Karen
- Spinal Cord Injury (SCI),
- C4, C5, Complete
Stem Cells, Epidural Stimulation
- Name:Karen
- Age at Time of Treatment:55+
- Sex:Female
- Nationality:Israeli
- Treatment Location:Thailand
- Diagnosis on Admission:Spinal Cord Injury (SCI)
- Injury Level:C4, C5, Complete
- Time Since Injury:2 - 5 years
- ASIA Before Treatment:A
- ASIA After Treatment:A
- Treatment Received:Stem Cells, Epidural Stimulation
- Date of Admission:19/08/2022
- Date of Discharge:09/10/2022
Patient Overview
Patient Condition on Admission
Karen has suffered from a spinal cord injury at the C4-5 level since February 2019 after a horse riding accident. This injury caused her to have severe loss of both upper and lower limb functions with very limited mobility in the upper limbs and no motor function in the lower limbs. She also suffers from neurogenic bowel and bladder function and is fully dependent on activities of daily life.
Treatment Received
Karen was evaluated for and accepted into a treatment protocol involving the implantation of 2 Epidural Stimulators, at the lumbar and cervical spinal cord levels. The surgery involved a two-level approach where one device was implanted at a lower cervical level to aid the recovery of her upper body motor functions and the second device was implanted over the lumbar spinal cord to restore her movements in the lower body, recover autonomic functions and improve her bowel and bladder functions. As part of her regenerative medicine, she also received 200 million mesenchymal stem cells in the form of 1 Intravenous and 2 Lumbar Puncture injections.
| Treatment received | Implantation site | Number of devices | Duration of stay |
|---|---|---|---|
| Epidural Stimulation | Cervical spinal cord | 1 | 50 days |
| Epidural Stimulation | Lumbar spinal cord | 1 | 50 days |
Stem Cells Treatment Summary
| Stem cells treatment | Total number of stem cells | Delivery method |
|---|---|---|
| Mesenchymal Stem Cells (MSCs) | 60 million cells | Intravenous Injection (IV Injection) |
| Mesenchymal Stem Cells (MSCs) | 70 million cells | Lumbar Puncture Injection |
| Mesenchymal Stem Cells (MSCs) | 70 million cells | Lumbar Puncture Injection |
| Total number of stem cell | 200 million cells |
Device Mapping and Therapy
| Post-surgical care | Total sessions | Sessions per week | Time (Hr.) per session |
|---|---|---|---|
| Physical Therapy & Lower Extremity Mapping | 106 | 17 | 1 |
| Occupational Therapy & Upper Extremity Mapping | 84 | 12 | 1 |
| Total Sessions of Rehabilitation | 190 |
Muscle Power Improvement Post-Surgery
Upper Body
| Muscle improvement | Before Epidural Stimulation surgery | At discharge (50 days after admission) | 1st remapping (1 year after discharge) | 2nd remapping (2 year after discharge) |
|---|---|---|---|---|
| Shoulder flexors | 3 | 3+ | 4 | 4 |
| Shoulder extensors | 3 | 3+ | 4 | 4 |
| Shoulder abductors | 3 | 3+ | 4 | 5 |
| Shoulder horizontal abductors | 3 | 3+ | 4 | 4 |
| Shoulder adductors | 3 | 4 | 4 | 4 |
| Shoulder horizontal adductors | 1 | 2 | 2+ | 2+ |
| Elbow flexors | 4 | 4 | 5 | 5 |
| Elbow extensors | 1 | 1+ | 2 | 3 |
| Wrist flexors | 1 | 1 | 1+ | 1+ |
| Wrist extensors | 2 | 3 | 3 | 3 |
| Finger flexors | 1 | 2 | 3 | 3 |
| Finger extensors | 1 | 2 | 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, 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 Epidural Stimulation surgery | At discharge (50 days after admission) | 1st remapping (1 year after discharge) | 2nd remapping (2 year after discharge) |
|---|---|---|---|---|
| Hip flexors | 0 | 2 | 2 | 2 |
| Hip extensors | 0 | 1 | 2 | 2 |
| Hip abductors | 0 | 1 | 1 | 1 |
| Hip adductors | 0 | 1 | 2 | 2 |
| Knee extensors | 0 | 1 | 2 | 3 |
| Knee flexors | 0 | 1 | 1 | 2 |
| Ankle dorsiflexors | 0 | 2 | 2 | 2 |
| Ankle plantarflexors | 0 | 1 | 1 | 2 |
| Long toe extensors | 0 | 1 | 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, 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 Epidural Stimulation surgery | At discharge (50 days after admission) | 1st remapping (1 year after discharge) | 2nd remapping (2 years after discharge) |
|---|---|---|---|---|
| Feeding | Supervision (using strap) | Improved (grasp and hold spoon with large holder) | Improved (more natural pattern) | No change |
| Grooming (personal hygienic care) | Supervision (using strap) | Improved (grasp and hold spoon with large holder) | No change | No change |
