Benaya
- Spinal Cord Injury (SCI),
- C5, C6, C7, Incomplete
Epidural Stimulation
- Name:Benaya
- Age at Time of Treatment:18 - 25
- Sex:Male
- Nationality:Israeli
- Treatment Location:Thailand
- Diagnosis on Admission:Spinal Cord Injury (SCI)
- Injury Level:C5, C6, C7, Incomplete
- Time Since Injury:1 - 2 years
- ASIA Before Treatment:A
- ASIA After Treatment:A
- Treatment Received:Epidural Stimulation
- Date of Admission:13/04/2023
- Date of Discharge:02/06/2023
Patient Overview
Benaya has been living with a traumatic spinal cord injury since May 2021 after sustaining a gunshot wound that caused damage to his C5–C7 vertebrae, resulting in quadriplegia. He is fully dependent on a caregiver for all activities of daily living.
Patient Condition on Admission
Benaya has been battling with a traumatic spinal cord injury since May 2021 with a gunshot injury and sustained a C5-C7 spinal cord injury resulting in quadriplegia. His injury caused a complete loss of motor and sensory functions in his lower limbs. He also suffers from moderate spasms and spasticity as well as neurogenic bowel and bladder dysfunction. He is completely dependent on a caregiver for his activities of daily living. The previous therapies that Benaya received included respiratory and neurological rehabilitation as well as physiotherapy. 2 months after the injury, he also underwent weaning off the tracheostomy.
Treatment Received
Benaya was evaluated for and accepted into a treatment protocol involving the implantation of 2 Epidural Stimulators, at the cervical and lumbar spinal cord levels. The surgery involved a two-level approach where one device was implanted at the cervical level to aid the recovery of his upper body motor functions and the 2nd device was implanted over the lumbar spinal cord to restore his movements in the lower body, recover autonomic functions and improve his bowel and bladder functions.
| Treatment received | Implantation site | Number of devices | Duration of Stay |
|---|---|---|---|
| Epidural Stimulation | Cervical spinal cord | 1 | Extened stay for neurorehabilitation (until April 2024) |
| Epidural Stimulation | Lumbar spinal cord | 1 | Extened stay for neurorehabilitation (until April 2024) |
Device Mapping and Therapy
| Post-surgical care | Date | Total sessions | Sessions per week | Time (Hr.) per session |
|---|---|---|---|---|
| Physical Therapy & Lower Extremity Mapping | 50 days after admission | 102 | 15 | 1 |
| Occupational Therapy & Upper Extremity Mapping | 50 days after admission | 69 | 10 | 1 |
| Physical Therapy & Lower Extremity Mapping | Extended stay | 614 | 20 | 1 |
| Physical Therapy & Lower Extremity MappingPhysical Therapy & Lower Extremity Mapping | Extended stay | 343 | 10 | 1 |
Muscle Power Improvement Post-Surgery
Upper Body
| Muscle improvement | Before ES surgery | At discharge (50 days after admission) | 18 months after discharge |
|---|---|---|---|
| Shoulder flexors | 1 | 1+ | 2+ |
| Shoulder extensors | 1+ | 2 | 3 |
| Shoulder abductors | 1 | 2+ | 2+ |
| Shoulder horizontal abductors | 2 | 3 | 3 |
| Shoulder adductors | 1 | 2+ | 3 |
| Shoulder horizontal adductors | 1 | 1+ | 2 |
| Shoulder flexors | 2+ | 2+ | 3+ |
| Shoulder extensors | 1 | 1+ | 1+ |
| Wrist flexors | 1 | 1 | 1+ |
| Wrist extensors | 2+ | 2+ | 2+ |
| Finger flexors | 1 | 1 | 1+ |
| Finger extensors | 0 | 1+ | 1+ |
Muscle power improvement was assessed according to the Manual Muscle Testing (MMT) protocol on the patient’s discharge date, with the stimulator on. 0 indicates total paralysis, 1 indicates visible contraction, 2 indicates active movement, full range of motion (ROM) with gravity eliminated, 3 indicates active movement, full ROM against gravity, 4 indicates active movement, full ROM against gravity and moderate resistance in a muscle-specific position, and 5 (normal) indicates active movement, full ROM against gravity, and moderate resistance in a muscle-specific position expected from an unimpaired person.
Lower Body
| Muscle improvement | Before ES surgery | At discharge (50 days after admission) | 18 months after discharge |
|---|---|---|---|
| Hip flexors | 0 | 3 | 5 |
| Hip extensors | 0 | 3 | 5 |
| Hip abductors | 0 | 2 | 2 |
| Hip adductors | 0 | 2 | 2 |
| Knee extensors | 0 | 3 | 5 |
| Knee flexors | 0 | 2 | 5 |
| Ankle dorsiflexors | 0 | 3 | 5 |
| Ankle plantarflexors | 0 | 2 | 3 |
| Long toe extensors | 0 | 2 | 2 |
Muscle power improvement was assessed according to the Manual Muscle Testing (MMT) protocol on the patient’s discharge date, with the stimulator on. 0 indicates total paralysis, 1 indicates visible contraction, 1+ indicates limbs movement without gravity loading less than one half available range of motion (ROM), 2 indicates active movement, full ROM with gravity eliminated, 3 indicates active movement, full ROM against gravity, 4 indicates active movement, full ROM against gravity and moderate resistance in a muscle-specific position, and 5 (normal) indicates active movement, full ROM against gravity, and moderate resistance in a muscle-specific position expected from an unimpaired person.
