Brown-Sequard Syndrome Clinical Presentation

Updated: Sep 06, 2018
  • Author: Carol Vandenakker-Albanese, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Presentation

History

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.

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Physical Examination

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. [18]

Classification

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.

American Spinal Injury Association (ASIA) standard American Spinal Injury Association (ASIA) standard neurologic classification of spinal cord injury.

The ASIA Impairment Scale reflects the degree of incomplete injury based on motor and sensory function below the neurologic level. (See the image below.)

American Spinal Injury Association (ASIA) Impairme American Spinal Injury Association (ASIA) Impairment Scale.
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