| Brown-Séquard syndrome |
| Classification and external resources |
Brown-Séquard syndrome is bottom diagram |
| ICD-10 |
G83.8 |
| ICD-9 |
344.89 |
| DiseasesDB |
31117 |
| eMedicine |
emerg/70 pmr/17 |
| MeSH |
D018437 |
Brown-Séquard syndrome, also known as Brown-Séquard's hemiplegia and Brown-Séquard's paralysis, is a loss of sensation and motor function (paralysis and ataxia) that is caused by the lateral hemisection (cutting) of the spinal cord. Other synonyms are crossed hemiplegia, hemiparaplegic syndrome, hemiplegia et hemiparaplegia spinalis, and spinal hemiparaplegia.
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Contents
- 1 Classification
- 1.1 Fine (light) touch verses crude touch
- 2 Diagnosis
- 3 Causes
- 4 Pathophysiology
- 5 Treatment
- 6 Epidemiology
- 7 History
- 8 References
- 9 External links
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Classification
Any presentation of spinal injury that is an incomplete lesion (hemisection) can be called a partial Brown-Séquard or incomplete Brown-Séquard syndrome.
Brown-Séquard syndrome is characterized by loss of motor function (i.e. hemiparaplegia), loss of vibration sense and fine touch, loss of proprioception (position sense), loss of two-point discrimination, and signs of weakness, on the ipsilateral (same side) of the spinal injury. This is a result of a lesion through the corticospinal tract, which carries motor fibers, and through the dorsal column-medial lemniscus tract, which carries fine (or light) touch fibers. On the contralateral (opposite side) of the lesion, there will be a loss of pain and temperature sensation and crude touch.
Fine (light) touch verses crude touch
Crude touch fibers are carried in the spinothalamic tract. These fibers decussate at the level of the spinal cord. Therefore, a hemi-section lesion to the spinal cord will demonstrate the ability to feel crude touch on the contralateral side of the lesion. The patient will not be able to localize where they were touched, only that they were touched. This is because fine touch fibers are carried in the dorsal column-medial lemniscus pathway. The fibers in this pathway decussate at the level of the medulla. Therefore, a hemi-section lesion of the spinal cord will demonstrate loss of fine touch sensation on the ipsilateral side (preserved on the contralateral side) but preserved crude touch.
Pure Brown-Séquard syndrome is associated with the following:
- Interruption of the lateral corticospinal tracts:
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- Ipsilateral spastic paralysis below the level of the lesion
- Babinski sign ipsilateral to lesion
- Abnormal reflexes and Babinski sign may not be present in acute injury.
- Interruption of posterior white column:
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- Ipsilateral loss of tactile discrimination, vibratory, and position sensation below the level of the lesion
- Interruption of lateral spinothalamic tracts:
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- Contralateral loss of pain and temperature sensation. This usually occurs 2-3 segments below the level of the lesion.
Diagnosis
Magnetic resonance imaging (MRI) is the imaging of choice in spinal cord lesions.
Brown-Séquard syndrome is an incomplete spinal cord lesion characterized by findings on clinical examination which reflect hemisection of the spinal cord (cutting the spinal cord in half on one or the other side). It is diagnosed by finding motor (muscle) paralysis on the same (ipsilateral) side as the lesion and deficits in pain and temperature sensation on the opposite (contralateral) side. This is called ipsilateral hemiplegia and contralateral pain and temperature sensation deficits. The loss of sensation on the opposite side of the lesion is because the nerve fibers of the spinothalamic tract (which carry information about pain and temperature) crossover once they meet the spinal cord from the peripheries.
Causes
Brown-Séquard syndrome may be caused by a spinal cord tumour, trauma (such as a gunshot wound or puncture wound to the neck or back), ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosis. In its pure form, it is rarely seen. Incomplete forms are also observed. The most common cause is penetrating trauma such as a gunshot wound or stab wound to the spinal cord. This may be seen most often in the cervical (neck) or thoracic spine.
The presentation can be progressive and incomplete. It can advance from a typical Brown-Séquard syndrome to complete paralysis. It is not always permanent, and progression or resolution depends on the severity of the original spinal cord injury and the underlying pathology that caused it in the first place.
