Ugarte-Sequelae of spinal cord trauma-(Argentina)

Name:Ugarte Martin Mario  

Sex:Male

Age:22 years old

Country: Argentina

Diagnoses: Sequelae of spinal cord trauma, urinary system infection

Before treatment:

The patient suffered from car accident a year ago. The patient couldn't move and he suffered from sensory deprivation below chest. He was sent to a local hospital and diagnosed with spinal cord trauma (T4-T6). He received thoracic spinal fixation surgery. After operation, his feeling flat had no improvement but the ability to control his sitting position was better than before. Both his lower limbs still couldn't move. From the onset of disease, the patient had normal appetite and sleep. Before the treatment, the patient had catheter and defecated 2-3 times each day.

Admission PE:
Temperature: 35.5degrees, Bp: 127/95mmHg; Hr: 76/min. Br: 20/min. There was pressure sores in bilateral heels. There were no yellow stains or hemorrhagic spots on skin. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious rales. The heart sounds were strong and the rhythm of his heartbeat was normal with no obvious murmur in the valves. The abdomen was enlarge and soft, with no pressing pain. The doctor did not touch the liver or the spleen under the ribs. There was a surgical scars in his back; size about 20cm. There was mild edema in both ankles.

Nervous System Examination:
Ugarte Martin Mario was alert and he was slightly dispirited. He spoke fluently. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 3.0mms, both eyeballs could move freely and the pupils reacted normally to light stimulus. The wrinkle pattern of his forehead was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. The neck moved normally. The muscle strength to shrug his shoulder was strong. The muscle strength of both upper limbs was at level 5 and the muscle tone was normal. The muscle strength of both lower limbs was at level 0; the muscle tone was very high. Both lower limbs of the patient had spasm and flexion with slight stimulus. The tendon reflex of both upper limbs was normal. The tendon reflex of both lower limbs was active. Bilateral ankle clonus was positive. A bilateral abdominal reflex disappeared. The deep and shallow sensation below chest 4 was slow. The deep and shallow sensation below chest 5 disappeared completely. Bilateral Hoffmann sign was negative. Bilateral palm jaw reflex was positive. The sucking reflex was negative. Bilateral Babinski sign was positive. The meningeal irritation was negative. He was unable to perform the finger-to-nose test, rapid rotation test or the heel-knee-shin test.

Treatment:
We initially gave Ugarte Martin Mario a complete examination and the diagnosis was clear. He received treatment to improve his blood circulation in order to increase the blood supply to the damaged neurons, to repair the damaged neurons and to nourish them. We also gave him daily physical rehabilitation. The patient was examined on his urine routine for many times after admission. The result showed red cells and white cells were full of visual field. The urinary system infection was considered by the doctor. The patient received anti-inflammation and bladder washing treatment.

Post-treatment:
The patient's neurological function is better than before. Both lower limbs are partly sensory. The muscle tones of both lower limbs have reduced obviously than before. Bilateral ankle clonuses have reduced significantly. The deep sensation and shallow sensation have increased and reached T7. Both lower limbs have autokinetic movement. After patient bent knees passively, the patient could finish adduction and abduction. The muscle strength of both lower limbs reached level 1-2. Bilateral middle and upper abdominal reflexes can be elicited again. The recheck of urine showed the urine routine is restored to normal.

(Download the Windows Media Player Firefox Plugin if you are using Firefox browser.
To know more,Please read Using the Windows Media Player plugin with Firefox.)