention) leads to loss of active movements of the corresponding half of the diaphragm and its rise. Initially, a weakening of respiratory movements is observed, then their paradoxical nature joins, which is demonstratively revealed during the Hitzenberger or Müller test. When inhaling, a rise in the affected part of the dome and a shift of the mediastinum to the healthy side are recorded. We emphasize that in healthy people, small paradoxical movements are found very rarely and only in the anterior parts of the diaphragm.

To dyskinesias and dystonias of the diaphragm include various disturbances of its tone and respiratory movements. Most of them are associated with neuromuscular diseases, acute inflammatory and traumatic lesions of the pleura, peritoneum, spine and ribs, and intoxications. A psychogenic effect, for example, a sudden feeling of fear, can cause a short-term spasm of the diaphragm. With hysteria, bronchial asthma, tetany and strychnine poisoning, tonic convulsions of the diaphragm are observed: the latter is located low, flattened and motionless when breathing.

Fluoroscopy clearly reveals a clonic spasm of the diaphragm (hiccups, sobbing), which occurs in a number of pathological conditions (mental disorders, consequences of encephalitis and stroke, uremia, alcohol intoxication, etc.). On the tap, at the moment of sobbing, a rapid lowering of the diaphragm at the moment of exhalation is observed with its further return to its original position.

Many authors have described manifestations of tics (chorea of ​​the diaphragm) and flutter of the diaphragm. Tics are short clonic contractions of varying frequencies, and flutters are extremely frequent (up to 200-300 per minute) paroxysms of contractions, observed in psychopathy and encephalitis. Among the peculiar disorders is athetosis - small irregular contractions of the muscle bundles of the diaphragm, both during inhalation and exhalation, observed in emphysema, mental illness and encephalitis.

A low location of the diaphragm and limited mobility are characteristic of obstructive pulmonary lesions with severe diffuse emphysema. A slight decrease in the level of the diaphragm is observed in bilateral pneumothorax. Unilateral pneumothorax (especially valvular) and pleural effusion (before the formation of adhesions) cause a decrease in the dome on its side.

CHILAIDITY SYNDROME

Khilaiditi syndrome is characterized by displacement of part of the colon to the pleura. This condition occurs more often in men than in women, and only in rare cases in children.

N.S. Pilipchuk, G.A. Podlesnykh, V.N. Pilipchuk (1993) observed this syndrome in one child. The heart was shifted to the left, and there was a history of frequent bronchitis. Considering the low-grade fever, loss of appetite, emaciation, weakness, sweating, a diagnosis of disseminated pulmonary tuberculosis was made, and the patient was treated with anti-tuberculosis therapy for a month. The X-ray shows focal shadows and cavities in the right lung, decreased transparency of the lung on the left. No positive dynamics were achieved as a result of treatment. Considering the dyspeptic syndrome, a contrast study of the stomach and colon was performed. Loops of the colon were found in the right hemithorax. Based on the results obtained, the correct diagnosis was established.

The course of Khilaiditi syndrome can be without clinical manifestations and is usually discovered accidentally during an X-ray examination of the digestive tract. But more often there is constipation, pain in the right hypochondrium, radiating to the shoulder and under the shoulder blade. Sometimes there are heart rhythm disturbances and shortness of breath. The pain may also resemble hepatic colic. Pain localized in the right hypochondrium is sometimes mistakenly regarded as a disease of the gallbladder. Suspicion that the case concerns Khilaiditi syndrome arises when a tympanic percussion sound is detected in areas of percussion dullness of the liver. In addition, displacement and expansion of the stomach is possible.

Diagnosis of the disease is based on X-ray examination of the stomach and intestines: the decisive factor is the radiologically determined interposition of the intestine between the liver and the right dome of the diaphragm.

DAMAGE TO THE DIAPHRAGM

Violation of the integrity of the diaphragm occurs as a result of injury from a firearm or bladed weapon, the end of a broken rib or chest injury, or a sudden sharp increase in intra-abdominal pressure. The possibility of damage to the diaphragm is indicated by the location of the wound (wound opening) below the level of the 6th rib. Closed injuries are observed during transport trauma, a fall from a height, and in some cases when lifting a heavy object, during childbirth, during severe vomiting and coughing (so-called spontaneous ruptures).

Regardless of the origin, diaphragmatic ruptures can be uncomplicated or complicated. The latter include injuries with transdiaphragmatic prolapse (prolapse) of the abdominal organs into the chest cavity. Many authors call prolapse a “false diaphragmatic hernia” in contrast to true diaphragmatic hernias, in which the prolapsed organs are surrounded by a hernial membrane, including the peritoneum and pleura.

Depending on the location and size of the rupture, the presence or absence of pneumothorax, hemothorax, damage to the lung and chest skeleton, the clinical picture is multifaceted - from shock with dyspnea and circulatory collapse to a relatively modest breathing disorder, slight pain, a feeling of heaviness in the epigastric region.

