Carlos Matias Garces Todorivich-Spinal Cord Injury-(Chile)-Posted on Aug.19th, 2015

Name: Carlos Matias Garces Todorivich
Sex: Male
Nationality: Chile
Age: 23Years
Diagnosis: 1. Spinal Cord Injury    2. Hyperthyroidism
Date of Admission: July 10th, 2015
Treatment hospital/period: Wu Medical Center/21 days

Before treatment:
3 years ago, patient had car accident from which he suffered from unconsciousness. He had motor and sensory disturbances accompanied with urinary and fecal disturbance. He had two times operations and regular rehab training. At present, he can perform daily activities along and walk alone with canes. He limps with the left leg， and it has apparent hypaesthesia and disorder.

Admission PE:
Bp: 125/75mmHg; Hr: 68/min. His body type was good. There was no yellow stain or petechia on mucous membrane. This was a scar on the left side of his breast because of operation and it is 1.5 centimeter’s long. On his back, there was a scar of 15 centimeter’s long. The scars healed well. There was scar observed on his head or face. The throat had no congestion and the tonsil had no swollen. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious moist or dry rales. The heart sounds was not regular but strong. The heart rate is 68/min. He had ventricular premature beat 5-6 times/minute. There was no obvious murmur in the valves. The abdomen was flat and soft, with no obvious masses. The spleen and liver were normal under palpation. The borborygmus sound was normal. The muscle of his left leg has been atrophied but there was no swollen. In the blood test, T3 and T4 of thyroid function were higher than normal. 

Nervous System Examination:
Carlos Matias Garces was alert and his speech was fluent. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 3.0 mms, both eyeballs could move freely. Both eyes had sensitive response to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. The neck moved normally. The muscle tension of both upper limbs was normal; the muscle strength was at level 5. The muscle strength of the near-end of his left leg was at level 3 while that of the distal-end was at level 0; the muscle tone of four limbs was normal. The bilateral abdominal reflex was normal. The cremasteric reflex of left side was retarded. The tendon reflex of biceps was normal. The achilles tendon reflex of left side was weaker than normal. The bilateral patellar tendon reflex cannot be elicited.

Examination of Sensory System: Pinprick sensation of left side: above L1 –normal; L1-L5 reduced sensibility; S1-S4 sensation disappeared. Vibratory sensation of left side: under L1 reduced sensibility. Complex sensation of left side: the shape identification of the distal-end reduced. That of area below ankle disappeared. The bilateral pathological sign was negative. The coordinate movement of upper limbs was normal. The knee-shin-heel test could be performed by right leg but not by left leg. The meningeal irritation sign was negative.

Treatment:
We initially gave Carlos Matias Garces a complete examination. According to the examination and medical history, he was diagnosed with 1. Spinal Cord Injury    2. Hyperthyroidism. He received four times of neural stem cell injection and four times of mesenchymal stem cell injection. He also received treatment to initiate nerve repair and regeneration. He had also medicines to nourish neurons, improve circulation and adjust immune function. We also gave him daily physical rehabilitation to improve the movement. He was also given treatment to control hyperthyroidism.

Post-treatment:
After 3 weeks' of treatment, the sensibility of left leg and motion of patient have improved.  The sensory range has expanded 2 levels. The walking gait of left leg has improved. The balance of body is better when he moves. He shakes less when he raises up his left leg or kick a ball. The muscle strength of left leg has improved. The near-end muscle strength is at level 4. The distal-end muscle strength is level 1-2. In supine position the slight movement of dorsal left foot can be observed. The thyroid function was normal when re-checked.

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