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History :
65-year-old lady went to Neck Pain Treatment in Pune Dr. Sangram Rajale with complaints of both upper hand pain since 15 years, and weakness for 8 years, right leg pain for 3 years, and right side half of the body pain.
She experiences fine motor disturbances, making kitchen work and holding objects challenging. There is a history of fine motor dysfunction, imbalance, right side footwear slipping, and lower back pain.
What is happening to her? :
The medical history of this 65-year-old lady presents a complex array of symptoms and findings suggestive of significant neurological involvement. These symptoms are indicative of widespread neural dysfunction.
Furthermore, she describes fine motor disturbances, making tasks like kitchen work and holding objects challenging. Her history also notes a progressive decline in fine motor skills, indicating a degenerative process affecting her neurological function. Imbalance and a history of right-side footwear slipping highlight issues with gait and coordination.
On clinical examination, her gait is spastic, suggesting increased muscle tone likely due to upper motor neuron involvement. Interestingly, her toe walk remains normal, suggesting preserved function in distal muscle groups despite the proximal weakness noted in her lower limbs.
Bilaterally weak handgrip strength indicates a generalized upper limb motor deficit.
Overall, this patient’s extensive medical history and examination findings warrant further investigation, including neuroimaging studies such as MRI to assess for structural abnormalities like disc herniation or spinal cord compression.
Operation:
The patient underwent a surgical procedure involving C4-C7 laminoplasty with decompression on July 15, 2022, under general anesthesia. The surgery aimed to alleviate pressure on the spinal cord and nerve roots in the cervical spine, and implants from the vendor Jayon and the surgery was done by Best Spine Specialist for Neck Pain in Pune Dr. Sangram Rajale .
- C4-C7 Laminoplasty: This refers to a surgical procedure aimed at relieving pressure on the spinal cord and nerve roots in the cervical spine (neck area) by creating more space within the spinal canal. Laminoplasty involves making a hinge on one side of the vertebrae, allowing them to be opened like a door, thus expanding the spinal canal and reducing compression on the spinal cord.
Condition On Discharge
The surgical results indicate a positive outcome following the C4-C7 laminoplasty with decompression surgery performed on the patient:
- After a long follow-up period of 2 years post-surgery, the patient reported significant improvements. One of the most notable improvements was in her fine motor skills, which had markedly enhanced. She reported being able to hold objects firmly in her hand, perform kitchen tasks with ease, and accomplish all activities requiring delicate hand movements. These improvements signify a substantial enhancement in her overall hand dexterity and control.
- Furthermore, the patient noted an improvement in her gait, indicating that her walking pattern had become smoother and more stable. This improvement in gait is often associated with increased upper limb strength, which the patient also reported. The surgery contributed to a significant increase in her upper limb strength, allowing her to perform tasks that were previously challenging or impossible due to weakness or pain.
- Overall, the patient was highly content with the outcome of the surgery and the achievements she had made in terms of her functional abilities. The successful surgical intervention not only relieved the pressure on her spinal cord and nerve roots but also resulted in tangible improvements in her fine motor skills, upper limb strength, and overall quality of life. This positive outcome highlights the effectiveness of the surgical approach and the patient’s dedication to rehabilitation and recovery.