With small ruptures, radiation symptoms are not rich. Using sonography, hemorrhage into the pleural cavity and weakening of the movements of the diaphragm are detected. X-rays indicate a high position of the affected part of the diaphragm and a limitation of its mobility; hemothorax (in some cases, curled), hemopneumothorax, hemorrhage into the lung may be detected. In rare cases, gas penetrates into the abdominal cavity in small quantities. In the future, pleural cords and adhesions may form, making it difficult to recognize prolapse. The detection on computed tomograms of damage to the upper part of the liver and at the same time hemothorax also indicates a rupture of the diaphragm.

The radiation picture changes dramatically with prolapse of the abdominal organs into the chest cavity, that is, with the formation of a diaphragmatic hernia of traumatic origin.

Hiccups are attacks of involuntary spasms of the diaphragm that occur during inhalation. This is manifested by chest movement and a characteristic sound. Does not represent a serious illness. The frequency of hiccups is usually 2-60 per minute. Usually lasts a few minutes and disappears spontaneously.

Causes of hiccups

The main causes of chronic hiccups This:

• diseases of the central nervous system (inflammation, vascular disease, tumors, etc.);
• metabolic diseases (uremia, hyponatremia, hypocalcemia, diabetes mellitus);
• diseases of the neck and chest (for example, pneumonia and pleura, pericarditis, myocardial infarction);
• diseases of the abdominal cavity (for example, hiatal hernia);
• operations within the chest and abdominal cavity;
• toxins, such as alcohol poisoning, as well as medications;
• pregnancy.

Pregnant women may experience hiccups, which are caused by the unborn baby. In the first 28 days of life, it can appear several times during the day. This is caused by immature nervous system fetus

In turn, hiccups that occur in infants during feeding are caused by irritation of the nerve endings of the diaphragm as a result of swallowing air.

Methods for treating hiccups

If this occurs, it may help:

• drinking ½-1 glass of warm boiled water once;
• inhalation and exhalation of air from a paper bag (bag);
• infusions of herbal mixtures or soothing tincture;
• pharmacological sedatives that weaken smooth muscle membranes.

You should definitely consult a doctor if hiccups are accompanied by:

• severe abdominal pain;
• acute diarrhea;
• bloating, belching;
• aversion to meat;
• chest pain, difficulty breathing, and coughing up blood;
• severe headaches and dizziness;
• visual impairment.

Medical consultation is also required in situations where:

• hiccups after taking a new drug;
• hiccups in an adult, which lasts more than 8 hours, in children – 3 hours.

If the doctor thinks that frequent hiccups– this is a result of stress, may recommend a sedative or relaxant. When stressful situations are eliminated, and the attacks of hiccups do not disappear, you should look for the cause elsewhere.

If all others are excluded possible reasons, hiccups are considered an independent disease that you need to learn to live with. Sometimes a surgical procedure is performed that involves cutting the phrenic nerve. Of course, this operation is performed very rarely.

The diaphragm, the “thoraco-abdominal barrier,” is a powerful muscular organ that separates the chest cavity from the abdominal cavity and maintains intra-abdominal pressure with its tone. This tone is maintained both at low (enteroptosis) and at high standing of the diaphragm (ascites, flatulence, pregnancy), ensuring the effectiveness of active contraction of the diaphragm during inhalation. The diaphragm is the main respiratory muscle, also involved in blood circulation. Rhythmic respiratory movements of the diaphragm contribute to breathing from the moment of birth and do not stop completely, as determined by x-rays, even during a pause during Chanestokes breathing. The diaphragm is especially important for ventilation of the lower parts of the lungs, where atelectasis most often develops, for example, after surgery. The diaphragm, contracting, brings together the edges of the lower opening of the chest, being to a certain extent an antagonist of the intercostal muscles, which raise the lowered arches of the ribs and thereby expand the lower opening of the chest. Interaction with the intercostal muscles is ensured especially effective increase lung volume. When the diaphragm is paralyzed, during inhalation the false ribs diverge to the sides, and the epigastric region bulges.
The participation of the diaphragm in blood circulation is also significant. Closely entwining the liver with its legs and dome, the diaphragm, during inhalation, squeezes venous blood out of the liver and at the same time relieves intrathoracic pressure, thus facilitating the suction of venous blood from the main venous collectors to the heart.
Its complex function muscular organ The diaphragm carries out breathing and blood circulation thanks to complex innervation, which also determines numerous neuroreflex reactions of the diaphragm in the event of a violation of the central nervous and autonomic regulation.
With pulmonary emphysema, a long-term increase in the function of the diaphragm leads initially to its hypertrophy, and then to degenerative changes (fatty degeneration) with decompensation of function, which has great importance in the development of respiratory and pulmonary-cardiac failure in lung diseases. Atrophy muscle layers diaphragms are found in cases of paralysis of the phrenic nerve, for example, after therapeutic phrenico-exeresis for pulmonary tuberculosis.
The standing height and movements of the diaphragm in the clinic are judged by the visible movement of the diaphragmatic shadow during breathing (Litten's phenomenon), by the percussion border of the lungs with the abdominal organs, as well as by the respiratory movements of the false ribs, partly by the rhythmic change in retraction and bulging of the epigastric region. Low the standing of the diaphragm is observed with pulmonary emphysema, effusion pleurisy, pericarditis, etc., high - with ascites, flatulence, intra-abdominal tumors.The most clear data is revealed by fluoroscopy.
Painful diaphragmatic syndrome is associated with the fact that the central part of the diaphragm is innervated by p. phrenicus, which is why pain is transmitted through the fourth cervical nerve to the neck and area trapezius muscle(shoulder, acromial sign) and there are pain points along the intercostal spaces near the sternum (especially on the right) and between the legs of the sternocleidomastial muscle. The peripheral part of the diaphragm is innervated by the intercostal nerves, and the pain is referred to the lower part of the chest, the epigastric region and the abdominal wall; reflex pains such as angina pectoris are also observed, transmitted through n. vagus

