Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes

Endogenous neurogenesis replaces oligodendrocytes and astrocytes after primate spinal cord injury

Neurogenesis has been described in various regions of the CNS throughout life. We examined the extent of natural cell division and replacement from 7 weeks to 7 months after cervical spinal cord injury in four adult rhesus monkeys. Bromodeoxyuridine (BrdU) injections revealed an increase of >80-fold in the number of newly divided cells in the primate spinal cord after injury, with an average of 725,000 BrdU-labeled cells identified per monkey in the immediate injury zone. By 7 months after injury, 15% of these new cells expressed mature markers of oligodendrocytes and 12% expressed mature astrocytic markers. Newly born oligodendrocytes were present in zones of injury-induced demyelination and appeared to ensheath or remyelinate host axons. Thus, cell replacement is an extensive natural compensatory response to injury in the primate spinal cord that contributes to neural repair and is a potential target for therapeutic enhancement.

Brown-Séquard Syndrome Following Removal of a Cerebrospinal Fluid Drainage Catheter After Thoracic Aortic Surgery

Neurological deficit remains a devastating complication of thoracic aortic surgery despite advances in methods to protect the spinal cord from ischemia. Various techniques have been used, including the combination of cerebrospinal fluid (CSF) drainage and distal aortic perfusion to decrease the incidence of postoperative neurological deficit. These deficits are usually bilateral and result in paraplegia. In this case report we present a patient with Type B aortic dissection and thoracoabdominal aortic aneurysm repair with insertion of a lumbar CSF drainage catheter. Postoperatively, the patient developed unilateral neurological features consistent with Brown-Séquard syndrome after removal of the CSF catheter. The lumbar cerebrospinal fluid catheter was reinserted and the CSF was drained. Medullary T6-7 signal abnormalities were seen on spinal cord magnetic resonance imaging, and we suggest that the spinal cord suffered a direct injury during catheter removal. The patient had an uneventful recovery.

IMPLICATIONS

We describe a patient who developed unilateral neurologic features suggestive of Brown-Sequard syndrome following removal of a cerebrospinal fluid catheter after thoracic aortic surgery. We suggest that the spinal cord was injured during catheter removal. The catheter was reinserted and the patient had a full neurologic recovery.

Cervical disc herniation producing Brown-Sequard syndrome: case report

BACKGROUND

Brown-Sequard syndrome is an incomplete spinal cord lesion characterized by a clinical picture reflecting hemisection of the spinal cord in the cervical or thoracic region. Brown-Sequard syndrome may be the result of penetrating injury to the spine, but many other etiologies have been described. In particular, cervical disc herniation has been rarely reported as a cause of this syndrome, and including the first article of Stookey in 1928, 9 only 22 cases have been reported.

METHODS

The case of a man with a large left paramedian C5-C6 disc herniation, with ipsilateral spinal cord compression, is reported. An area of left-sided spinal cord hyperintensity was also present on MRI, an expression of left hemicord damage. Microdiscectomy and anterior cervical fusion with carbon fiber cage containing a core of granulated coralline hydroxylapatite was performed. A complete motor deficit recovery and a marked sensitive deficit improvement was obtained.

CONCLUSION

A critical review of the pertinent literature is proposed, and the neuroradiologic, therapeutic, and prognostic implications are discussed. Brown-Sequard syndrome produced by a cervical disc herniation is presumably often underdiagnosed, and early surgical intervention is always recommended.

Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients

OBJECTIVE

To develop an objective and uniform means for classifying patients with incomplete spinal cord injury (SCI) according to SCI syndromes.

DESIGN

Criteria for assigning the syndromes (defined by the International Standards for Neurological and Functional Classification of SCI Patients) were operationalized by means of sensory and motor scores and were incorporated into a set of six independent algorithms and two composite algorithms.

SETTING

A regional SCI rehabilitation center in Canada.

PATIENTS

SCI patients (n = 56) with incomplete injuries (American Spinal Injury Association classes B, C, D) and stable neurologic deficits.

