Mr. Lee-Spinal Cord Injury-(USA)

Name: Mr. Lee
Sex: Male
Nationality: USA
Age: 25Y
Diagnosis: 1. Spinal cord injury 2. Bedsore Grade3

Before treatment:
The patient had a car accident 2 years ago (October 23, 2014) and he was in a coma with no spontaneous breathing and he was sent to the local hospital for treatment. He was diagnosed with severe brain and spinal cord injury. He had tracheal intubation, gastrostomy and bladder fistula surgery. One day later he had C2 vertebral resection and C5-C7 vertebral fixation. About 6 weeks after that the patient woke up and 3 months later the tracheal intubation was removed. He did rehabilitation training every day and the situation was basically stable but with no obvious improvement in limb movement. At present the patient cannot take care of himself, he has exercise and sensory disturbances, he is unable to control urination or defecation. He came to our hospital for further treatment.
The patient has good spirit, diet and sleep, he is unable to control urination or defecation.

Admission PE:
Bp: 108/69mmHg, Hr: 90/min, breathing rate: 20/min, body temperature: 36 degrees. Nutrition status is not bad with normal physical development. There is no injury or bleeding spots of his skin and mucosa, no blausucht. There is 10cm surgery scar on the  right side of his neck and there is scar post tracheotomy at middle of both claviculate sides. There are also gastrostomy scars on the left upper belly and a cystostomy scar at the bladder area. There is a burning scar which diameter around 5mm and there are many scar tissues on the right side of his back. There is a skin burst at his buttock around 2.4cm, with the depth  around 1cm with exudation, skin surrounding is pale. His chest develop is normal, the respiratory sounds of left lung is clear, of right lower lung is weaker but with no dry or moist rales. The heart beat is powerful with regular cardiac rhythm and no obvious murmur in the valves. The abdomen is soft and bulging, no masses or tenderness.   The liver and spleen were normal, shifting dullness is negative. The spinal column is normal and there was no edema in both lower limbs.

Nervous System Examination:
Patient was alert and his mental status is good with clear speech. His memory and the orientation and calculation ability were normal . Both pupils were equal in size and round, diameter of 3 mm, react well to light and the eyeballs can move freely. No nystagmus. Bilateral forehead wrinkle and nasolabial fold are symmetrical, showing of teeth is normal. His tongue is in middle. His neck can move freely but the shrug ability is slightly decreased. He can lift the left arm but cannot control it very well, the right arm cannot stretch straight, he can only stretch around 150 degree and touch his forehead. His upper arm can lift around 10 cm, and his fingers cannot stretch, the legs can lift up off the bed around 10cm when his muscle tone is high, no voluntary muscle power. Muscle tone of the legs is increased, right side is much higher, he had leg spasms occasionally. Tendon reflex of the right arm is normal. Tendon reflex of the left arm and legs are active, the abdomen reflex cannot be induced by examination. There is hypesthesia of his superficial sensation below the C2 level, the Hoffmann sign of both side are positive, bilateral palm-jerk reflex is negative, Babinski sign of both sides are positive. He cannot perform the coordinated movement test, the meningeal irritation sign is negative.

After the admission, he received related examinations and was diagnosed with Spinal cord injury. He received 3 times nerve regeneration treatment to repair his damaged spinal nerves, replace dead nerves, nourish nerves, regulate his immune system and improve blood circulation He also undertook rehabilitation training.     

After 30 days’ treatment the patient's muscle tone of the lower limbs decreased obviously and the spasm alleviated greatly. His right upper arm can stretch around 170 degrees, the muscle power of the left arm increased 1 degree, his left wrist joint can move with much more flexibility than before. Part of his left hand fingers can start to move again, thumbs of both hands activity increased, his grip force is 2- degrees. Both legs adduction and abduction control power are obviously enhanced with knees bent, the muscle strength increased to level 2 +, the control power of waist and back increased as well. The pinprick sensation is much more sensitive than before below the trunk, sensitivity of the legs is much stronger than before when he moves, the bedsore is around 1.5 -2 mm now and the depth is around 0.5cm.

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