Anesthetic Management and Considerations of Diaphragmatic Pacemaker Placement for Cervical Spine Injury: A Case Report.

High cervical spinal cord injuries (SCIs) can lead to diaphragmatic paralysis, necessitating long-term mechanical ventilation. Diaphragmatic pacemakers (DPs) offer an alternative by stimulating the phrenic nerve to restore diaphragmatic function, thereby improving quality of life and reducing ventilator dependence. However, anesthetic management for DP placement presents unique challenges due to the need to preserve diaphragmatic activity and manage autonomic instability. This case reports a 35-year-old male with complete C4 SCI resulting in quadriplegia and respiratory failure requiring mechanical ventilation. After multiple interventions, including spinal fusion and tracheostomy, he underwent DP placement to reduce ventilator dependency. The patient was successfully transitioned to DP postoperatively and discharged from the hospital on room air via a tracheostomy collar. DP is a valuable intervention for high cervical SCI patients but requires anesthetic strategies that preserve diaphragmatic function and manage common complications such as pneumothorax, autonomic dysreflexia, and ventilator challenges with abdominal insufflation. Avoiding muscle relaxants, continuous diaphragmatic monitoring, and proactive hemodynamic management are essential. The literature highlights rare but serious device-related complications, emphasizing the importance of vigilant intraoperative monitoring and interdisciplinary planning. As DP becomes more accessible, particularly in community hospitals, anesthesiologists must be prepared to navigate its perioperative challenges. This case underscores the importance of tailored anesthetic approaches to support safe and effective DP implantation.