Nikita
- Spinal Cord Injury (SCI),
- C4, Complete
Stem Cells, Epidural Stimulation
- Name:Nikita
- Age at Time of Treatment:18 - 25
- Sex:Male
- Nationality:Israeli
- Treatment Location:Thailand
- Diagnosis on Admission:Spinal Cord Injury (SCI)
- Injury Level:C4, Complete
- Time Since Injury:1 - 2 years
- ASIA Before Treatment:A
- ASIA After Treatment:A
- Treatment Received:Stem Cells, Epidural Stimulation
- Date of Admission:27/08/2022
Patient Overview
Patient Condition on Admission
Nikita has suffered from a spinal cord injury at the C4 level since January 2021 after getting hit by a car. This injury caused him to have severe loss of upper limbs and complete loss of lower limb functions. He also suffers from moderate to severe neuropathic pain, mild to moderate spasms, neurogenic bowel and bladder, and he is completely dependent on activities of daily life. He had approximately 1 year and 6 months of training in Israel before coming to Verita Neuro as his last hope to regain movements in his hands, arms and legs.
Treatment Received
Nikita 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 his upper body motor functions and the second 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. Also, as part of his treatment, he receives regenerative medicine every 4-6 months.
| Implantation site | Number of devices | Duration of stay |
|---|---|---|
| Cervical spinal cord | 1 | Extended stay for neurorehabilitation |
| Lumbar spinal cord | 1 | Extended stay for neurorehabilitation |
Stem Cells Treatment Summary
| Stem cell 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 | Session per week | Time (Hr.) per session |
|---|---|---|---|
| Physical Therapy & Lower Extremity Mapping | 129 | 17 | 1 |
| Occupational Therapy & Upper Extremity Mapping | 86 | 12 | 1 |
| Total Sessions of Rehabilitation | 215 |
Muscle Power Improvement Post-Surgery
Upper Body
| Muscle improvement | Before Epidural Stimulation surgery | At discharge (50 Days after admission) | 1 year after discharge | 2 years after discharge |
|---|---|---|---|---|
| Shoulder flexors | 1+ | 2 | 2+ | 3 |
| Shoulder extensors | 1 | 2 | 3 | 4 |
| Shoulder abductors | 1+ | 2 | 3 | 3+ |
| Shoulder horizontal abductors | 1 | 2 | 3 | 3 |
| Shoulder adductors | 2 | 3 | 3 | 3 |
| Shoulder horizontal adductors | 1 | 2 | 3 | 3+ |
| Elbow flexors | 3 | 4 | 5 | 5 |
| Elbow extensors | 2 | 2+ | 3 | 3 |
| Wrist flexors | 0 | 1 | 1 | 1 |
| Wrist extensors | 0 | 1 | 1 | 1 |
| Finger flexors | 0 | 3 | 3 | 3 |
| Finger extensors | 0 | 0 | 1 | 1 |
Muscle power improvement was assessed according to the Manual Muscle Testing (MMT) protocol with the stimulator on. 0 indicates total paralysis, 1 indicates visible contraction, 2 indicates active movement, full range of motion (ROM) with gravity eliminated, 2+ indicates active movement, less than one half ROM against gravity, 3 indicates active movement, full ROM against gravity, 3+ indicates active movement, less than one half ROM against gravity and moderate resistance 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) | 1 year after discharge | 2 years after discharge |
|---|---|---|---|---|
| Hip flexors | 0 | 2 | 3 | 3 |
| Hip extensors | 0 | 1 | 2 | 2 |
| Hip abductors | 0 | 1 | 2 | 2 |
| Hip adductors | 0 | 1 | 2 | 2 |
| Knee extensors | 0 | 1 | 2 | 2 |
| Knee flexors | 0 | 2 | 3 | 3 |
| Ankle dorsiflexors | 0 | 2 | 3 | 3 |
| Ankle plantarflexors | 0 | 2 | 2 | 2 |
| Long toe extensors | 0 | 1 | 2 | 2 |
Muscle power improvement was assessed according to the Manual Muscle Testing (MMT) protocol with the stimulator on. 0 indicates total paralysis, 1 indicates visible contraction, 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) | 1 year after discharge | 2 years after discharge |
|---|---|---|---|---|
| Feeding | Not possible | Improved (hold large handle but cannot bring to mouth) | No change | Improved (hold large handle and bring to mouth stably) |
| Grooming (Personal hygienic care) | Not possible | Not possible | Improved (hold large handle/ electric toothbrush) | No change |
| Dressing | Not possible | Not possible | Improved (able to reach arms to help caregiver) | No change |
| Writing | Not possible | Not possible | Not possible | Not possible |
| Grasping | Not possible | Improved (squeeze, hold, pinch and grasp object) | No change | No change |
| Wheelchair control (Hand controlled wheelchair) | Not possible | Improved (controlled by himself for short distance) | Improved (controlled by himself outdoor) | Improved (controlled by himself in general) |
