0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation |

Traumatic Brown-Séquard–Plus Syndrome FREE

Mark O. McCarron, MA, MRCP, MD; Peter A. Flynn, MRCP, FRCR; Kiang A. Pang, FRCP; Stanley A. Hawkins, FRCP
[+] Author Affiliations

From the Departments of Neurology (Drs McCarron and Hawkins), Neurophysiology (Dr Pang), and Neuroradiology (Dr Flynn), Royal Victoria Hospital, Belfast, Northern Ireland.


Arch Neurol. 2001;58(9):1470-1472. doi:10.1001/archneur.58.9.1470.
Text Size: A A A
Published online

ABSTRACT

Background  In the 1840s Brown-Séquard described the motor and sensory effects of sectioning half of the spinal cord. Penetrating injuries can cause Brown-Séquard or, more frequently, Brown-Séquard–plus syndromes.

Objective  To report the case of a 25-year-old man who developed left-sided Brown-Séquard syndrome at the C8 level and left-sided Horner syndrome plus urinary retention and bilateral extensor responses following a stab wound in the right side of the neck.

Results  Magnetic resonance imaging demonstrated a low cervical lesion and somatosensory evoked potentials confirmed the clinical finding of left-side dorsal column disturbance. At follow-up, the patient's mobility and bladder function had returned to normal.

Conclusion  This patient recovered well after a penetrating neck injury that disturbed function in more than half the lower cervical spinal cord (Brown-Séquard–plus syndrome).

Figures in this Article

STAB WOUNDS are a recognized cause of traumatic spinal cord injury. The resulting deficits depend on the location and extent of spinal cord involvement. We describe the clincal and neurophysiological findings in a patient with a stab wound injury to the neck.

REPORT OF A CASE

A 25-year-old man was stabbed in the right side of his neck (Figure 1A). Neurologic examination revealed Horner syndrome on the left side (Figure 1B) and left-sided hemiparesis. Joint position and vibration modalities were reduced on the left side. There was also a right-sided decrease in pain and temperature sensations below the C8 level. He had absent abdominal reflexes, brisk limb reflexes, bilateral ankle clonus, and extensor plantar responses. He developed urinary retention. The findings were consistent with Brown-Séquard syndrome caused by disturbance to the left side of the lower cervical cord1,2 plus some disturbance on the right side (because of the urinary retention, bilateral brisk reflexes, and extensor plantar responses).3 Magnetic resonance imaging of the cervical spine revealed a cord lesion at the level of the fifth through sixth cervical vertebrae (Figure 2), which was predominantly left sided on sequential parasagittal sections, and median nerve evoked potentials confirmed left-sided dorsal column disturbance (Figure 3). The patient made a good recovery, walking independently, and regaining bladder function.

Place holder to copy figure label and caption
Figure 1.

A, Right-sided neck stab wound; B, left-sided Horner syndrome.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A sagittal T2-weighted magnetic resonance image of cervical cord demonstrating a slitlike lesion at the fifth through sixth cervical vertebrae with minimal surrounding edema.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Sensory evoked responses illustrating a poorly formed response at cortical and cervical (N13) levels on left median nerve stimulation (A). The cortical response is also significantly delayed compared with the right median nerve stimulation (B).

Graphic Jump Location

COMMENT

Brown-Séquard is credited with the description of the classic syndrome of ipsilateral hemiplegia and loss of proprioceptive sensation with contralateral loss of pain and temperature sensations following a spinal hemisection.1 The presence of Horner syndrome combined with a Brown-Séquard syndrome has seldom been reported.2,46 However, most descriptions of Brown-Séquard syndrome are less pure forms of the syndrome; these have been termed "Brown-Séquard–plus syndromes,"6,7 a term appropriate for our patient.

Intriguingly, the stab injury occurred on the right side of the patient's neck and hemisection at the fifth through sixth cervical vertebrae, clinically on the left side of the spinal cord. This trajectory has been previously described.2 Coexistent Horner syndrome clearly reflects ipsilateral involvement of descending sympathetic fibers within the cervical spinal cord. There was clinical and neurophysiological evidence of ipsilateral dorsal column involvement, a feature seldom documented in putative Brown-Séquard syndrome or Brown-Séquard–plus syndromes.

ARTICLE INFORMATION

Accepted for publication May 14, 2001.

Corresponding author: Mark McCarron, MA, MRCP, MD, Department of Neurology, Quin House, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland (e-mail: mark.mccarron@royalhospitals.n-i.nhs.uk).

REFERENCES

Aminoff  MJ Historical perspective: Brown-Séquard and his work on the spinal cord. Spine.1996;21:133-140.
Firlik  ADWelch  WC Images in clinical medicine: Brown-Séquard syndrome. N Engl J Med.1999;340:285.
Roth  EJPark  TPang  TYarkony  GMLee  MY Traumatic cervical Brown-Séquard and Brown-Séquard–plus syndromes: the spectrum of presentations and outcomes. Paraplegia.1991;29:582-589.
Garcia-Manzanares  MDBelda-Sanchis  JIGiner-Pascual  MMiguel-Leon  IDelgado-Calvo  MAlio y Sanz  JL Brown-Séquard syndrome associated with Horner's syndrome after a penetrating trauma at the cervicomedullary junction. Spinal Cord.2000;38:705-707.
Shen  CCWang  YCYang  DYWang  FHShen  BB Brown-Séquard syndrome associated with Horner's syndrome in cervical epidural hematoma. Spine.1995;20:244-247.
Koehler  PJEndtz  LJ The Brown-Séquard syndrome: true or false? Arch Neurol.1986;43:921-924.
Taylor  RGGleave  JRW Incomplete spinal cord injuries—with Brown-Séquard phenomena. J Bone Joint Surg Br.1957:39:438-450.

Figures

Place holder to copy figure label and caption
Figure 1.

A, Right-sided neck stab wound; B, left-sided Horner syndrome.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A sagittal T2-weighted magnetic resonance image of cervical cord demonstrating a slitlike lesion at the fifth through sixth cervical vertebrae with minimal surrounding edema.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Sensory evoked responses illustrating a poorly formed response at cortical and cervical (N13) levels on left median nerve stimulation (A). The cortical response is also significantly delayed compared with the right median nerve stimulation (B).

Graphic Jump Location

Tables

References

Aminoff  MJ Historical perspective: Brown-Séquard and his work on the spinal cord. Spine.1996;21:133-140.
Firlik  ADWelch  WC Images in clinical medicine: Brown-Séquard syndrome. N Engl J Med.1999;340:285.
Roth  EJPark  TPang  TYarkony  GMLee  MY Traumatic cervical Brown-Séquard and Brown-Séquard–plus syndromes: the spectrum of presentations and outcomes. Paraplegia.1991;29:582-589.
Garcia-Manzanares  MDBelda-Sanchis  JIGiner-Pascual  MMiguel-Leon  IDelgado-Calvo  MAlio y Sanz  JL Brown-Séquard syndrome associated with Horner's syndrome after a penetrating trauma at the cervicomedullary junction. Spinal Cord.2000;38:705-707.
Shen  CCWang  YCYang  DYWang  FHShen  BB Brown-Séquard syndrome associated with Horner's syndrome in cervical epidural hematoma. Spine.1995;20:244-247.
Koehler  PJEndtz  LJ The Brown-Séquard syndrome: true or false? Arch Neurol.1986;43:921-924.
Taylor  RGGleave  JRW Incomplete spinal cord injuries—with Brown-Séquard phenomena. J Bone Joint Surg Br.1957:39:438-450.

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 8

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles