Case Stusies

He Zhining

Gender: Male

Age: 3 years and 6 months

Admission condition:

The patient, at the age of over 1 year, was found unable to sit independently. Subsequently, they were taken to the Heze Maternal and Child Health Hospital for diagnosis and treatment, where they were diagnosed with cerebral palsy. The patient had previously undergone treatment with mouse nerve growth factors, but the specific treatment plan is unknown. Currently, the patient exhibits low intelligence, with a limited language capacity of only 7-8 syllables, and is unable to stand or walk independently. They have high muscle tone in both upper limbs, with a bias towards the right side and use of the left hand. Their head control is poor, lower back strength is inadequate, lower limb muscle strength is low, and their feet tend to curl inward when lifted. Bowel and bladder functions are normal. To further diagnose and treat the condition, the patient was transferred to our hospital. Since the onset of the condition, the patient has maintained clear consciousness, good mental status, normal eating and sleeping patterns, regular bowel and bladder functions, and stable weight without significant fluctuations.

Admission Diagnosis: Cerebral Palsy

Treatment Process

The patient, named He Zhining, male, aged 3 years and 6 months, underwent robot-assisted stereotactic brain surgery for cerebral palsy under intravenous combined anesthesia on February 20, 2023, at 16:00. The surgery involved attaching marker points to the head first for CT scanning, followed by importing the scan data into the Remebot robot. The surgery targeted the left basal ganglia, entering through the left frontal area with a predetermined surgical path. The patient was placed in a supine position, and their head was immobilized using a customized pillow. After routine disinfection and draping, a local incision was made on the scalp, followed by drilling a hole and piercing the dura mater with a sharp needle. Subsequently, electrode needles were used for electrical impedance detection of brain tissue, followed by mild electrical stimulation therapy using radiofrequency needles at the target site for nerve modulation. The surgery on the left target site was successfully completed with approximately 3ml of blood loss. The needle was removed post-surgery, and the incision site was closed with local skin closure and pressure dressing. A post-operative head CT scan showed no significant bleeding, indicating accurate targeting. The patient was safely transferred back to the ward and received standard intravenous fluids, oxygen therapy, and cardiac monitoring. Their vital signs were closely monitored, and appropriate measures were taken promptly. The family was informed about the surgical outcome.

Discharge Summary:

The patient's mental status was good upon discharge, with normal sleep, diet, and bowel and bladder functions, along with stable vital signs. Physical examination revealed clear breath sounds in both lungs without crackles or friction rubs. Normal heart rate and rhythm were noted, with no murmurs heard over any valve areas. The patient had clear consciousness, equal and round pupils with a diameter of approximately 3mm, reactive to light, normal eye movements, intact hearing, present gag reflex, absence of tongue atrophy or tremors, symmetrical nasolabial folds, midline tongue protrusion, normal neck, and normal muscle strength in all four limbs at grade V. The Babinski reflex was negative bilaterally. The patient was able to lift both legs alternately off the bed without edema in the lower limbs. The surgical incision was dry without erythema, discharge, or swelling. Based on these findings, it was decided to discharge the patient today.

Discharge Instructions:

1、Keep the wound dry after discharge and remove stitches after 5 days.

2、Rest well, avoid vigorous head movements, and strengthen protective measures.

3、Follow up with rehabilitation training based on the child's condition after discharge.

4、Seek medical attention promptly if there are any discomforts.