| Dressing | Assistance required | Improved | Improved | Improved |
| Writing | Not possible | Improved (light-large holder pen) | No change | No change |
| Grasping | Not possible | Improved (light object) | Improved (hold firmly) | No change |
| Wheelchair control (head controlled wheelchair) | Supervision (low endurance) | Improved (short distance) | Independent (outdoor controlled) | No change |
| Standing with support | Absent * | Poor * | No change | Fair * |
| Stepping with support | Absent * | Poor * | No change | Fair * |
| Standing balance | Absent * | Poor * | No change | Poor to fair * |
| Sitting balance | Poor * | Poor to fair * | No change | Fair * |
| Motor coordination (while walking) | Absent * | Poor to fair * | No change | Fair * |
| Sit to stand (in walker) | Absent * | No change | No change | No change |
| Ability to transfer | Dependent | No change | Minimum assistance | No change |
| Ability to use abdominal muscles during bowel program | Dependent | Dependent (easier with program on) | No change | No change |
| Stamina & Fatigue | Poor * | Increase endurance | Increase endurance | Increase endurance |
| Spasticity | Moderate | Mild (with program on) | No change | No change |
Sensory Function
| Abilities & Symptoms | Before Epidural Stimulation surgery | At discharge (50 days after admission) | 1st remapping (1 year after discharge) | 2nd remapping (2 years after discharge) |
|---|---|---|---|---|
| Neuropathic Pain | Absent * | No change | No change | Increase |
| Temperature Sensations | Absent * | No change | No change | No change |
| Proprioception | Absent * | No change | No change | Increase |
| Bladder Sensation | Absent * | No change | No change | No change |
| Bowel Sensation | Absent * | No change | No change | No change |
Autonomic Function
| Abilities & Symptoms | Before Epidural Stimulation surgery | At discharge (50 days after admission) | 1st remapping (1 year after discharge) | 2nd remapping (2 years after discharge) |
|---|---|---|---|---|
| Sweating Ability | Absent * | No change | No change | No change |
| Temperature Regulation | Normal * | Normal * | Normal * | Normal * |
| Blood Pressure Regulation | Unstable | Stable | Stable | Stable |
Motor Funtions
93%
Sensory Funtions
20%
Autonomic Function
50%
Overall
74%
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
The motor areas were significantly improved including her biceps, triceps, her ability to lock the elbow and stay in upright position in the parallel bars. Her fine and gross motor skills in upper limbs improved. She also regained muscle movements in lower limbs and was able to stand and walk with support.
Sensory Function
Mild improvements were reported in her sensory function and proprioception.
Autonomic Function
Her blood pressure and body temperature regulation saw moderate improvements compared to before the treatment.
Sitting
Her sitting balance improved significantly, she was able to sit for extended periods of time with minimal assistance.
Standing
Karen’s standing function saw major improvements. She was able to lock the left knee while standing.
Case Summary
Karen sustained a traumatic spinal cord injury at the C4 level resulting in a severe injury. This rendered her paralyzed from the neck down with minimal upper limbs and no function in lower limbs. She received standard physiotherapy until she travelled to Verita Neuro in Thailand for further treatment.
Upon arrival she received extensive check ups and MRI scans and was deemed a suitable candidate for both upper and lower body Epidural stimulation surgeries, coupled with regenerative stem cells treatment. She went ahead with the surgery which went well without any complications and there was normal recovery of the surgical wounds. After a 2 days break we started the mapping process and we were able to see strong muscle contractions in the corresponding muscle groups. Her motor functions gradually started to return as well as her muscle mass, strength, and stamina.
Overall, Karen reported moderate to significant improvements in her motor areas and mild improvements in her sensory functions. She reported improvements in her upper limbs and lower limbs and regained the ability to stand and walk with upper body support. Her autonomic functions improved moderately as well as her sitting balance. She also reported marked improvements in her muscle mass and strength, and overall, her quality of life was improved.