RESULTS

Individual algorithms allowed the highest classification rate but with some patients meeting the criteria for more than one syndrome. A composite, differential allocation algorithm, with selected thresholds at decision nodes, yielded a classification rate approximating that of the individual algorithms but without double classifications.

CONCLUSIONS

The composite algorithm provided an objective and standardized means of assigning patients to syndromes based on clinically measurable sensory and motor scores. The thresholds used to implement criteria and the order of decision nodes greatly influenced the outcomes and may be adjusted to suit the needs of the classification, that is, embracing liberal or stringent criteria. Controversy remains about the interpretation of some syndromes, and many patients remain unclassifiable because of mixed clinical presentation.

Postoperative prognosis of Brown-Séquard-type myelopathy in patients with cervical lesions

BACKGROUND

Postoperative prognosis of the hemihypalgesia in patients with Brown-Séquard-type myelopathy (BSM) caused by cervical lesions is of great interest to surgeons. However, there are very few reports discussing the postoperative prognosis of BSM.

METHODS

We evaluated the prognosis of BSM using the criteria of the Japanese Orthopaedic Association (JOA) score in 16 (seven ossification of the posterior longitudinal ligament [OPLL], 5 cervical spondylosis [CS], and 4 disc herniation patients) out of 233 surgically treated patients with cervical diseases. The mean follow-up duration was 2 years and 11 months.

RESULTS

After surgery, none of these patients showed complete resolution of hemihypalgesia, although the most rostral level of hemihypalgesia moved in a caudal direction in 13 patients (81%), whose recovery ratios of JOA score were significantly better than those of hemihypalgesia-level-persisted patients. In our BSM series, OPLL occurred most frequently and the anterior element compressing the spinal cord existed most frequently in the central area of the vertebra (44%). Postoperative improvement in the motor function of the legs in the disc herniation group was significantly better than in the OPLL and CS groups (p < 0.05, respectively). There were no significant differences in the functional prognosis between the BSM and non-BSM patient groups.

CONCLUSIONS

BSM patients can expect almost the same functional outcome as non-BSM patients, with the exception of the disappearance of hemihypalgesia.

Predicting neurologic recovery in traumatic cervical spinal cord injury

OBJECTIVE

Traumatic spinal cord injury (SCI) affects 8,000 to 10,000 individuals per year in the United States. One of the most difficult tasks confronting the clinician is the discussion of neurologic recovery and prognosis with the patient and/or family. Our objective is to provide a guide for practitioners to accurately predict neurologic outcome in acute traumatic cervical SCI (tetraplegia).

DATA SOURCE

Published reports obtained through MEDLINE search, texts, and studies presented at national conferences.

STUDY SELECTION

Peer reviewed studies, in English language, that discussed prognosis after traumatic SCI.

CONCLUSION

A comprehensive physical examination of the acute SCI patient is essential in determining the initial level and classification of the injury and is the most accurate method to predict neurologic recovery. Other diagnostic tests, including somatosensory evoked potentials, magnetic resonance imaging, and transcranial magnetic stimulation, may be helpful in further determining outcome when used in association with the clinical examination. The understanding of neurologic recovery should help predict ultimate functional capability and potential needs.

[Tetraplegia following cervical stab wound]

We report two cases of tetraplegia caused by cervical stab wounds. In the first one, in a 34-year-old patient, the injury caused an immediate tetraplegia from cervical spine section and had a rapid lethal outcome. The second case occurred in a 30-year-old woman, who experienced a progressive tetraplegia associated with a Brown-Séquard syndrome from an oedema of the bulbo-spinal junction. Three months later, the motor recovery was satisfactory, however a thermo-algesic hemi-anaesthesia still persisted after the 6th month.

Early predictors of functional independence 2 years after spinal cord injury

OBJECTIVE

To determine: (1) how well factors measured at admission to an acute care facility predict functional independence measure (FIM) scores, use of personal care assistance, and wheelchair ownership 2 years after traumatic spinal cord injury (SCI); (2) the extent that factors measured during inpatient stay add to these predictions; and (3) if FIM scores differ through use of assistance and wheelchair ownership 2 years after SCI.

DESIGN

Prospective, longitudinal.

