Brown Sequard Syndrome

Brown-Sequard Syndrome
Brown-Squard syndrome is an incomplete spinal cord lesion characterized by a clinical

picture reflecting hemisection of the spinal cord, often in the cervical cord region. It was
first described in the 1840s after Dr. Charles Edouard Brown-Sequard sectioned half of
the spinal cord. It is a rare syndrome, consisting of ipsilateral hemiplegia with
contralateral pain and temperature sensation deficits because of the crossing of the fibers
of the spinothalamic tract.
Pathophysiology
The pure Brown-Squard syndrome reflecting hemisection of the cord is not often
observed. A clinical picture comprising fragments of the syndrome or the hemisection
syndrome plus additional symptoms and signs is more common. Interruption of the
lateral corticospinal tracts, the lateral spinal thalamic tract, and at times the posterior
columns produces a picture of a spastic weak leg with brisk reflexes and a strong leg with
loss of pain and temperature sensation. Note that spasticity and hyperactive reflexes may
not be present with an acute lesion.
Epidemiology
Frequency
Brown-Sequard syndrome is a seldom encountered syndrome, usually the result of
penetrating trauma to the cervical or thoracic spine. It is also associated rarely with
herniated cervical disks.
Mortality/Morbidity
Brown-Sequard syndrome morbidity and mortality is related to the initial associated
injuries that may have occurred with the insult that created Brown-Sequard. Often the
result of penetrating trauma, other wounds may coexist that threaten exsanguinating
hemorrhage. Morbidity is associated with the resulting hemiplegia, with infection a
significant long-term risk.
History
Brown-Squard syndrome may be the result of penetrating injury to the spine, but many
other etiologies have been described. Complete hemisection, causing classic clinical
features of pure Brown-Squard syndrome, is rare. Incomplete hemisection causing
Brown-Squard syndrome plus other signs and symptoms is more common. These
symptoms may consist of findings from posterior column involvement such as loss of
vibratory sensation.
Physical
Partial Brown-Squard syndrome is characterized by asymmetric paresis with hypalgesia
more marked on the less paretic side. Pure Brown-Squard syndrome is associated with
the following:
Interruption of the lateral corticospinal tracts

o Ipsilateral spastic paralysis below the level of the lesion
o Babinski sign ipsilateral to lesion
o Abnormal reflexes and Babinski sign may not be present in acute injury.
Interruption of posterior white column - Ipsilateral loss of tactile discrimination,
vibratory, and position sensation below the level of the lesion
Interruption of lateral spinothalamic tracts: Contralateral loss of pain and
temperature sensation. This usually occurs 2-3 segments below the level of the
lesion.
Causes
Spinal cord tumor, metastatic or intrinsic

Trauma, penetrating or blunt - May include needle injection of illicit substances;
stab wounds
Degenerative disease such as disk herniation and cervical spondylosis
Ischemia
Infectious/inflammatory causes
o Meningitis
o Empyema
o Herpes zoster
o Herpes simplex
o Myelitis
o Tuberculosis
o Syphilis
o Multiple sclerosis
Hemorrhage, including spinal subdural/epidural and hematomyelia
Chiropractic manipulation (rare but reported
Laboratory Studies
Diagnosis of Brown-Squard syndrome is made on the basis of history and
physical examination. Laboratory work is not necessary to evaluate for the
condition but may be helpful in following the patient's clinical course. Laboratory
studies may be useful in nontraumatic etiologies; otherwise, they do not
contribute to diagnosis.
Imaging Studies
Spinal plain radiographs may depict bony injury in penetrating or blunt trauma.
Lateral mass fracture may cause Brown-Squard syndrome after blunt injury.
MRI defines the extent of spinal cord injury and is helpful when differentiating
among nontraumatic etiologies.
CT myelography may be useful if MRI is contraindicated or unavailable.
Procedures
Patients with traumatic Brown-Squard syndrome need to be evaluated for the
possibility of other injuries, as in any trauma victim. This evaluation may include
the following:
o Bladder catheterization may identify varying degrees of bladder
dysfunction in some cases.
o Immobilization may be required.
o Nasogastric (NG) tube insertion and subsequent low-wall suction may
help to prevent aspiration. Additionally, these patients are prone to
developing ileus in the acute stage.
o Cervical spine immobilization, or lower dorsal vertebra immobilization, is
required with trauma or suspicion of an unstable spine. Hard-collar
immobilization or Gardner Wells tongs may be required if cervical
fracture/injury is identified.
o Patients with Brown-Squard syndrome have varying levels of sensation
loss, mandating investigation of possible intra-abdominal injury, for
example, through CT scan or ultrasonography.
Prehospital Care
The key to successful prehospital care of patients with Brown-Squard syndrome is to
suspect a cervical or other spinal injury. A low threshold for cervical spine/backboard
immobilization is appropriate. One issue with prehospital evaluation of cervical spine
injury is the potential for assumption of a complete spinal cord lesion rather than an
incomplete lesion. Prehospital providers must be educated to the findings of incomplete
cord syndromes and how to make a brief assessment of complete versus incomplete cord
lesion.
Emergency Department Care
Care in the ED consists of a thorough evaluation, including neurologic
examination for level of injury. Careful cervical spine/dorsal spine immobilization
is necessary, with elimination of neck movement.
The nature of sensory loss makes investigation of other injuries more difficult.
This mandates thorough and complete physical examination, relying on imaging
studies to supplement physical examination.
Consultations
Neurosurgical or orthopedic consultation is necessary. Practice patterns may
dictate involvement of different services. It is essential that physical medicine and
rehabilitation specialists be consulted early on in the initial stages of their care.
Medication Summary
The goal of pharmacotherapy is to prevent complications.
Corticosteroids
Multiple studies have demonstrated the improved outcomes of patients with traumatic
spinal cord injuries who are given high-dose steroids early in the clinical course.
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Decreases inflammation by suppressing polymorphonuclear leukocytes and reversing
increased capillary permeability.
Transfer
Transfer to a level I trauma center or to a facility with expertise in the care of
spinal cord injuries is appropriate; however, transfer should not impede the
overall evaluation of these patients, including assessment for possible other
injuries.
Complications
Complications associated with spinal injury may be present. These may include
hypotension initially ("spinal shock") to pulmonary emboli if not prophylactically
treated. Subacute and chronic care periods may be complicated by infection to
sites such as lungs, urine, etc. Depression frequently occurs in patients with spinal
cord injuries and should be observed for in these patients.
Prognosis
The prognosis for Brown-Squard syndrome is poor and depends to a large degree
on the etiology of the syndrome. Early treatment with high-dose steroids has
shown benefit.
http://emedicine.medscape.com/article/791539-overview

Brown Sequard Syndrome

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Brown Sequard Syndrome

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Brown-Sequard Syndrome

Brown-Squard syndrome is an incomplete spinal cord lesion characterized by a clinical

Interruption of the lateral corticospinal tracts

Spinal cord tumor, metastatic or intrinsic

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