Diaphragmatitis

Clonic spasm of the diaphragm (hiccups)

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Clonic spasm of the diaphragm (hiccups) is usually a harmless phenomenon, sometimes life-threatening, more often it occurs reflexively in response to irritation of neighboring organs, when the stomach is overloaded, when peritonitis begins, when the phrenic nerve is irritated by a tumor of the mediastinum, an aortic aneurysm, or from excitation of a center located nearby with respiratory, agonal hiccups, which have such a poor prognostic value, uremic hiccups, hiccups with cerebral apoplexy, encephalitis, with venous stagnation of the brain.
Treatment. Skin irritation (mustard plasters, rubbing the skin with brushes, ether under the skin), distraction of the patient’s attention, stimulation of the respiratory center (inhalation of carbon dioxide in its pure form or in the form of carbogen), lobelia, quinidine (as a decreaser in the excitability of the diaphragmatic muscle), alcoholism and, in extreme cases, transection phrenic nerve.
Tonic spasm of the diaphragm observed with tetany, tetanus, and peritonitis. Therapy-chloroform, ether.

Diaphragmatic paralysis

Paralysis of the diaphragm is characterized by its high standing. When breathing, a divergence occurs towards the lower ribs, the epigastric region does not bulge, as is normal, and the liver does not descend. Shortness of breath develops during work and excitement. There is a change in voice, weakness of coughing, sneezing. Tension is released during defecation. With complete paralysis, minimal exertion may result in fatal asphyxia.
Diaphragmatic hernia (false and true). A diaphragmatic hernia is usually called a false traumatic hernia (hernia diaphragmatica spuria, traumatica; evisceratio), when in typical cases after a puncture wound or blunt trauma, as a rule, the stomach and intestines protrude into the chest cavity on the left through the gap of the diaphragm. Severe shortness of breath, vomiting, hiccups develop, and death from shock may even occur. The examination reveals tympanitis in the chest, absence of respiratory noise, displacement of the heart, especially characteristic iridescent bowel sounds in the chest or hemothorax, concomitant pleurisy, peritonitis, and sudden radiological changes.
A general practitioner more often deals with the long-term consequences of an injury, which the patient does not always find necessary to talk about without special questioning.
The patient usually experiences only nausea, vomiting, or symptoms of intestinal obstruction. There may be signs of compression of the mediastinal organs. When examining, it is important to pay attention to the wound scar. An unusual area of ​​tympanic sound is also found in the chest; respiratory mobility of the chest is limited (usually on the left), respiratory sounds are weakened or cannot be heard, the heart is displaced. Unlike pneumothorax, there is no bulging of the intercostal spaces, but a seemingly empty epigastric region is characteristic, especially the intestinal sounds of the prolapsed stomach and intestines heard near the hailstone. An X-ray examination after taking barium clarifies the picture in detail.
The most serious, sometimes fatal complication is intestinal obstruction. The treatment is surgical and technically difficult.
Less often emb. a true diaphragmatic hernia (hernia diaphragmatica vera) is given when, due to a congenital defect in the development of the diaphragm (usually behind the xiphoid process), the stomach or large intestine ends up in the anterior or posterior mediastinum, in a sac of one or all layers of the diaphragm.
IN last years During a wide X-ray examination of patients, it is not uncommon to find small diaphragmatic hernias at the hiatus oesophageus itself, with the upper part of the stomach protruding above the diaphragm. The patient presents vague dyspeptic complaints, and sometimes suffers from more severe reflex angina due to irritation of the nearby vagus nerve and coronary spasm. One should also distinguish from a diaphragmatic hernia the rare unilateral relaxation, relaxation or insufficiency of the diaphragm, which opens accidentally when, in the absence of complaints, tympanitis is found by percussion, and an x-ray examination reveals a high position of the diaphragm.