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Cervical nerve root contribution to diaphragm motor innervation revisited via intraoperative clinical and neurophysiological observations.

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Τίτλος: Cervical nerve root contribution to diaphragm motor innervation revisited via intraoperative clinical and neurophysiological observations.
Συγγραφείς: Sindou M; University of Lyon1, Lyon, France; Groupe ELSAN - Clinique Bretéché - CETD, Nantes, France., Georgoulis G; Department of Neurosurgery, General Hospital of Athens 'G. Gennimatas', Athens, Greece. Electronic address: gdgeorgoulis@gmail.com.
Πηγή: Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology [Clin Neurophysiol] 2026 Oct; Vol. 190, pp. 2111980. Date of Electronic Publication: 2026 Jun 18.
Τύπος έκδοσης: Journal Article
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Elsevier Country of Publication: Netherlands NLM ID: 100883319 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1872-8952 (Electronic) Linking ISSN: 13882457 NLM ISO Abbreviation: Clin Neurophysiol Subsets: MEDLINE
Imprint Name(s): Original Publication: Amsterdam : Elsevier, c1999-
Ιατρικοί όροι (MeSH): Diaphragm*/innervation , Diaphragm*/physiology , Spinal Nerve Roots*/physiology , Spinal Nerve Roots*/surgery , Spinal Nerve Roots*/physiopathology , Intraoperative Neurophysiological Monitoring*/methods, Electric Stimulation/methods ; Humans ; Female ; Middle Aged ; Adult ; Male ; Aged ; Cervical Vertebrae
Περίληψη: Objective: Classical descriptions state that diaphragmatic motor innervation arises predominantly from the fourth cervical nerve root (C4), with additional contributions from C3 and C5. However, clinical evidence supporting the functional involvement of C3 and C5 remains limited. Study aimed to reassess cervical root contribution to diaphragmatic innervation through intraoperative observations.
Methods: Eighteen consecutive patients undergoing dorsal root entry zone (DREZ) lesioning for refractory pain in upper-limb mostly due to brachial plexus injury were included. The procedure allowed intradural exposure of the C4 and C5 roots. During surgery, cervical roots were evaluated for anatomical integrity, and electrical stimulation of the ventral roots of C4 and C5 was performed to assess their functional contribution to diaphragmatic activation. The functional role of the C3 ventral root, not directly exposed, was not explored.
Results: Stimulation of an intact C4 ventral root (n = 10) or damaged but with preserved responsiveness (n = 2) constantly produced diaphragmatic contraction; when C4 was avulsed or unresponsive (n = 6), diaphragmatic paralysis was present in all but one patient (p < 0.001); Stimulation of an intact C5 ventral root (n = 6) never elicited diaphragmatic contraction (p > 0.05). In one patient with normal C5 but avulsed C4, diaphragm was paralyzed.
Conclusions: Intraoperative observations support C4 as the critical contributor to diaphragmatic motor innervation. No functional contribution of C5 was identified.
Significance: These findings, harvested in clinical conditions, refine the functional anatomy of the phrenic motor pathways and may assist neurological evaluation, and surgical planning in cervical and brachial plexus pathologies.
(Copyright © 2026 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)
Competing Interests: Declaration of competing interest The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Contributed Indexing: Keywords: Brachial plexus injury; Cervical nerve roots; Diaphragm innervation; Dorsal root entry zone (DREZ) lesioning; Intraoperative neurophysiology; Ventilatorymonitoring
Entry Date(s): Date Created: 20260627 Date Completed: 20260812 Latest Revision: 20260812
Update Code: 20260813
DOI: 10.1016/j.clinph.2026.2111980
PMID: 42364299
Βάση Δεδομένων: MEDLINE
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  Data: Cervical nerve root contribution to diaphragm motor innervation revisited via intraoperative clinical and neurophysiological observations.
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  Data: &lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Sindou+M%22&quot;&gt;Sindou M&lt;/searchLink&gt;; University of Lyon1, Lyon, France; Groupe ELSAN - Clinique Bret&#233;ch&#233; - CETD, Nantes, France.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Georgoulis+G%22&quot;&gt;Georgoulis G&lt;/searchLink&gt;; Department of Neurosurgery, General Hospital of Athens &#39;G. Gennimatas&#39;, Athens, Greece. Electronic address: gdgeorgoulis@gmail.com.
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– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: Classical descriptions state that diaphragmatic motor innervation arises predominantly from the fourth cervical nerve root (C4), with additional contributions from C3 and C5. However, clinical evidence supporting the functional involvement of C3 and C5 remains limited. Study aimed to reassess cervical root contribution to diaphragmatic innervation through intraoperative observations.&lt;br /&gt;Methods: Eighteen consecutive patients undergoing dorsal root entry zone (DREZ) lesioning for refractory pain in upper-limb mostly due to brachial plexus injury were included. The procedure allowed intradural exposure of the C4 and C5 roots. During surgery, cervical roots were evaluated for anatomical integrity, and electrical stimulation of the ventral roots of C4 and C5 was performed to assess their functional contribution to diaphragmatic activation. The functional role of the C3 ventral root, not directly exposed, was not explored.&lt;br /&gt;Results: Stimulation of an intact C4 ventral root (n&#160;=&#160;10) or damaged but with preserved responsiveness (n&#160;=&#160;2) constantly produced diaphragmatic contraction; when C4 was avulsed or unresponsive (n&#160;=&#160;6), diaphragmatic paralysis was present in all but one patient (p&#160;&amp;lt;&#160;0.001); Stimulation of an intact C5 ventral root (n&#160;=&#160;6) never elicited diaphragmatic contraction (p&#160;&amp;gt;&#160;0.05). In one patient with normal C5 but avulsed C4, diaphragm was paralyzed.&lt;br /&gt;Conclusions: Intraoperative observations support C4 as the critical contributor to diaphragmatic motor innervation. No functional contribution of C5 was identified.&lt;br /&gt;Significance: These findings, harvested in clinical conditions, refine the functional anatomy of the phrenic motor pathways and may assist neurological evaluation, and surgical planning in cervical and brachial plexus pathologies.&lt;br /&gt; (Copyright &#169; 2026 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)
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  Data: Declaration of competing interest The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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  Data: &lt;i&gt;Keywords: &lt;/i&gt;Brachial plexus injury; Cervical nerve roots; Diaphragm innervation; Dorsal root entry zone (DREZ) lesioning; Intraoperative neurophysiology; Ventilatorymonitoring
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        Value: 10.1016/j.clinph.2026.2111980
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        Text: English
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        StartPage: 2111980
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      – SubjectFull: Electric Stimulation methods
        Type: general
      – SubjectFull: Humans
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      – SubjectFull: Female
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      – SubjectFull: Cervical Vertebrae
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      – SubjectFull: Diaphragm innervation
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      – SubjectFull: Spinal Nerve Roots physiology
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      – SubjectFull: Spinal Nerve Roots surgery
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      – SubjectFull: Spinal Nerve Roots physiopathology
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      – SubjectFull: Intraoperative Neurophysiological Monitoring methods
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      – TitleFull: Cervical nerve root contribution to diaphragm motor innervation revisited via intraoperative clinical and neurophysiological observations.
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              Text: 2026 Oct
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