eMedicine Specialties > Emergency Medicine > Neurology

Brown-Sequard Syndrome

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System

Updated: Dec 17, 2008

Introduction

Background

Brown-Séquard 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-Séquard 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.

Frequency

United States

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.

Clinical

History

Brown-Séquard 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-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.

Physical

Partial Brown-Séquard syndrome is characterized by asymmetric paresis with hypalgesia more marked on the less paretic side. Pure Brown-Séquard syndrome is associated with the following:

Interruption of the lateral corticospinal tracts
- Ipsilateral spastic paralysis below the level of the lesion
- Babinski sign ipsilateral to lesion
- 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
Degenerative disease such as disk herniation and cervical spondylosis
Ischemia
Infectious/inflammatory causes
- Meningitis
- Empyema
- Herpes zoster
- Herpes simplex
- Myelitis
- Tuberculosis
- Syphilis
- Multiple sclerosis
Hemorrhage, including spinal subdural/epidural and hematomyelia
Chiropractic manipulation (rare but reported^1,2)

Differential Diagnoses

Fractures, Cervical Spine
Multiple Sclerosis
Spinal Cord Infections
Spinal Cord Injuries
Stroke, Ischemic

Workup

Laboratory Studies

Diagnosis of Brown-Séquard 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-Séquard 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-Séquard syndrome need to be evaluated for the possibility of other injuries, as in any trauma victim. This evaluation may include the following:
- Bladder catheterization may identify varying degrees of bladder dysfunction in some cases.
- Immobilization may be required.
- 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.
- 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.
- Patients with Brown-Séquard syndrome have varying levels of sensation loss, mandating investigation of possible intra-abdominal injury, for example, through CT scan or ultrasonography.

Treatment

Prehospital Care

The key to successful prehospital care of patients with Brown-Séquard 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

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.

Dosing

Adult

30 mg/kg IV bolus over 15 min, then 5.4 mg/kg/h infusion for 23 h; should be initiated within 8 h of injury

Pediatric

Administer as in adults (NACSIS study enrolled patients as young as 13 y)

Interactions

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Slightly higher rates of wound infection and GI bleeding in methylprednisolone group in the NACSIS study (not statistically significant); other possible complications include hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections

Follow-up

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-Séquard syndrome is poor and depends to a large degree on the etiology of the syndrome. Early treatment with high-dose steroids has shown benefit.

Miscellaneous

Medicolegal Pitfalls

Failure to realize that a cord lesion may be partial instead of complete, for example, in the anterior cord, central cord, or as in Brown-Séquard syndrome
- 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.
Failure to consider other injuries, if the cause was traumatic, while focusing only on the spinal cord injury
- One area commonly neglected is the abdomen; the possibility of intra-abdominal injury must be considered.
- Always consider imaging of the abdomen/pelvis when the spinal cord is injured.
Failure to recognize that hypotension may be the result of something other than neurogenic shock: If the cause of spinal injury is traumatic, always consider hemorrhagic causes of hypotension before assuming it is neurogenic shock.
Failure to administer steroids in a timely manner: Initiate steroids promptly on the basis of the initial ED evaluation.

References

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Egido Herrero JA, Saldana C, Jimenez A, et al. Spontaneous cervical epidural hematoma with Brown-Sequard syndrome and spontaneous resolution. Case report. J Neurosurg Sci. Apr-Jun 1992;36(2):117-9. [Medline].
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Miyake S, Tamaki N, Nagashima T, et al. Idiopathic spinal cord herniation. Report of two cases and review of the literature. J Neurosurg. Feb 1998;88(2):331-5. [Medline].
Moon SJ, Lee JK, Kim TW, Kim SH. Idiopathic transverse myelitis presenting as the Brown-Sequard syndrome. Spinal Cord. Mar 11 2008;[Medline].
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Keywords

spinal cord lesion, Brown-Sequard's syndrome, Brown-Séquard syndrome, Brown-Séquard's syndrome, Brown-Sequard paralysis, Brown-Séquard paralysis, Brown-Séquard's paralysis, hemisection of the spinal cord, ipsilateral hemiplegia, penetrating injury to the spine, incomplete spinal cord lesion

Contributor Information and Disclosures

Author

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Further Reading