| Standing with support | Absent* | Poor* | Fair* (with moderate assistance) | Fair* (with moderate assistance) |
| Stepping with support | Absent* | Poor* | Fair* | Fair* |
| Standing balance | Absent* | Poor* | Fair* | Fair* |
| Sitting balance | Poor* | Poor* | Fair* | Fair* |
| Motor coordination (while walking) | Absent* | Poor* (both legs jump up together) | Fair* | Fair* |
| Sit to stand (in parallel bar) | Maximum assistance | Maximum assistance | Maximum assistance | Maximum assistance |
| Ability to transfer | Absent* | Absent* | Absent* | Absent* |
| Ability to use abdominal muscles during bowel program | Absent* | Poor* | Poor to fair* | Poor to fair* |
| Stamina & Fatigue | Poor endurance | Fair endurance | Fair to good endurance | Fair to good endurance |
| Spasticity | Minimal | Minimal | Moderate Spasticity (Increased) | Moderate Spasticity (Decreased by programs) |
Sensory Function
| Abilities & Symptoms | Before Epidural Stimulation surgery | At discharge (50 days after admission) | 1 year after discharge | 2 years after discharge |
|---|---|---|---|---|
| Neuropathic pain | Absent * | Increased (slightly) | Increased (severe) | Decreased (by programs) |
| Temperature sensations | Absent * | No change | Poor * | No change |
| Proprioception | Absent * | Poor * | No change | No change |
| Bladder sensation | Absent * | Poor * | Fair * | No change |
| Bowel sensation | Absent * | Poor * | No change | Poor to Fair * |
Autonomic Function
| Abilities & Symptoms | Before Epidural Stimulation surgery | At discharge (50 days after admission) | 1 year after discharge | 2 years after discharge |
|---|---|---|---|---|
| Sweating ability | Absent * | Improved (slightly sweating) | Improved (sweating during exercise) | Improved (upper body sweating during exercise) |
| Temperature regulation | Absent * | Poor * | No change | Poor to Fair * |
| Blood pressure regulation | Stable | Stable | Stable | Stable |
Motor Funtions
75%
Sensory Funtions
80%
Autonomic Function
66%
Overall
75%
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 had been remarkable recovery in Nikita’s motor functions, his sitting and standing balance, and fine and gross motor skills. Nikita is now able to stand and walk with the help of upper body support, has an improved sitting and standing balance and regained visible movements back in his arms, wrist and finger function.
Sensory Function
Nikita reported persistent improvements in his sensory functions including better proprioception and temperature sensations below the level of injury. He is able to locate his limbs in space and time when walking.
Autonomic Function
His body temperature and blood pressure regulation improved after the treatment. He is now able to sweat more and does not have any major fluctuations in his blood pressure levels or any significant drop while standing and walking.
Sitting
Nikita now has a better trunk stability and improved sitting balance. He is able to hold his body without any back support even when challenged by sideway movements.
Standing
Nikita’s standing function and postural stability has improved remarkably since he started his treatment.
Case Summary
Nikita sustained a traumatic spinal cord injury and was diagnosed with traumatic spinal cord at C4 with very minimal and nonfunctional motor function in his shoulders. He went through the standard physical therapy in Israel for one and half years before heading to Verita Neuro in Thailand.
Upon arrival he received extensive check-up and MRI scan after which he was confirmed as a candidate for cervical and lumbar epidural stimulation surgeries. The surgery and post operative course went well without any adverse events and after 2 days break Nikita started the mapping process. We were able to see muscle contractions as soon as the stimulator was turned on and slowly we were able to restore the muscle movements in major muscle groups. This has been improving gradually since then.
Overall there had been visible improvements in all of the affected areas which included motor functions, sensory functions and autonomic functions. Nikita is now able to stand and walk and have an improved upper body function. His sensory functions as well as autonomic functions has improved. His stamina and fatigue levels, his muscles mass and strength, as well as his general wellbeing have improved.