Pathophysiology
Brown-Séquard syndrome's symptoms:
1 = hypotonic paralysis
2 = spastic paralysis and loss of vibration and proprioception (position sense) and fine touch
3 = loss of pain and temperature sensation
The hemisection of the cord results in a lesion of each of the three main neural systems:
- the principal upper motor neuron pathway of the corticospinal tract
- one or both dorsal columns
- the spinothalamic tract
As a result of the injury to these three main brain pathways the patient will present with three lesions:
- The corticospinal lesion produces spastic paralysis on the same side of the body below the level of the lesion (due to loss of moderation by the UMN). At the level of the lesion, there will be flaccid paralysis of the muscles supplied by the nerve of that level (since Lower motor neurones are affected at the level of the lesion).
- The lesion to fasciculus gracilis or fasciculus cuneatus results in ipsilateral loss of vibration and proprioception (position sense) as well as loss of all sensation of fine touch.
- The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion.
Treatment
Treatment is directed at the pathology causing the paralysis. If it is because of trauma such as a gunshot or knife wound, there may be other life threatening conditions such as bleeding or major organ damage which should be dealt with on an emergent basis. If the syndrome is caused by a spinal fracture, this should be identified and treated appropriately. Although steroids may be used to decrease cord swelling and inflammation, the usual therapy for spinal cord injury is expectant.[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
Epidemiology
Brown-Séquard syndrome is rare as the trauma would have to be something that damaged the nerve fibres on just one half of the spinal cord.[15] The classic cause is a stab wound in the back.
History
The syndrome was first described in 1850 by the famed British / Mauritian neurologist Charles-Édouard Brown-Séquard (1817–1896), who studied the anatomy and physiology of the spinal cord.[16][17] He described this injury after observing spinal cord trauma happen to farmers while cutting sugar cane in Mauritius.
French physician Paul Loye attempted to confirm Brown-Séquard's observations on the nervous system by experimentation with decapitation of dogs and other animals and recording the extent of each animal's movement after decapitation.[18][19]
References
- ^ Egido Herrero JA, Saldanã C, Jiménez A, Vázquez A, Varela de Seijas E, Mata P (1992). "Spontaneous cervical epidural hematoma with Brown-Séquard syndrome and spontaneous resolution. Case report". J Neurosurg Sci 36 (2): 117–9. PMID 1469473.
- ^ Ellger T, Schul C, Heindel W, Evers S, Ringelstein EB (June 2006). "Idiopathic spinal cord herniation causing progressive Brown-Séquard syndrome". Clin Neurol Neurosurg 108 (4): 388–91. doi:10.1016/j.clineuro.2004.07.005. PMID 16483712.
- ^ Finelli PF, Leopold N, Tarras S (May 1992). "Brown-Sequard syndrome and herniated cervical disc". Spine 17 (5): 598–600. doi:10.1097/00007632-199205000-00022. PMID 1621163.
- ^ Hancock JB, Field EM, Gadam R (1997). "Spinal epidural hematoma progressing to Brown-Sequard syndrome: report of a case". J Emerg Med 15 (3): 309–12. doi:10.1016/S0736-4679(97)00010-3. PMID 9258779.
- ^ Harris P (November 2005). "Stab wound of the back causing an acute subdural haematoma and a Brown-Sequard neurological syndrome". Spinal Cord 43 (11): 678–9. doi:10.1038/sj.sc.3101765. PMID 15852056.
- ^ Henderson SO, Hoffner RJ (1998). "Brown-Sequard syndrome due to isolated blunt trauma". J Emerg Med 16 (6): 847–50. doi:10.1016/S0736-4679(98)00096-1. PMID 9848698.
- ^ Hwang W, Ralph J, Marco E, Hemphill JC (June 2003). "Incomplete Brown-Séquard syndrome after methamphetamine injection into the neck". Neurology 60 (12): 2015–6. PMID 12821761. http://www.neurology.org/cgi/pmidlookup?view=long&pmid=12821761.
- ^ Kraus JA, Stüper BK, Berlit P (1998). "Multiple sclerosis presenting with a Brown-Séquard syndrome". J. Neurol. Sci. 156 (1): 112–3. doi:10.1016/S0022-510X(98)00016-1. PMID 9559998.
- ^ Lim E, Wong YS, Lo YL, Lim SH (April 2003). "Traumatic atypical Brown-Sequard syndrome: case report and literature review". Clin Neurol Neurosurg 105 (2): 143–5. doi:10.1016/S0303-8467(03)00009-X. PMID 12691810.
- ^ Lipper MH, Goldstein JH, Do HM (August 1998). "Brown-Séquard syndrome of the cervical spinal cord after chiropractic manipulation". AJNR Am J Neuroradiol 19 (7): 1349–52. PMID 9726481. http://www.ajnr.org/cgi/pmidlookup?view=long&pmid=9726481.