Functional Improvement Post-Surgery
Motor Function
| Abilities & Symptoms | Before ES surgery | At discharge (50 days after admission) | 18 months after discharge |
|---|---|---|---|
| Feeding | Not possible | Improved (able to hold large handle with strap, but bring to mouth unstably) | Improved (able to hold large handle with strap, but bring to mouth stably) |
| Grooming (personal hygienic care) | Not possible | No Change | No Change |
| Dressing | Maximal assistance (able to lift arms for caregiver) | Improved (able to lift arms higher for caregiver) | No Change |
| Writing | Not possible | No Change | No Change |
| Grasping | Not possible | Improved (able to squeeze, hold and grasp objects) | Improved (able to squeeze, hold, grasp and pinch objects) |
| Wheelchair Control (powered wheelchair) | Independent (able to control by himself) | Independent (able to control by himself) | Independent (able to control by himself) |
| Standing with support | Absent * | Poor * | Good * |
| Stepping with support (for more than 10 meters) | Absent * | Fair * | Good * |
| Standing balance | Absent * | Poor * | Fair * (moderate support) |
| Sitting balance | Poor * | Fair * | Good * |
| Motor coordination (while walking) | Absent * | Fair * | Good * |
| Sit to stand (in walker) | Absent * | Poor * | No Change |
| Ability to transfer | Absent * | Poor * | No Change |
| Ability to use abdominal muscles during bowel program | Absent * | Poor * | No Change |
| Stamina & Fatigue | Poor endurance | Fair endurance | Good endurance |
| Spasticity | Minimal spasticity | Moderate spasticity (controllable and profitable to strengthen movement) | No Change |
Sensory Function
| Abilities & Symptoms | Before ES surgery | At discharge (50 days after admission) | 18 months after discharge |
|---|---|---|---|
| Neuropathic pain | Absent * | Absent * | Absent * |
| Temperature sensations | Absent * | No change | No change |
| Proprioception | Absent * | No change | No change |
| Bladder sensation | Absent * | No change | No change |
| Bowel sensation | Absent * | No change | No change |
Autonomic Function
| Abilities & Symptoms | Before ES surgery | At discharge (50 days after admission) | 18 months after discharge |
|---|---|---|---|
| Sweating ability | Absent * | No change | No change |
| Temperature regulation | Fair * | Normal * | Normal * |
| Blood pressure regulation | Fair * | Normal * | Normal * |
Motor Funtions
87%
Sensory Funtions
0%
Autonomic Function
66%
Overall
70%
Improvements are monitored in 24 targeted areas: 16 Motor areas, 5 Sensory areas and 3 autonomic areas. However, the number of targeted areas may vary depending on patient’s condition prior to admission. If patient does not experience symptoms in certain Motor/Sensory functions, or is not impaired in a specific targeted area prior to surgery, it is excluded from the report (Not Applicable). If there is progress in any given area — either mild, moderate, or significant — it is measured and reported as positive. No improvement, the existence of pain or spasms, or an inability to perform a measured function is reported as negative.
*According to the Functional Balance Grades, ‘Absent’ indicates that the patient is unable to perform a particular activity or function. ‘Poor’ indicates that the patient requires support and moderate to maximal assistance for a particular activity or function. ‘Fair’ indicates that the patient is able to perform a particular activity or function with minimal assistance. ‘Good’ indicates that the patient is able to perform a particular activity or function and can accept moderate challenge. ‘Normal’ indicates that the patient can perform a particular activity or function without any support.
Results Intrepretation
Motor Function
There was significant motor function gains in Benaya’s upper and lower limbs with improved muscle mass, mass tone, and overall strength.
Sensory Function
After stem cell treatments and long term training, Benaya started to regain proprioception. He started to feel his limbs in space and time which greatly helped him improving and control his overall walking ability.
Autonomic Function
Benaya had significant improvements to his autonomic functions including blood pressure and body temperature regulations.
Sitting
He regained significant trunk stability, core muscle function and paraspinal muscles. This significantly improved his sitting balance, improved his overall posture, and reduced the risk of potential scoliosis or any structural deformity. He is able to sit and control his abdominal muscles and his dynamic sitting balance is significantly improved even when challenged.
Standing
Benaya is able to stand, lock his knees and stay upright for prolonged periods of time. His standing balance has been improving significantly.
Case Summary
Benaya sustained a severe and life-altering spinal cord injury, primarily from the C5 to C7 levels and his MRI scan showed severe cystic changes in his spinal cord. The injury resulted in almost complete loss of upper limb and complete loss of limb functions meaning he was fully dependent on all activities of his daily living. After a comprehensive medical evaluation, he went through the implantations of cervical and lumbar Epidural Stimulations surgeries. Both surgeries were performed together on the same day. After the surgery, he took 2 days to recover before starting the mapping process.
Immediately after the implantation of the spinal cord stimulator, his motor function started to improve as shown by the contractions in previous dormant muscle groups that consistently strengthened as we moved forward with more extensive training. His upper limbs shows improved proximal and distal muscle function. He started to train how to feed and drink by himself and reported improved finger, wrist, and arm functions. For the first time since his injury, we saw muscle contractions and motor function coming back in his lower limbs. Both flexor and extensor groups improved. Eventually, he was able to stand up, maintain postural stability in a standing position, and walk with upper body support without anyone requiring to lock his knees. His blood pressure levels became very stable and in the last 2 years, he never reported any major fluctuations. He does not suffer from postural hypotension anymore. His body temperature regulation improved. He is now able to stand and perform locomotor training for two hours or more without going through any kind of body temperature irregulation and any major fluctuations in his blood pressure levels.
Benaya has been staying with us for more than 2 years now and consistently improving. The major recovery is in his motor functions, both upper and lower limbs including the ability to stand and walk. He is also learning to perform the activities of his daily life (ADLs) by himself.