Brown-Sequard syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Safakhah, MD[2]

Synonyms and keywords: Brown-Séquard's hemiplegia; Brown-Séquard's paralysis

Brown-Sequard syndrome
Brown-Sequard syndrome is bottom diagram
ICD-10	G83.8
ICD-9	344.89
DiseasesDB	31117
MeSH	D018437

Overview

Brown-Sequard syndrome is an uncommon spinal cord disorder in which the spinal cord is injured but is not severed completely. Brown sequard syndrome results from an injury to one side of the spinal cord typically to the spine in the region of the neck or back. In many cases, some type of puncture wound in the neck or in the back that injures the spine and causes symptoms to appear.

Typically, loss of touch, vibration and position below the level of injury is seen which is known as hemi paralysis or asymmetric paresis. However, the sensory loss is mostly ipsilateral to the spine injury. Loss of sensation for pain and temperature on the contralateral to the side were injury was sustained.

Historical Perspective

It was first described in 1850 by the historically famous British neurologist Charles Édouard Brown-Sequard (1817-1896), who studied the anatomy and physiology of the spinal cord. Brown-Sequard was quite a controversial and eccentric figure, and is also known for self-reporting "rejuvinated sexual prowess after eating extracts of monkey testis". The response is now thought to have been a placebo effect, but apparently this was "sufficient to set the field of endocrinology off and running."

Interestingly, many nations claim him as their own, he was the son of an American sea captain and a French woman, living in a British territory. He studied in the US, France, as well as the UK. He described this injury which resulted from caning knives trauma in Mauritius.

Pathophysiology

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 (the loss of moderation by the UMN).

• The lesion to fasciculus gracilis or fasciculus cuneus results in ipsilateral loss of vibration and proprioception (position sense).

• 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. At the lesion site all sensory modalities are lost on the same side, and also an ipsilateral flaccid paralysis.

Causes

Brown-Sequard syndrome may be caused by a spinal cord tumor, 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.

Differentiating Brown-Sequard syndrome from Other Diseases

Brown -Sequard syndrome must be differentiated from other diseases that cause poor muscle tone, muscle weakness, muscle spasticity and areflexia such as Motor neuron disease, Progressive spinal muscular atrophy, Primary lateral sclerosis and stroke..

Epidemiology and Demographics

Brown sequard syndrome affects both male and female equally. The incidence of this disease is 2% of all traumatic spinal cord injury.

In 2007, the prevalence of brown- sequard syndrome was estimated to be 17.1% of patients diagnosed with spinal cord injuries admitted to Virginia commonwealth university,Virginia,USA..

Risk Factors

There is no established risk factor for Brown -sequard syndrome.

Screening

There is insufficient evidence to recommend routine screening for [brown -sequard syndrome].

Natural History, Complications, and Prognosis

Common complications of Brown -sequard syndrome include hypotension, spinal shock,UTI and pneumonia,hypercalcemia,osteoporosis,vertebral artery dissection,pressure ulcers and bowel impaction. These complications could be due to the trauma causing 'BSS or the overall problem in the body . Also patients with the pathology in their cervical or upper thorax spine need respiratory support.

Diagnosis

Diagnostic Criteria

There are no established criteria for the diagnosis of Brown-Sequard Syndrome.

History and Symptoms

The majority of patients with Brown-Sequard Syndrome experience this syndrome following a trauma to their neck or back region. First symptoms are usually loss of pain and temperature sensation in dermatomes below the traumatized region ,which is due to the decussation of antero- lateral fibers within spinal tract through white commissure resulting in contralateral loss of pain and temperature sensation. Also ,decussation of corticospinal tract at medulla leads to ipsilateral spastic paresis and ipsilateral of vibration and proprioception sensation.

Physical Examination

Although there are various cause for Brown-Sequard Syndrome, the main cause is due to traumatic injury.So initial examination for these patients should follow the ABCDE protocol suggested by advanced trauma life support.cervical spine should be immobilized. furthermore,Rectal exam should be done and ASIA score should be evaluated'Also other important causes of this syndrome such as infection,mass effect,stroke and multiple sclerosis should be ruled out. The majority of patients with this syndrome ,usually experience classic hemi -cord syndrome,ipsilateral motor paralysis and loss of vibration and proprioception sense .IN addition loss of pain and temperature sense on the other side.Loss of bowel and bladder control may be seen.

Laboratory Findings

There are no diagnostic laboratory findings associated with Brown-Sequard Syndrome unless the disesase is due to spinal cord infections.

Imaging Findings

MRI is the imaging of choice in spinal cord lesions.The features of MRI in any case depends on the underlying cause. However, all of them may show unilateral pathology.

Treatment

Like any other diseases, treatment of Brown-Sequard Syndrome is based upon the underlying cause. As the most common cause of this syndrome is due to spinal cord injuries,the first step in the management would be dealing with injury then proceeding to BSS management . There are various options for treatment plan of BSS, such as medical,physical,occupational,recreational and surgical but there isn't any specific choice for it's treatment. Early intervention is usually associated with good prognosis. Although, in severe motor injury there is a low chance of improvement.

Medical Therapy

corticosteroids are used in acute treatment of SCI through reducing the spinal cord inflammation .Also drugs that control muscle spasms may be prescribed to control muscle symptoms. Supportive treatments including braces, hand splits and wheelchairs may be essential to help the affected population to resume their daily activities. However, there are some resources recommending not to use corticosteroids .

Surgery

surgery for those patients with BSS with specific underlying causes such as acute disc herniation or tumors is associated with good surgical outcome.

Also, surgery is recommended in patients with progressive neurologic deficits and unstable spine fracture.

Prevention

There are no established measures for the primary prevention of Brown -Sequard Syndrome.

References

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