Working Diagnosis:
C2-C4 intraspinal abscess with hemiplegia
Treatment:
Long and extensive IV and oral antibiotic treatment
Patient underwent multiple procedures:
o Bilateral complete C2-C3 laminectomy
o Bilateral partial C1 laminectomy
o C2-C4 durotomy
o Right-sided C2-C3 myelotomy with drainage of intraparenchymal abscess
o C2-C4 artificial dural patch graft
Patient had a long and extensive rehabilitation program
Outcome:
Patient's symptoms have improved, but he still has significant spastic hemiplegia mainly in his right upper extremity 2 ½ years later Case Photo #4 Case Photo #5 .
• Follow Up:
Recent abdominal ultrasound revealed no focal liver lesion. MRI also showed C2-C4 cord enlargement consistent with possible scar formation Case Photo #3 . Initially he was not able to walk with extensive motor deficit. He was very dedicated to extensive rehabilitation and exercise therapy. He eventually reached his goal of walking with no need for a wheelchair. Patient continues to follow his rehabilitation programs.
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