A 68-years-old woman presented with weakness and numbness of all four limbs. The patient consented to participate in this case report. She could slide her legs sideways but was unable to lift them. She was able to move both arms with better movement in the left arm. However, she had difficulty clenching and grasping objects using her hands and fingers. The patient was right-handed. She was able to turn over in bed and sat reclining with the caregiver's assistance. All of her daily activities were performed with assistance, and she could not sit without support. She also could not feel the urge to urinate and defecate, and had incontinence.
She felt pain in the middle back, which radiated to her legs, with a numerical rating scale (NRS) of 7. The pain was sharp and was accompanied by a burning sensation unrelated to any activity. The patient was administered gabapentin 300 mg daily for the last two weeks, and the NRS score was reduced to 5. The patient also experienced localized pain in her right shoulder and buttocks, with an NRS of 5, respectively. In addition, she complained of bilateral knee pain with an NRS score of 3. The patient often refused to be seated in a reclined position and preferred to lie prone all day. She slept a lot during the day and had difficulty sleeping at night.
She also experienced malaise, epigastric discomfort, nausea, episodic vomiting, and a yellowish appearance on the sclera and skin in the previous week. She lost her appetite, which resulted in decreased food and drink intake, although she had no difficulty swallowing liquids or solid foods. The presumptive diagnosis was spondylitis tuberculosis. She had consumed anti-tuberculosis drugs for two months. Magnetic resonance imaging (MRI) revealed destruction of the vertebral bodies at the level of the 5th and 6th cervical area, with paravertebral and longus colli muscle abscesses (Figure 1). Subsequently, she underwent debridement and spinal stabilization surgery. The spine stabilization procedure was anterior cervical corpectomy decompression and fusion (ACDF).
Her body mass index (BMI) was 14.98 kg/m2 (categorized as underweight). Her vital signs were uneventful, and communication was good. Both the sclera and skin were icteric. No palpable enlargement of the liver or spleen was observed. She also had a pressure injury at the sacrum measuring 2 x 1 cm, grade II. This patient had a limited range of movement (ROM) in the neck and upper extremities. She also had limited flexion in all parts of the metacarpal joints. Neurological examination revealed that she had SCI with an Asia Impairment Score (AIS) grade C and neurological level (NL) at the 5th cervical area (SCI AIS C NL C5). The patient wishes to return to her role as a grandmother and perform activities in a sitting position.
We found that this patient was categorized as malnourished, with a score of 4, as assessed using the validated Mini Nutritional Assessment (MNA) tools. She also had a mid-upper arm circumference of 17 cm, categorized as low circumference. She had mild cognitive impairment (MCI) with a score of 22 as measured using Montreal Cognitive Assessment Indonesian version (MOCA-INA). This patient also had suggestive sarcopenia with a score of 18 on the SARC-Calf score. We could not perform a bioelectrical impedance analysis (BIA) to confirm the diagnosis of sarcopenia because the patient could not stand properly on her own. We also tried using a hand dynamometer to measure the strength of the hand grip, but the patient was unable to press the handle maximally due to the stiffness of the metacarpophalangeal (MCP) joints in both hands. In addition, she was considered inactive according to the International Physical Activity Questionnaire (IPAQ). She was also regarded as dependent, with a score of 21/100 on Spinal Cord Independence Measurement (SCIM) with poor QOL. This patient had probable depression based on the Geriatric Depression Scale (GDS). Her caregiver has a caregiver burden, scoring 44, based on the Zarit Burden Scale (ZBS).
She received pain management therapy during hospitalization. We used extracorporeal shock wave therapy (ESWT) and infrared radiation (IRR) to manage the right shoulder pain due to tendonitis, with an NRS score of five. Both were assigned to the insertion of the rotator cuff muscle area. ESWT was performed once a week, and IRR was performed twice a week. Laser therapy has been used to treat buttock pain caused by piriformis syndrome. It was administered to the piriformis muscle twice a week. All therapy modalities will be administered for one month and will be evaluated monthly.
Our patient performed the 3-month outpatient PRM program after the initial assessment with flexibility and strengthening exercises for the extremities (Figure 2), as well as activity of daily living (ADL) adjustment training (for eating, grooming, and upper dressing). Additionally, she received psychological support from a psychologist. The short-term goals of our PRM intervention were increasing body weight, reducing shoulder pain, ensuring appropriate sleep time, independent ADL for eating, grooming, and upper body dressing, partial dependency on bed mobilization, partial dependency on transfer, managing depression, and no SCI complications. The long-term goals for the patient include managing tuberculosis, increasing the QOL, and reversing the sarcopenia condition.