Case Study: Spinal Cord Reconstruction Surgery for Spinal Cord Injury

Patient Information

• Name: Aditya
• Date of Birth: January 1, 1993
• Gender: Male
• Country: Nepal

Diagnosis

• Spinal Cord Injury (SCI)

Medical History
Admitted to Beijing Puhua International Hospital six months post-motor vehicle accident with complaints of limbs mobility disorder.

Preoperative Status

• Alert and oriented, with fluent speech and normal visual acuity.
• Equal, round pupils with brisk response to light; intact ocular movements and pharyngeal reflex.
• Soft and supple neck, no deviation noted with the uvula.
• Muscle strength: 5/5 in upper limbs, slightly low muscular tension in lower limbs.
• Pain sensation absent below bilateral inguinal level (3 cm).
• Incision scar present on lumbar back; bladder stoma noted in abdomen.

Surgical Intervention

• Intra-spinal exploration via post-midline approach was performed on May 30, 2013.
• Postoperative management included fluid infusion, neural nutrition, hemostasis, anti-secretory, and anti-infective medications.

Postoperative Status (21 days post-surgery)

• Alert with stable vital signs and clear speech; pupils equal, round, and responsive to light.
• Limb movements unchanged from preoperative status.
• Sensation improved in right lower limb, sensory level moved down to 3.0 cm above the knee.
• Incision well-healed.

Treatment Plan

• Ongoing rehabilitation therapy and traditional medicine support alongside postoperative care.