Juan - Sequelae of spinal cord injury (Uruguay) Posted on May 19, 2014

Name:Juan Carlos Vico Rovetta                   

Sex: Male

Country: Uruguay

Age: 19 years

Diagnosis: Sequelae of spinal cord injury

Date:April 10, 2014

Days Admitted to Hospital: 29days

Before treatment:

The patient suffered from car accident on June 23, 2012. He then suffered from movement disorders of both hands and below the chest suddenly. But there was no loss of consciousness. He was diagnosed with cross-sectional spinal cord injury and rib fracture in a local hospital ICU. He received conservative treatment. 1 week later, the patient suffered from breathing difficulty and coma post rib fracture and pulmonary parenchyma wound. The patient suffered from cardiac arrest, after 1 week positive rescue, the patient's consciousness soon returned. But the pulmonary infection still existed. Patient spent about 75 days in intensive care unit until the patient's condition was stable gradually enough. Then he was sent to general ward for continuation of treatment. 2 months later, the patient was discharged. He still resist rehabilitation training, but his condition has not improve. From the onset of disease, he had normal diet. The sleep was regular. He had defecation each day, but needed great effort. He needed catheterize discontinuously. His weight reduced by 15 Kg than before.

Admission PE:

Bp: 106/60mmHg; Hr: 80/min. The nutrition was normal. The skin was intact, with no ecchymosis, petechia or yellow stains on skin. There was a scar after tracheostomy in center of neck. The union of the scar was good. There was a scar post bedsore in the sacrococcygeal region, the union was good. The skin was uneven, with no rupture or exudation. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious dry or moist rales. The heart sounds were strong and the rhythm of his heartbeat was normal, with no obvious murmur in the valves. The abdomen was enlarged and soft, with no obvious masses. The doctor did not touch the liver or the spleen under the ribs. Through auscultation, the bowel sound was normal. The skin temperature and color of both feet was normal. The pulse of the dorsal artery of his foot was strong.

Nervous System Examination:

Juan Carlos Vico Rovetta was alert and 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 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 strength to shrug his shoulder was strong. The muscle tone of both upper limbs was normal, the muscle tone of both lower limbs was slightly higher than normal.  The muscle strength of both upper limbs was at level 5. The grasp power of both hands was at level 4-. The muscle strength of both fingers was at level 3. The muscle strength of both lower limbs was at level 0. The tendon reflex of both upper limbs was normal. Bilateral abdominal reflex was not elicited. The tendon reflex of both lower limbs was active. There was obvious muscle atrophy in both metacarpophalangeal and interphalangeal joints. The volume of muscle of both lower limbs was slightly reduced. The shallow sensation below thoracic vertebrae 2 disappeared. The vibration sense below T3 disappeared. Bilateral Hoffmann sign and Babinski sign were negative. The ankle clonus of left foot was positive.  He was able to perform the finger-to-nose test and rapid rotation test of both upper limbs, but the action was clumsy. His left hand couldn't point thumb with the little finger, his right hand couldn't point thumb with ring finger or little finger. He was unable to cooperate with the coordinate movement examination.

Treatment:

We initially gave Juan Carlos Vico Rovetta a complete examination and the diagnosis was clear. He received treatment for nerve regeneration and to activate stem cells in the body. He received treatment to improve the blood circulation in order to increase the blood supply to the damaged neurons and to nourish them. We also gave him daily physical rehabilitation.

Post-treatment:

The muscle strength of both upper limbs has improved. The grasp power of both hands is at level 4. The muscle strength of fingers is at level 3+. The right hand is slightly better than the left hand. The flexibility of all fingers has improved. He does the finger-to-nose test and rapid rotation test in a more stable manner. Both his hands can point thumb with all other fingers. Both lower limbs' near-end has 1 level strength. The patient suffered from nausea and vomiting on the first day of admission. This was accompanied with mild increased temperature. The acute gastro-enteritis was considered. He received treatment to stop the vomit and fluid infusion was given. 1 day later, the patient was restored to normal. The patient suffered from urinary infection and had chill, fever and headache during his stay in the hospital. After anti-inflammation and bladder irrigation, the infection was cured.