SETTING

Tertiary care acute, rehabilitation hospitals and home settings.

PATIENTS

One hundred sixty SCI admissions.

MAIN OUTCOME MEASURES

FIM, use of personal care assistance (yes/no), and wheelchair ownership (manual/electric/none) 2 years after SCI.

RESULTS

Year 2 FIM scores were highly correlated (> or = .68) to the ASIA admission and discharge light touch, pin prick, and motor scores. Admission neurological status and age accounted for 65% of year 2 FIM score variance. Adding hospital events and the discharge ASIA motor score increased prediction to 76% of the variance. A separate regression model using only year 2 neurological scores and age accounted for 73% of the total FIM variance. Discriminant function analysis indicated 86% correct classification regarding use of personal care assistance and 88% correct classification of wheelchair ownership. Using a separate cross-validation sample, overall classification accuracy for assistance was 80% and wheelchair ownership 67%. FIM scores were significantly lower in assistance users (78 +/- 24) than nonusers (120 +/- 8) and were significantly different between wheelchair ownership groups: manual (103 +/- 21), electric (61 +/- 15), and none (125 +/- 2).

CONCLUSIONS

Late disability can be predicted using early impairment measures. The FIM prediction from variables measured during the early treatment phase was as good as prediction based on concurrent measures.

Emergency department approach to acute thoracolumbar spine injury

This review provides a literature-based approach to the management of acute thoracolumbar spine (TLS) injury. The epidemiology of spinal cord injury and pertinent spinal cord anatomy are reviewed. A review of current TLS fracture/dislocation classification schemes is provided. The principal focus of this review is the immediate diagnostic and therapeutic interventions needed to maximize the recovery of patients with acute TLS injury.

Brown-Sequard syndrome produced by cervical disc herniation: case report and literature review

BACKGROUND

The Brown-Sequard Syndrome is most commonly described in conjunction with a traumatic injury to the spinal cord. the condition involves ipsilateral loss of motor function, proprioception, and vibratory sensation, combined with contralateral loss of pain and temperature sensation.

CASE REPORT

A 56 year-old female developed left thigh discomfort and numbness. Over the next five months, this spread to involve her left leg and chest to the axilla. Physical examination revealed myelopathy. Also present were motor, proprioceptive, and vibratory deficits in the right leg. A left sensory level to T2 was present. An MRI scan showed a large right cervical herniated disc with unilateral spinal cord compression. Following anterior cervical discectomy and fusion, the patient's symptoms have steadily improved.

CONCLUSIONS

The Brown-Sequard Syndrome can be caused by a herniated cervical disc. MRI scans should be employed early in the diagnostic evaluation of such patients, particularly in the absence of penetrating trauma or other obvious causes of the syndrome.

Spared descending pathways mediate locomotor recovery after subtotal spinal cord injury

The location of pathways responsible for locomotor recovery after incomplete spinal cord injury has been studied in adult rats. Animals were allowed to recover from subtotal mid-thoracic cord section which spared left lateral and ventral funiculus fibers. Subsequent lumbar commissurotomy or left thoracic cord hemisection abolished the locomotor recovery. Spared descending fibers passing through the initial incomplete cord lesion appear to mediate locomotor recovery.

[Brown-Séquard syndrome after closed injury of the cervical spine]

The case of a Brown-Séquard syndrome at the C5 level, in a 21-year-old young man after a traffic accident is reported. Initially, the symptoms of spinal injury were concealed by those related to head and face trauma. The neurologic assessment showed a hemiplegia located in the same side as the medullar injury with a controlateral thermo-algesic anaesthesia. X-rays, CT-scan and MRI of the cervical spine confirmed the diagnosis. The treatment included the immobilization of the spine combined with i.v. methylprednisolone (bolus of 30 mg.kg-1 followed by a continuous infusion at a rate of 5 mg.kg-1.h-1 for 23 hours). The outcome was favourable. Six weeks later, the patient was again able to walk. However the thermo-algesic anaesthesia remained unchanged. This case report underlines the necessity of a careful and complete neurologic assessment of trauma patients and reminds of the possibility of occurrence of a Brown-Séquard syndrome in them.