Case based learning: Brown Sequard Syndrome

A 22 year old[1]  man[2]  was speeding on a motorbike when he had a collision with a lorry[3]. He was thrown over a pavement where he became unconscious at the scene[4]. He was rushed to the hospital. He regained consciousness after about 4 hours and was unable to move his neck and limbs. He was wavering in and out of consciousness. Blood pressure was 90/70 with a pulse of 120/min. Supportive treatment was given for re hydration. Screening x-ray[5] showed a C-6 fracture dislocation. He was placed in traction. No other injuries were found. On the third day, he regained full consciousness and was noted to have loss of vibration, position, two point discrimination and localization sense on the left side of the body[6] and loss of pain and thermal sensation on the right side[7]. In addition, he had lost motor function on the left side of the body. A diagnosis of Brown-Sequard syndrome[8] was made as his further treatment[9] was planned.

Explanation:

[1] Age:

Population based study reveals that the syndrome occurs most frequently between 16-30 years of age but this mean age has been increasing over the past few years.

[2] Sex

Syndrome is more prevalent among the males but this might be due to greater traumatic injuries in males.

[3] Vehicle accident:

A vehicle accident might result in:

1. Head injury

2. Spinal injury

3. Blunt cervical vascular injuries

4. Thoracic injury

5. Aortic injuries

6.Blunt cardiac injury

7. Blunt tracheobronchial injuries

8. Diaphragmatic injuries

9. Abdominal injury

10. Extremity injury

[4] Loss of consciousness:

This might be due to:

a. Trauma to the brain and spinal cord

b. Infections- Encephalitis and meningitis

c. Defects in the metabolic system- diabetes

d. Drug exposure

e. Structural abnormalities of the brain

[8] Brown-Séquard syndrome

Loss of sensation and motor function caused by lateral hemisection of the spinal cord.

Causes:

 a. Tumor of the spinal cord

b. Trauma

c. Degenerative diseases

d. Infection

e. Hemorrhage

[5] Imaging:

Spinal radiograph might show bony injury in case of blunt trauma or penetrating injuries.

MRI makes clear the extent of bony injury and helps in diferential diagnosis.

CT myelography might be useful if MRI is not unavailable.

[6] Brown Sequrad syndrome results in ipsilateral loss of tactile discrimination and of vibratory and proprioceptive sensations below the level of the lesion. This is caused by the destruction of ascending tracts in posterior white column on same side of the lesion.

[7] Syndrome causes contralateral loss of pain and temperature sensations below the level of the lesion. This is due to destruction of crossed lateral spinothalamic tracts on side of lesion. Sensory loss occurs two to three segments below the level of the lesion distally.

[9] Treatment

1. Immobilization

2. Steroids supplementation

3. To treat the underlying cause.