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Abstract: The patient had a history of upper respiratory tract infection 1 week prior to consultation, followed by gradual onset of weakness of the extremities with numbness, which was considered to be a cervical spinal cord injury due to inflammation after examination. The patient was promptly given oxygen and medication after admission to control disease progression, and the lesion did not continue to involve the high cervical segment and respiratory center. After 10 days of treatment, the patient’s symptoms of numbness and weakness in the extremities were relieved, and continued rehabilitation treatment was recommended.
Basic information】Female, 64 years old
Disease Type】Cervical spinal cord injury
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】January 2022
Treatment plan】Oxygen absorption + medication (sodium cytarabine injection, methylcobalamin injection, glycerol fructose sodium chloride injection, vitamin B1 tablets, sodium methylprednisolone succinate for injection, lanchin injection) + rehabilitation treatment
[Treatment period] 10 days of inpatient treatment, review after 1 month
Effectiveness】The numbness and weakness of the extremities were relieved.
I. Initial consultation
The patient had a history of upper respiratory tract infection one week before the visit. 2 days ago, he developed numbness and weakness of the extremities, starting with weakness of both lower extremities, unable to walk, but still able to lift off the bed, so he did not pay special attention to it, thinking that he was tired and ignored it. Emergency ion check showed normal potassium ion, not potassium deficiency, suggesting that the patient might have spinal cord injury.
II. Treatment process
After admission, the patient was evaluated in detail and spinal MRI, liver function, kidney function, ion, cardiac enzymes, blood gas analysis, blood routine, urine routine, lumbar puncture and other tests were completed. Blood gas analysis showed that the oxygen saturation was 98%, which was within the normal range, body temperature was 36.9℃, blood pressure was 140/80mmHg, heart rate was 70 beats/min, respiration was 17 breaths/min, mental clarity, muscle strength of both upper limbs was grade 3, muscle strength of both lower limbs was grade 2, ataxic motor investigation was not cooperative, spinal magnetic resonance showed abnormal signals at the level of cervical 3-4 vertebrae and vertebral instability, and the preliminary diagnosis was cervical spinal cord injury caused by inflammation The preliminary diagnosis was cervical spinal cord injury due to inflammation. We communicated with the patient’s family about the condition, such as ascending myelitis and life-threatening respiratory distress, and gave the patient oxygen, cytarabine injection to improve metabolism, methylcobalamin injection to nourish nerves, glycerol fructose sodium chloride injection to relieve spinal edema, oral vitamin B1 tablets to nourish nerves, injectable methylprednisolone sodium succinate hormone shock therapy, and lanchin injection to improve microcirculation.
III. Treatment effect
After 10 days of drug treatment, the patient’s symptoms did not further aggravate and did not involve the respiratory muscles, which were developing in a good way, and the vital signs were relatively stable. On the fourth day of treatment, the patient complained that the numbness was reduced, and the dorsiflexion of the distal foot of the lower limbs was stronger than before, so the hormone and other medications showed good effects on the patient. At the same time, we communicated with the patient to enhance confidence in the fight against the disease. After 10 days, the patient’s numbness and weakness of the extremities were relieved and the discharge indications were reached. The patient needed rehabilitation after discharge, and the affected limb could be placed in a functional position, massage, passive movement of joints, acupuncture and physiotherapy. The patient is instructed to review after 1 month to assess the degree of disease recovery.
IV. Notes
We are glad that the patient’s disease has been controlled after treatment. Since the patient has not fully recovered from the weakness of the limbs and numbness of the hands, he needs to pay attention to rest after discharge from the hospital and is not recommended to carry out strenuous activities to prevent pain in the chest and back during activities. After discharge, patients need to continue treatment, especially rehabilitation. Patients can place the affected limb in a functional position, massage and passively move the joints, and perform acupuncture and physical therapy. Patients still need to be treated with injectable methylprednisolone sodium succinate, and need to pay attention to the presence of peptic ulcer symptoms such as vomiting blood and blood in stool, as well as the presence of elevated blood pressure and blood sugar, and the presence of hip pain and other manifestations of femoral head necrosis. Patients need to take blood regularly to recheck ions and observe whether there are electrolyte disorders such as low potassium and low calcium.
V. Personal insight
Cervical spinal cord injury caused by inflammation is a relatively difficult disease to treat, causing many problems for the patient and family members. The patient’s limb weakness requires family members to take care of the living, and it is easy to recur, and the etiology is not completely clear, which may be related to autoimmune abnormalities caused by cold, diarrhea, and vaccination, and the patient’s illness in this case may be related to upper respiratory tract infection. Therefore, infection should be avoided as much as possible in life, people with contraindications should not be vaccinated, and symptoms such as upper respiratory tract infection or diarrhea need to be treated actively. During the treatment period, eat a light diet and eat well-digested food as much as possible for early recovery.