Kashif Zafar-Sequelae of Spinal Cord Injury-(Pakistan)

Name: Kashif Zafar
Sex: Male
Nationality: Pakistani
Age: 43
Diagnoses: 1. Sequelae of Spinal Cord Injury (Mechanical Ventilation Dependant) 2. Urinary Infection 3. Thyroid Hypofunction
Date of Admission: June 29th, 2016
Treatment hospital/period: Wu Medical Center/21days

Before treatment:
Kashif was severely injured in an explosion in 2012 and suffered a coma for 7 minutes. He found that his four limbs were hard to more when he woke up. He was taken to the local hospital and had a tracheotomy performed and was put on a breathing machine, 2 hours later he woke up again. There was no autonomous respiration. He was able to recognize his family members, he spoke clearly and he began to eat. But his four limbs were unable to move. There were sensation problems below C3. He had urination and fecal incontinence. He felt better 1 year later, but he felt pain when he urinated, sometimes he needed painkillers, he had oppressing sensation when he wanted to defecate, but he was unable to urinate or defecate by himself. He used a breathing machine for 4 years. His movement and sensation did not improve.
He was in good spirits. His diet and sleep were normal.

dmission PE:
Bp: 114/82mmHg; Hr: 54/min. Temperature: 36.2 degrees. Br: 18/min. There were no yellow stains or petechia on the mucous membrane. There was endotracheal intubation in the middle of the neck. The bony thorax was symmetrical, barrel chested, he used a breathing machine to breathe. The respiratory sounds in the upper part of the lungs were clear. The respiratory sounds in the lower part of the lungs were lower than normal, with no obvious moist or dry rales. The heart sounds were low, the rhythm of his heartbeat was normal. There was no obvious murmur in the valves. The abdomen was distended and soft, the liver and spleen were normal. Percussion revealed tympanic sounds in the abdomen. The bowel sounds were normal. The indwelled urinary catheter was normal. There was blood in the urine, with a lot of flocculation. There was no edema in the lower limbs. Urine routine: white cells 3+, erythrocyte 2+, blood test: FT3. FT4 decreased.

Nervous System Examination:
Kashif Zafar was alert and his speech was fluent. His mood was good. His memory, calculation abilities 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 responses to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. He was able to move his neck normally. The shoulders’ ability to shrug was a little weak. He didn’t have spontaneous breathing. He was not able to move his limbs at all. The muscle tension of all four limbs was a little higher, the tendon reflex was normal. The bilateral side ankle reflex and Achilles reflex were abnormal. Negative ankle clonus. There was mild muscle atrophy in all four limbs. The abdominal reflex was normal. The sensation above C3 was normal. The superficial sensation of the right side C4 and left side C4-6 were reduced. The superficial sensation below the right side C5 and left side C7 were non-existent. The T2 level sensation was reduced. Below the T2, the sensation was non-existent. The vibration sensation of the right side C4 was reduced. Below the C5, the vibration sensation was non-existent. The vibration sensation of the left C4-6 was decreased, below C7, the vibration sensation was non-existent. He was unable to feel his knee position. The bilateral Hoffmann sign was positive. The bilateral Babinski sign was neutral. The meningeal irritation sign was negative. The rapid rotation test, finger-to-nose test and the heel-knee-shin test were not able to be done.

Treatment:
After admission, Kashif was diagnosed with 1.  sequelae of spinal cord injury(mechanical ventilation dependant) 2. urinary infection, 3. thyroid hypofunction. He received 4 neural stem cell injections and 4 mesenchymal stem cell injections to repair the damaged nerves, regenerate new nerves, activate the stem cells in his body, anti-infection, increase his thyroid hormone, regulate the immune system and nourish the neurons. We also gave him daily physical rehabilitation.

Post-treatment:
After 21 days of treatment, Kashif’s thyroid function was normal. His urinary infection was under control His hands moved better, his left hand was able to move. His right thumb and middle finger had slight movement. When he tried to move, his wrist joints, right elbow joint and lower limbs had obvious muscular contractions. His sensation level improved to almost T4. His breathing condition was better, sat: 96-98%. When he did maximum breathing training, he was able to breathe by himself in a few seconds. 

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