Имя: Umair Pirzada
Возраст: 33 года
Диагноз: Травма спинного мозга
Дата поступления в клинику: 10 февраля 2017
Длительность лечения: 15 дней
The patient bumped his neck 19 years ago (June 1998) while swimming and at that time he was unable to move body parts below neck and he lost sense,. He was taken to a local hospital and diagnosed with “traumatic spinal cord injury” and he was given traction treatment but no surgical treatment. 2 months later he was able to move his fingers and this was followed by slow movement onset of the upper limbs. He did neck traction for 15 months and regular rehabilitation treatment for 6 years. At present he is able to put on clothes and shoes by himself. He could use an electric wheelchair and he can complete the movement from bed to a wheelchair but both legs cannot move. The patient came to our hospital for further treatment.
His diet, sleep and spirit are good, he has intermittent catheterization, 3-4 times / day. He requires topical medications for defecation 3 times a week.
При поступлении на лечение
Bp: 121/70mmHg, Hr: 88/min, breathing rate: 20/min, body temperature: 36.5 degrees. Patient was strong and overweight, nutrition status is good. There is no injury or bleeding spots of his skin and mucosa, chest develop is sound but chest movement when breathing is slightly weak. The respiratory sounds in both lungs were clear, there was no dry or moist rales. The heart beat is powerful with regular cardiac rhythm and with no obvious murmur in the valves. The abdomen was flat and soft with no masses or tenderness. The liver and spleen were normal. There was no edema in either leg. Sat: 92-93%.
Patient was alert and his mental status is good, his memory, the orientation and calculation ability were normal . Both pupils were equal in size and round, diameter as 3.0 mm, react well to light and the eyeballs can move freely. Bilateral forehead wrinkles are symmetrical, he can extend his tongue out and show teeth as normal. His neck can move freely, the shoulders can shrug powerfully. Muscle power of right arm is 4+, grip force of right hand is 4 degrees, muscle power of left arm is 3+ degree, grip force of left hand is 4- degree, his left hand fingers are bending and he cannot stretch the fingers as normal. Muscle power of the left leg is 0, of right leg is 1 degree, muscle tone of the arms is normal, of the legs is higher than normal. The patient had lower limbs muscle spasm sometimes. Tendon reflex of the arms are normal, of the legs are hyperactive. Bilateral ankle clonus are positive, the abdominal reflex of both sides cannot be induced by examination. Patient had deep and superficial sensory decrease below the T3 level, Hoffmann sign of both sides are positive, bilateral palm-jerk reflex are positive, sucking reflex are negative, Babinski sign of both sides are negative, meningeal irritation sign is negative, the finger to nose test and fast alternate movement test are normal. His left hand cannot perform the finger opposite movement because of the muscle strength limitation and he can only do the index finger opposite movement with his right hand. Patient cannot perform the heel-knee-tibia test.
After the admission, he received related examinations and diagnosed with SCI. He received 3 neural stem cell injections and 3 mesenchymal stem cell injections to repair his damaged nerves, replace dead nerves with new injected stem cells, nourish nerves, regulate his immune system and improve blood circulation. This was done along with rehabilitation training.
After 15 days treatment he can breathe well, his blood oxygen of the finger tips is maintained within the 95-98% range which is an improvement. His arms can rotate much easier than before, proximal muscles of the legs had obvious contraction, muscle power is around 1 degree. Pinprick sensation of lumbar and pars sacralis is more sensitive, the myoclonus strength of both legs is reduced.