Mr. B. C. D., a 25-year-old gentleman from Romania, suffered severe fracture of cervical vertebrae due to diving accident on June 30, 1996. He was done the internal fixation and decompression at C4-C5. He was rendered a complete paraplegia associated with no feeling and control to his bladder or bowel.
DIAGNOSIS: Traumatic Chronic Spinal Cord Injury (C4-C5 ASIA A)
PHYSICAL EXAMINATION: Mental status was normal. There were no abnormal signs in his head, chest and abdomen. Motor power: Elbow flexor was 3/5 billaterally; Wrist extensors were 0/5 bilaterally; Elbow extensors were 3/5 bilaterally; Lower extremities were 0/5 bilaterally. Light touch disappeared below C5 bilaterally. Pin prick disappeared below C5 bilaterally. The legs were absent sweating. He cannot sit and stand. Hoffmann and Babinski sign was positive bilaterally. He was not able to perform heel-to-shin examinations. No voluntary anal contraction. No any anal sensation.
l ASIA motor score was 6 points on the right, left 6 points.
l ASIA light touch score was 6 points on the right, left 6 points.
l ASIA pin prick score was 6 points on the right, left 6 points.
l Score of Xishan Hospital Spinal Cord Injury Functional Rating Scale was 6 points.
OPERATIVE PROCEDURE: After the procedure of cell HLA-matching finished, the surgical transplantation of olfactory ensheathing glial cells procedure was performed under general anesthesia on July 9, 2007. 50 µliters containing 1 million cells was injected into spinal cord of patient at the level C3 and C5. Intrathecal injection of fetal neural stem cells was done on July 17, July 23 and July 30, 2007.
POST-OPERATIVE COURSE: The course of the operation was uneventful. Eleven days after surgery, the stitches were removed. He underwent the adjunct regimens including the massage, physical therapy and acupuncture therapy during admission. At discharge strength of the wrist extensor was increased from 0/5 to 1/5 on the right and elbow extensor was increased from 3/5 to 4/5 on the left. Light touch decreased at T3 bilaterally. Pin prick decreased at T3 bilaterally. Before the operation light touch and pin prick was disappeared at T3 bilaterally. Other function is the same as before operation.
l ASIA motor score was 7 points on the right, left 7 points.
l ASIA light touch score was 7 points on the right, left 7 points.
l ASIA pin prick score was 7 points on the right, left 7 points.
l Score of Xishan Hospital Spinal Cord Injury Functional Rating Scale was 6 points.
FOLLOW UP(2007-8-13):
In the follow-up email dated on August 13, 2007, he said: “My condition it’s the same”.
FOLLOW UP (2007-8-24):
In the follow-up email dated on August 24, 2007, he said: “There is sweating under the injury level but it is not unusual because I was sweating the same before. I will let you know if something is changing.”
FOLLOW UP (2007-9-26):
In the follow-up email dated on September 23, 2007, he said: “Nothing is changing this month. I'm not sweating so much. The spasm are biger.”
FOLLOW UP (2007-12-1):
In the follow-up email dated on December 1, 2007, he told us that there was nothing change.
FOLLOW UP (2008-1-24):
In the follow-up email dated on January 24, 2008, he said: “In the past few weeks, every time I stay in weelchair, I'm sweating very much.”
FOLLOW UP (2008-4-11):
We got in touch with Mr. B.C.D. on April 11, 2008 and he told us that “My health condition is the same. No improvements yet. I'm sweating a lot after the surgery. I hope in the future there will be some changes.”
FOLLOW UP (2008-7-11):
In the follow-up email dated on July 11, 2008, he said: “My health condition is unchanged.”
FOLLOW UP (2008-8-5):
In the follow-up email dated on August 5, 2008, he told that his condition is unchanged.