- ^ Mastronardi L, Ruggeri A (January 2004). "Cervical disc herniation producing Brown-Sequard syndrome: case report". Spine 29 (2): E28–31. doi:10.1097/01.BRS.0000105984.62308.F6. PMID 14722422.
- ^ Miyake S, Tamaki N, Nagashima T, Kurata H, Eguchi T, Kimura H (February 1998). "Idiopathic spinal cord herniation. Report of two cases and review of the literature". J. Neurosurg. 88 (2): 331–5. doi:10.3171/jns.1998.88.2.0331. PMID 9452246.
- ^ Rumana CS, Baskin DS (April 1996). "Brown-Sequard syndrome produced by cervical disc herniation: case report and literature review". Surg Neurol 45 (4): 359–61. doi:10.1016/0090-3019(95)00412-2. PMID 8607086.
- ^ Stephen AB, Stevens K, Craigen MA, Kerslake RW (October 1997). "Brown-Séquard syndrome due to traumatic brachial plexus root avulsion". Injury 28 (8): 557–8. doi:10.1016/S0020-1383(97)83474-2. PMID 9616398.
- ^ "Brown-Sequard Syndrome: Overview - eMedicine Emergency Medicine". http://emedicine.medscape.com/article/791539-overview.
- ^ synd/973 at Who Named It?
- ^ C.-É. Brown-Séquard: De la transmission croisée des impressions sensitives par la moelle épinière. Comptes rendus de la Société de biologie, (1850)1851, 2: 33-44.
- ^ "Loye: Death by Decapitation". The American Journal of the Medical Sciences 97 (4): 387. 1889. http://scholar.google.ca/scholar?q=info:g58GK6wqlh4J:scholar.google.com/. Retrieved 2009-08-05.
- ^ Alex Boese (2007). Elephants on Acid: And Other Bizarre Experiments. Houghton Mifflin Harcourt. p. 13. ISBN 0-15-603135-3, 9780156031356. http://books.google.com/?id=Wc-UlRRWQ1EC&pg=PA13#v=onepage&q=. Retrieved 2009-08-05.
Here is a complete dedicated forum related for discussions about brown sequard syndrome , Check this out Brown Sequard Syndrome
External links
- Case studies of Brown-Séquard syndrome
- Image
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Lesions of spinal cord and brain
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Spinal cord/
vascular myelopathy |
- sensory: Sensory ataxia
- Tabes dorsalis
- motor: Motor neurone disease
- mixed: Brown-Séquard syndrome
- cord syndrome (Posterior
- Anterior
- Central/Syringomyelia)
- Subacute combined degeneration of spinal cord (B12)
- Cauda equina syndrome
- Anterior spinal artery syndrome
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| Brainstem |
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Medulla (CN 8, 9, 10, 12)
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- Lateral medullary syndrome/Wallenberg
- Medial medullary syndrome/Dejerine
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Pons (CN 5, 6, 7, 8)
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- Lateral pontine syndrome (AICA) (lateral)
- Medial pontine syndrome/Millard-Gubler syndrome
- basilar/Foville's syndrome
- Locked-in syndrome (ventral)
- Internuclear ophthalmoplegia
- One and a half syndrome
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Midbrain (CN 3, 4)
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- Weber's syndrome
- Benedikt syndrome
- Parinaud's syndrome
- Nothnagel's syndrome
- Claude's syndrome
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Other
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| Cerebellum |
- lateral (Dysmetria
- Dysdiadochokinesia
- Intention tremor)
- medial (Cerebellar ataxia)
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| Basal ganglia |
- Chorea
- Dystonia
- Parkinson's disease
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| Cortex |
- ACA syndrome
- MCA syndrome
- PCA syndrome
- frontal lobe: Expressive aphasia
- Abulia
- parietal lobe: Receptive aphasia
- Hemispatial neglect
- Gerstmann syndrome
- Astereognosis
- occipital lobe: Balint's syndrome
- Cortical blindness
- Pure alexia
- temporal lobe: Cortical deafness
- Prosopagnosia
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| Other |
- Subclavian steal syndrome
- Upper motor neurone lesion (Clasp-knife response)
- Lower motor neurone lesion
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anat(n/s/m/p/4/e/b/d/c/a/f/l/g)/phys/devp
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noco(m/d/e/h/v/s)/cong/tumr, sysi/epon, injr
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proc, drug(N1A/2AB/C/3/4/7A/B/C/D)
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