Case Study: Spinal Cord Reconstruction Surgery for Complete Spinal Cord Injury

Patient Information:

• Name: Tamer Saied Ahemed
• Date of Birth: January 1, 1980
• Gender: Male
• Country: Egypt

Admission History:
A 34-year-old male presented to Beijing Puhua International Hospital with a history of lower limb mobility disorder following a car accident more than three months prior.

Diagnosis:
Complete spinal cord injury (SCI) at D5-6 level, secondary paraplegia, left hemo-thorax, right pneumothorax, comminuted fracture of the left tibia, and minimal abdominal fluid collection with fractured ribs. The injury was confirmed by MRI on July 15, 2012.

Treatment:
The patient underwent Spinal Cord Reconstruction Surgery and Neural Growth Factor Therapy in two stages:

1. First Stage (October 17, 2012): Intra-spinal exploration via a posteromedial approach through the original incision was performed. Nerve cell activation with lesion biopsy was also conducted.

2. Second Stage (July-August 2013): Four courses of Neural Growth Factor Therapy were administered via lumbar puncture on July 15, 19, 22, and 26, respectively.

Medical Condition before Treatment:

• Muscle strength: 5/5 in upper limbs, 0/5 in lower limbs
• Deep-tendon reflex symmetrically absent in legs
• Sensation below T4 level absent
• Both feet congested and edematous with multiple bedsores on the lower limbs

Postoperative Course:

One month after surgery (November 2012):

• Patient's condition improved significantly
• Vital signs stable, clear speech, and good spirits
• Limb movement started to improve
• Sensory level showed remarkable improvement from T4 to T6
• Incision healing well

Nine months after surgery (July 2013):

• Sensory level further improved to T6
• Muscle tone of lower limbs improved
• Deep sensation felt in knees and ankles while standing
• Muscular contractions noted in the left calf

Patient Satisfaction and Follow-up:
Tamer expressed satisfaction with his initial response to the Spinal Cord Reconstruction Surgery and Neural Growth Factor Therapy. Close monitoring of his physical condition will continue at Beijing Puhua International Hospital.

Conclusion:
This case study demonstrates the potential benefits of Spinal Cord Reconstruction Surgery combined with Neural Growth Factor Therapy for complete spinal cord injury, highlighting improvements in sensory levels, muscle tone, and motor function.