Brown-Sequard Syndrome Clinical Presentation
- Author: Carol Vandenakker-Albanese, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Clinical history often reflects the etiology of Brown-Séquard syndrome. Onset of symptoms may be acute or gradually progressive. Complaints are related to hemiparesis or hemiparalysis and sensory changes, paresthesias, or dysesthesias in the contralateral limb(s). Isolated weakness or sensory changes may be reported.
Complete hemisection, causing classic clinical features of pure Brown-Séquard syndrome, is rare. Incomplete hemisection causing Brown-Séquard 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.
Diagnosis and identification of Brown-Séquard syndrome is based on physical examination findings. Partial Brown-Séquard syndrome is characterized by asymmetrical paresis, with hypalgesia more marked on the less paretic side. Pure Brown-Séquard syndrome (rarely seen in clinical practice) is associated with the following:
Interruption of the lateral corticospinal tracts - Ipsilateral spastic paralysis below the level of the lesion and Babinski sign ipsilateral to the lesion (abnormal reflexes and Babinski sign may not be present in acute injury)
Interruption of posterior white column - Ipsilateral loss of tactile discrimination, as well as 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
Try to differentiate levels of sensation loss, motor loss, temperature loss, and vibratory sense loss. Evaluate bilateral versus unilateral neurologic findings when determining level of loss.
Motor examination in patients with Brown-Séquard syndrome reveals spastic weakness or paralysis with upper motor neuron signs of increased tone, hyperreflexia, clonus, and a Hoffmann sign on 1 side of the body. Motor strength of key muscles representing cervical and lumbar spinal root levels should be graded on the standard 0-5 scale. Special care must be taken to test in positions with gravity eliminated and against gravity.
The sensory examination is notable for contralateral decreased sensations of light touch and hot or cold. Sensory function should be recorded in representative dermatomes from C2-S4/5 for absent, impaired, or normal sensations of light touch and pinpricks.
Motor and sensory findings can be classified according to the American Spinal Injury Association (ASIA) standard neurologic classification of SCI (see the image below). The neurologic level is defined as the most caudal segment with normal function. Complete or incomplete assessment is based on sensory or motor function in S4-S5.
The ASIA Impairment Scale reflects the degree of incomplete injury based on motor and sensory function below the neurologic level. (See the image below.)
McCarron MO, Flynn PA, Pang KA, et al. Traumatic Brown-Séquard-plus syndrome. Arch Neurol. 2001 Sep. 58(9):1470-2. [Medline]. [Full Text].
Saadon-Grosman N, Tal Z, Itshayek E, Amedi A, Arzy S. Discontinuity of cortical gradients reflects sensory impairment. Proc Natl Acad Sci U S A. 2015 Dec 29. 112 (52):16024-9. [Medline]. [Full Text].
Musker P, Musker G. Pneumocephalus and Brown-Sequard syndrome caused by a stab wound to the back. Emerg Med Australas. 2011 Apr. 23(2):217-9. [Medline].
Mac-Thiong JM, Parent S, Poitras B, Joncas J, Labelle H. Neurological Outcome and Management of Pedicle Screws Misplaced Totally Within the Spinal Canal. Spine (Phila Pa 1976). 2012 Jul 18. [Medline].
Moin H, Khalili HA. Brown Séquard syndrome due to cervical pen assault. J Clin Forensic Med. 2006 Apr. 13(3):144-5. [Medline].
Urrutia J, Fadic R. Cervical disc herniation producing acute Brown-Sequard syndrome: dynamic changes documented by intraoperative neuromonitoring. Eur Spine J. 2012 Jun. 21 Suppl 4:S418-21. [Medline]. [Full Text].
Chen PY, Lin CY, Tzaan WC, et al. Brown-Sequard syndrome caused by ossification of the ligamentum flavum. J Clin Neurosci. 2007 Sep. 14(9):887-90. [Medline].
Lipper MH, Goldstein JH, Do HM. Brown-Séquard syndrome of the cervical spinal cord after chiropractic manipulation. AJNR Am J Neuroradiol. 1998 Aug. 19(7):1349-52. [Medline].
Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine. 2007 Nov. 7(5):571-4. [Medline].
Spinal Cord Injury Information Network. Facts and Figures at a Glance. February. [Full Text].
McKinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007. 30(3):215-24. [Medline]. [Full Text].
Little JW, Halar E. Temporal course of motor recovery after Brown-Sequard spinal cord injuries. Paraplegia. 1985 Feb. 23(1):39-46. [Medline].
Pollard ME, Apple DF. Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine. 2003 Jan 1. 28(1):33-9. [Medline].
Kohno M, Takahashi H, Yamakawa K, et al. Postoperative prognosis of Brown-Séquard-type myelopathy in patients with cervical lesions. Surg Neurol. 1999 Mar. 51(3):241-6. [Medline].
Hayes KC, Hsieh JT, Wolfe DL, et al. Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients. Arch Phys Med Rehabil. 2000 May. 81(5):644-52. [Medline].
Clatterbuck RE, Belzberg AJ, Ducker TB. Intradural cervical disc herniation and Brown-Séquard's syndrome. Report of three cases and review of the literature. J Neurosurg. 2000 Apr. 92(2 Suppl):236-40. [Medline].
Jacobsohn M, Semple P, Dunn R, et al. Stab injuries to the spinal cord: a retrospective study on clinical findings and magnetic resonance imaging changes. Neurosurgery. 2007 Dec. 61(6):1262-6; discussion 1266-7. [Medline].
Parmar H, Park P, Brahma B, et al. Imaging of idiopathic spinal cord herniation. Radiographics. 2008 Mar-Apr. 28(2):511-8. [Medline].
Miranda P, Gomez P, Alday R, et al. Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. Eur Spine J. 2007 Aug. 16(8):1165-70. [Medline].
Winchester PK, Williamson JW, Mitchell JH. Cardiovascular responses to static exercise in patients with Brown-Séquard syndrome. J Physiol. 2000 Aug 15. 527 Pt 1:193-202. [Medline]. [Full Text].
Massicotte EM, Montanera W, Ross Fleming JF, et al. Idiopathic spinal cord herniation: report of eight cases and review of the literature. Spine. 2002 May 1. 27(9):E233-41. [Medline].
Scivoletto G, Cosentino E, Morganti B, et al. Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions. Disabil Rehabil. 2007 May 11. 1-8. [Medline].