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Angel-Spinal Cord Injury-(USA)-Posted on June 18th,2015

Author Zhangqi Views Posted at 2015/06/18

Name: Angel
Sex: Female
Age: 65Y
Nationality: USA
Diagnosis: 1. Post of spinal vascular diseases 2. Spinal cord injury
Date: March. 11th, 2015
Days Admitted to Hospital: 19 days

Before treatment:
Four years ago, the patient was presented with pain of her waist and right leg. Her legs became increasingly numb and stiff. She was diagnosed with Spinal Dural Arteriovenous Fistula and had interventional vascular operation. After the operation, her legs still had pain and numbness. One year ago, she had an intrathecal pump with Baclofen and had oral medicines such as ‘Tramadol, Oxycodone, and Clonazepam’. After that the stiffness of legs was alleviated but the pain persisted. At present, she felt severe pain and numbness on her legs and has paresthesia. Her legs were weak and she has to walk with a cane. She had poor sleep because of pain but has a normal diet and defecation.

Admission PE:
Bp: 122/82mmHg; Hr: 84/min. She had a normal figure and was well nourished. The skin and mucosa were without yellow stains or petechia. Her throat was normal and her tonsil was not swollen. The respiration of both lungs was clear, with no dry or moist rales. Her heart rhythm was normal and strong, with no obvious murmur in the valves. The abdomen was soft with no rebound tenderness. There was an intrathecal pump in her left down corner. The liver and spleen were normal under palpation. There is no swollen of her legs.

Nervous System Examination:
Joo Jungsook was alerted and her speaking was fluent. Her memory, calculation and orientation were normal. Her eyeballs moved normally. Both pupils were equal in size and round. Her neck was soft and she could shrug with ease. The muscle strength of upper limbs was at level 5. The muscle strength of right leg was at level 4- and that of left leg was at level 4. The muscle tone of four limbs was normal. The abdominal reflex could be elicited. The knee reflex of right leg was weaker than normal but that of left leg was normal. The deep and shallow sensation of her upper limbs and body trunk was normal. The pathological sign was negative. The finger-to-nose test, rapid rotation test and knee-heel-tibia test was normal. The meningeal irritation sign was negative.

Treatment:
We gave her a complete examination and she was diagnosed with 1. Post spinal vascular diseases; 2. Spinal cord injury. She received treatment to initiate nerve repairing and regenerating. She also received treatment to activate her own stem cells, nourish neurons, improve circulation and adjust immune function. These were accompanied with rehabilitation.

Post-treatment:
After the treatment, the pain has been greatly alleviated. The paresthesia has been lowered. The muscle strength of legs has improved. The muscle strength of right leg and left leg is at level 4+ and level 5- respectively. Her walking gait is better and she walks easier. Her sleep is better and the dosage of pain killers have been reduced.

 

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