Hayder Hatam Maihool - Sequelae of spinal cord trauma (Iraq) Posted on November 26, 2014

Author Tracy Views Posted at 2014/11/26

Name: Hayder Hatam Maihool
Sex: Male
Country: Iraq
Age: 31 years
Diagnosis: 1. Sequelae of spinal cord trauma; 2. Infection of urinary tract. 3. Sleep apnea syndrome.
Date: Oct 30, 2014
Days Admitted to Hospital: 21days

Before treatment:
At about Four and half years ago (July 2010), patient fell down from stairs and his body part below thorax appeared to have motor disability temporarily. Also his nose bled and he felt difficult to breathe. The patient did not pay too much attention to it and a few hours after falling down he moved as normal. Four hours later, his lower part of body under chest showed motor disability again. He went to a local hospital and had cervical MRI which revealed space occupying focus between C3-C5 and not excluding the possibility of tumor. He had conservative treatment and took some corresponding neurological medicines but his condition did not improve. In April 2011, he suddenly had serious dizziness when he sat. Local doctor judged that hematoma pressed nerves so he had operation to remove the hematoma. After the operation, patient's dizziness was alleviated but the motor function of his lower part of the body did not improve. Moreover, because of voiding dysfunction and repeated infection of urinary tract, he had cystostomy. The joints of his right palm fingers became crooked and deformed. The paroxysmal spasm of his legs aggravated than before post operation. Now he cannot take care of himself.

Since the onset of the disease, his diet was normal but his sleep was not good. He had sleep apnea at night. It was also difficult for him to defecate and he had to use enema to help him defecate every other day. He used the bladder tube to void urine and had frequently infection in urinary tract. His weight had not changed much.

Admission PE:
Bp: 113/79mmHg; Hr: 92/min. His skin and mucous membrane were intact, with no yellow stain or petechia. There was no bedsore. There was a surgical scar observed in his middle neck. The length of the scar was about 9cm and it healed well. There was a scar in right abdomen post operation, the length of the scar was about 12cm. The place of fistula was clean and dry, with no hemorrhagic secretion or purulent secretion. There was no congestion at throat and the tonsil was not enlarged. The thorax was symmetrical, but had subsidence area. The respiratory sounds in both lungs were clear, with no obvious moist or dry rales. The heart sounds was strong, the rhythm of his heartbeat was normal. There was no obvious murmur in the valves. The abdomen was enlarged, with no obvious masses. There was no pressing pain or rebound tenderness. The liver and spleen were normal during palpation. The pulse of Dorsalis pedis was strong and the legs had no swollen. The urine routine test showed that white blood cells full of screen.

Nervous System Examination:
Hayder Hatam Maihool was alert and his speech was fluent. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 2.5 mms, both eyeballs could move freely. Both eyes had sensitive response to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. The neck moved almost normal. The muscle strength to shrug shoulders was strong. The muscle tone of both upper limbs was normal. The muscle tone of both lower limbs was higher than normal. Both lower limbs had involuntary convulsive seizure. The muscle strength of left upper limb was at level 5-. The muscle strength of right upper limbs was at level 4+. The hold power of left hand was at level 4+. The hold power of right hand was at level 4-. The activity of right wrist was limited. Right palm and fingers' joints were curved. The muscle strength of both lower limbs was at level 0. The tendon reflex of both upper limbs was normal. Bilateral abdominal reflex could not be elicited. The patellar tendon reflex of both lower limbs was active. Bilateral Achilles tendon reflex could be elicited. The deep sensation and shallow sensation above T4 was normal. The deep and shallow sensation below T4 was lowered down gradually. Bilateral Hoffmann and Rossilimo were positive. Bilateral palm jaw reflex was negative. Bilateral Babinski sign was positive. Bilateral ankle clonus was negative. Right hand had difficulty to compete with finger-to-finger test due to muscle tendon contracture. Thumb of left hand can reach three fingers except the little finger. Other examination of both upper limbs was normal. Both lower limbs couldn't finish the coordinate movement examination of both lower limbs.

Spinalcord MRI: C3-C5 cervical cord had abnormal signal.

Treatment:
We initially gave Hayder a complete examination. He received treatment of nerve regeneration and restoration of neural system. He received treatment to activate his own stem cells, improve the blood circulation in order to increase the blood supply to the damaged neurons and to nourish them. This was accompanied with daily physical rehabilitation.

Post-treatment:
The myospasm has been alleviated greatly. His muscle tone of both lower limbs has decreased. His sleep is better than before and symptom of sleep apnea has been alleviated. He breathes easier than before. The muscle strength of four limbs has increased. The grip power of right hand is at level 4 and that of left hand is to level 5-. The muscle strength of legs is between levels 1-2. The deformation of finger joints of right hand has been alleviated. He is able to compete with finger-to-finger test of right hand. The wrist of right arm moves flexibly than before. The positive index of Bilateral Babinski sign has reduced. The infection of urinary tract has been alleviated. The discharge urine routine test shows that white cells are of 2/3 of high power field.