Brown-Séquard syndrome
Background
- Hemisection (or unilateral compression) of the spinal cord
- Pure Brown-Séquard is rare; most cases are Brown-Séquard plus syndrome with incomplete hemisection
- Most common cause: penetrating trauma (stab wounds > gunshot wounds)
- Other causes: tumor, epidural abscess, epidural hematoma, multiple sclerosis, spinal cord infarction
Clinical Features
- Classic pattern results from the anatomy of spinal tract decussation:
- Ipsilateral motor deficits: spastic paresis/paralysis (corticospinal tract — decussates at medulla)
- Ipsilateral loss of proprioception, vibration, and light touch (dorsal columns — decussate at medulla)
- Contralateral loss of pain and temperature (spinothalamic tract — decussates 1-2 levels above entry in anterior white commissure)
- Ipsilateral Horner syndrome if cervical cord involvement
- At the level of the lesion: ipsilateral LMN signs, band of ipsilateral anesthesia
Differential Diagnosis
Spinal Cord Syndromes
- Complete spinal cord transection syndrome
- Anterior cord syndrome
- Central cord syndrome
- Brown-Séquard syndrome
- Epidural compression syndromes
Evaluation
- MRI spine — imaging modality of choice to identify the lesion
- CT spine if MRI not immediately available or if penetrating trauma
- Neurological level assessment: motor, sensory (pinprick and light touch), rectal tone
Management
Acute Management of Spinal Cord Injury
- Neurogenic shock management
- Consider intubation injuries at C5 or above
- Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization[1][2]
- Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
- Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension[3]
- Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
- Consider surgical intervention for:
- Progressive neurologic deficits
- Unstable spine fractures
- Steroids are no longer recommended
Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is NOT approved by the FDA for this indication. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.
[6]- See EBQ:High Dose Steroids in Cord Injury for further discussion
- Address underlying etiology (surgical decompression for compressive lesions, antibiotics for abscess)
Prognosis
- Best prognosis of all incomplete spinal cord syndromes
- >90% of patients regain ambulatory function
- Motor recovery typically begins within 1-6 months
Disposition
- Admit all patients — neurosurgery or spine surgery consult
- ICU admission for high cervical lesions or hemodynamic instability
See Also
- Spinal cord syndromes
- Anterior cord syndrome
- Central cord syndrome
- Spinal cord compression (non-traumatic)
References
- ↑ The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.
- ↑ Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.
- ↑ Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.
- ↑ Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.
- ↑ Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.
- ↑ Hurlbert RJ et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 http://www.ncbi.nlm.nih.gov/pubmed/23417182