The patient was admitted due to cerebral palsy for over 3 years. At the age of 2, she was found unable to sit or walk independently and was subsequently diagnosed with cerebral palsy at the Tai'an Maternal and Child Health Hospital, although she did not receive specialized treatment. She has been undergoing rehabilitation therapy at a local rehabilitation institution since then. Currently, the patient exhibits intellectual impairment, unclear speech with 5-6 syllables, and drooling. She has poor fine motor skills in both hands, with slow grip movements. There is increased muscle tone in both lower limbs, especially on the right side, requiring assistance for walking. Bowel and bladder control is acceptable, but she needs assistance with feeding. Mentally, she is clear and in good spirits, but her speech is unclear, and her intelligence and orientation are below her peers. Pupils are equal, round, and reactive to light, with a diameter of about 3mm. Eye movements are normal, and hearing is intact. Pharyngeal reflex is present. There is no tongue atrophy or tremor, and facial features are symmetrical. The patient can alternate lifting her legs off the bed. There is no edema in the lower limbs. The surgical incision is clean without redness, swelling, or discharge. Today, she is deemed fit for discharge.
Admission Diagnosis:
Cerebral Palsy
Treatment Process:
Patient Zhang Yuqing, female, 5 years and 9 months old, underwent robot-assisted stereotactic brain surgery for cerebral palsy under general anesthesia on February 27, 2023, at 8:00 in the morning. The surgical procedure involved placing head markers post-anesthesia, followed by a head CT scan and importing the scan data into the Remebot robot. The surgery targeted the left temporal lobe, accessed through the left frontal area, with a well-planned surgical trajectory. The patient was positioned supine with a molded pillow to stabilize the head. After routine disinfection, the scalp was locally incised, a bone hole was drilled, and a sharp needle punctured the dura. Initially, an electrode needle was used to measure brain tissue resistance, followed by the implantation of brain electrical monitoring electrodes. After identifying the epileptic focus at the target site, a radiofrequency needle was used for ablation, eliminating the epileptic focus. Neuroregulatory treatment with mild electrical stimulation was then applied at the target site to complete the surgery on the left side. Subsequently, the right anterior limb of the internal capsule was selected as the target, and a similar neuroregulatory treatment was performed using a radiofrequency needle. The procedure went smoothly with a blood loss of 3ml. Post-operatively, the needle was removed, and the skin around the incision was sutured and dressed. A postoperative head CT scan showed no significant bleeding, confirming accurate surgical targeting. The patient safely returned to the ward and received routine intravenous fluids, oxygen therapy, and cardiac monitoring. Medical staff will closely monitor her vital signs and promptly address any issues as needed. The patient's family has been informed of the surgical details.
Discharge Summary:
The patient's mental status is good, with normal sleep, diet, bowel and bladder function, and stable vital signs. Physical examination reveals clear lung sounds, normal heart rate and rhythm without murmurs, equal and reactive pupils, intact eye movements and hearing, and normal muscle strength in the limbs. There is no edema in the lower extremities, and the surgical incision is clean without signs of infection or bleeding. Following assessment, the patient is discharged 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.
