From the Departments of Neurology (Drs McCarron and Hawkins), Neurophysiology (Dr Pang), and Neuroradiology (Dr Flynn), Royal Victoria Hospital, Belfast, Northern Ireland.
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.
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.
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.
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).
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.
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.
A, Right-sided neck stab wound; B, left-sided Horner syndrome.
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.
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).
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.2,4- 6 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.
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: firstname.lastname@example.org).
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