Treatment of Lower Limb Movement Disorder in Complete Paraplegia Caused By Spinal Cord Injury with Spinal Neuromodulation: A Case Report

Keywords: Traumatic complete paraplegia; Lower extremities; Spinal cord injury; Spinal neuromodulation

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Spinal Cord Injury (SCI) may result in the impairment of motor, sensory, and voluntary functions below the spinal level of injury. The global prevalence of SCI is 1:1000, with an incidence of 4–9 new cases per 100 000 people per year. The most common causes of traumatic SCI are traffic accidents, falls, and acts of violence. Currently, the prevalence of quadriplegia is comparable to that of paraplegia [1]. To the best of our knowledge, this case report highlights the use of spinal cord stimulation for the first time to treat traumatic complete paraplegia of the lower extremities, with substantial efficacy. We present the case of a 38-year-old Asian male, a truck driver by profession. He had suffered a complete loss of motor and sensory functions in both lower extremities in a traffic accident 3 years ago. The accident also resulted in an AIS-B injury (the sensory function is preserved in the S4-S5 area of the sacral segment, but no motor function is preserved) at the T11/T12 level, accompanied by alternating numbness, deep sensory disturbances, and dyskinesia in both lower extremities, with no spasticity in the legs, and a motor score of 0 for all key leg muscles (No muscle contraction). The patient did not show any clinical improvement in both lower extremities after spinal internal fixation and could not stand or walk (walking index score for SCI: 0), despite extensive rehabilitation in a rehabilitation center. Therefore, with the consent of the patient and his family, we exploratively implanted a Spinal Cord Stimulation (SCS) device in his body on April 26, 2020, to improve the symptoms of the lower extremities.

During the operation, an approximately 4-cm-long straight incision of was made on the L2-L3 dorsal surface under C-arm guidance. The corresponding lamina was opened, and electrodes (model 565 DEFINE 2 × 8; Medtronic, USA) were inserted upward in the epidural space. Thereafter, the electrodes were connected to an Implantable Pulse Generator (IPG), and the working parameters were set as follows: voltage, 1.8 V; pulse width, 210 μs; and frequency, 300 HZ through repeated tuning. The motor score of the patient’s key muscles in both lower extremities was graded 1 after surgery. The muscles can contract slightly, but they can not move the joints. The contraction of the muscles can be felt only when the muscles are touched. The patient’s spinal cord injury grade was AIS-C. For position sensation assessment, we requested the patient to close his eyes and then placed his lower extremities in a certain position, and asked the patient to describe the position of the extremities. For movement sensation assessment, we requested the patient to close his eyes, and then flexed or bent his extremities, and asked the patient to describe the direction of movement. For vibration sensation assessment, we placed a vibrating tuningfork on the bony prominence of the patient and asked the patient to describe the sensation of vibration and the duration of sensation. The patient underwent long-term, extensive rehabilitation training, including comprehensive limb training, gait and balance training, and whole-body muscle training. At the 2-year discharge follow-up, the patient was able to stand and walk with the assistance of a limb appliance (Video 1), and The patient’s spinal cord injury grade wasAIS-D. (Motor function is preserved below the nerve plane of spinal cord injury, and at least half of the key muscle strength below the nerve plane of spinal cord injury is restored to grade 3; (Table 1)

  

    
Study 
    
Deep sensation
    
Alternating numbness
    
Muscle strength (grade)
  
  

    
Test 
    
Position sensation 
    
Movement sensation 
    
Vibration sensation 
  
  

    
Before surgery 
    
- 
    
- 
    
- 
    
+ 
    
0 
  
  

    
1 day after surgery 
    
+ 
    
+ 
    
+ 
    
- 
    
I 
  
  

    
2 years after surgery 
    
+++ 
    
+++ 
    
+++ 
    
- 
    
III 
  
  

    
-, +, and ++++ represent the degree of a    symptom 
  

Table 1: Changes in sensory and motor functions in both lower extremities of the patient.