Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations

Brown-Sequard syndrome associated with hangman fracture after blunt trauma: A case report

Background:

The association of Brown-Sequard syndrome (BSS) and hangman fracture (HF) is rarely reported.

Case Description:

We present a case of a 28-year-old female with a HF sustained after a motor vehicle accident and BSS. Diagnosis was established based on typical loass of motor function ipsilaterally and loss of pain and temperature sensation contralaterally. Furthermore, magnetic resonance imaging delineated the location of the injury to the right side of the spinal cord at cervical level 2. Near-complete neurological recovery was achieved after anterior fusion and fixation at cervical level 2–3 after 8 months of follow-up.

Conclusion:

HF from blunt trauma can be directly associated with BSS. Surgery was effective and associated with a near-complete resolution of symptoms.

An unusual case of Brown-Sequard syndrome associated with Horner’s syndrome after a penetrating injury with a khuru (Bhutanese dart) to the neck: A case report

The occurrence of Brown-Sequard syndrome with Horner’s syndrome in a child with spinal trauma is a very rare and unusual entity. Brown-Sequard syndrome results from hemisection injury of the spinal cord, mostly in the cervical cord region. The Horner’s syndrome presents when the injury is in the cervical region involving the sympathetic pathway. We present you with the case of a 12-year-old boy who was referred from a local hospital with weakness on the left half of his body after sustaining a penetrating injury to his neck by a khuru (Bhutanese dart). Clinical examination was consistent with the diagnosis of Brown-Sequard syndrome with ipsilateral Horner’s syndrome. Although cervical spine plain radiographs showed no fracture, computed tomography and magnetic resonance imaging showed a C2 lamina fracture at the left side of the spinous process with indentation to the cord. He was managed conservatively with a soft cervical collar, intravenous antibiotics, and physiotherapy. He had complete resolution of Brown-Sequard syndrome and Horner’s syndrome after 1 year. Patients with Brown-Sequard syndrome associated with Horner’s syndrome usually have a good prognosis and full recovery rate with regular physiotherapy and rehabilitation. Early diagnosis and treatment will have a better chance of recovery and return to pre-injury status.

Unilateral loss of thoracic motion after blunt trauma: a sign of acute Brown-Séquard syndrome

Late-onset Brown-Séquard syndrome (BSS) is a rare condition resulting from a spinal cord injury that develops weeks to years after a blunt trauma. Acute-onset BSS after a blunt injury has been rarely reported. Here, we report on a case of BSS, in a 58-year-old man, that developed immediately after a motor vehicle accident. Upon admission, loss of right thoracic motion, complete right paresis, and loss of pain and temperature sensations below the C3 level on the left side were observed. Magnetic resonance imaging showed hyperintensities within the cervical spinal cord at the C2–C3 level, confirming the diagnosis of BSS. Thoracic motion rapidly recovered, but other neurological sequelae persisted. BSS related to cervical cord injury should be suspected when patients develop hemiparesis and contralateral sensory loss immediately after a blunt trauma. Likewise, clinicians should be aware that unilateral loss of thoracic motion could be an important sign of BSS.

Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis

OBJECTIVE

Predicting neurological recovery following traumatic spinal cord injury (TSCI) is a complex task considering the heterogeneous nature of injury and the inconsistency of individual studies. This study aims to summarize the current evidence on neurological recovery following TSCI by use of a meta-analytical approach, and to identify injury, treatment, and study variables with prognostic significance.

METHODS

A literature search in MEDLINE and EMBASE was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales were included in the meta-analysis. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. The potential effect of severity, level and mechanism of injury, type of treatment, time and country of study, and follow-up duration were evaluated using meta-regression analysis.

RESULTS

A total of 114 studies were included, reporting AIS/Frankel changes in 19,913 patients and AMS changes in 6920 patients. Overall, the quality of evidence was poor. The AIS/Frankel conversion rate was 19.3% (95% CI 16.2-22.6) for patients with grade A, 73.8% (95% CI 69.0-78.4) for those with grade B, 87.3% (95% CI 77.9-94.8) for those with grade C, and 46.5% (95% CI 38.2-54.9) for those with grade D. Neurological recovery was significantly different between all grades of SCI severity in the following order: C > B > D > A. Level of injury was a significant predictor of recovery; recovery rates followed this pattern: lumbar > cervical and thoracolumbar > thoracic. Thoracic SCI and penetrating SCI were significantly more likely to result in complete injury. Penetrating TSCI had a significantly lower recovery rate compared to blunt injury (OR 0.76, 95% CI 0.62-0.92; p = 0.006). Recovery rate was positively correlated with longer follow-up duration (p = 0.001). Studies with follow-up durations of approximately 6 months or less reported significantly lower recovery rates for incomplete SCI compared to studies with long-term (3-5 years) follow-ups.

CONCLUSIONS

The authors' meta-analysis provides an overall quantitative description of neurological outcomes associated with TSCI. Moreover, they demonstrated how neurological recovery after TSCI is significantly dependent on injury factors (i.e., severity, level, and mechanism of injury), but is not associated with type of treatment or country of origin. Based on these results, a minimum follow-up of 12 months is recommended for TSCI studies that include patients with neurologically incomplete injury.

Brown-Séquard Syndrome Caused by Blunt Cervical Trauma with Radiographic Correlation

Brown-Séquard syndrome, while uncommon, is a neurological condition that classically results from the hemisection of the spinal cord as a result of a penetrating injury to the spinal cord. We present a reported case of blunt trauma causing a high-energy cervical burst fracture/dislocation with a significant cord signal change producing Brown-Séquard syndrome. In this case, the burst fracture at the level of C5 obtained from the motor vehicle accident led to the damage of the left-sided lateral spinal thalamic tract, descending lateral cortical spinal tracts, and ascending dorsal column. This is a unique case of blunt nonpenetrating trauma leading to a high-energy cervical burst fracture/dislocation causing significant cord signal change on T2-weighted magnetic resonance imaging (MRI). These physical changes produced symptoms of neurologic impairment commonly seen in those patients with Brown-Séquard syndrome.

Brown-Séquard Syndrome as a First Presentation of Multiple Sclerosis

A female patient aged 48 years presented with sub-acute onset of weakness in right upper and lower limb over the past one month and numbness over left side of body below neck level. Multiple sclerosis (MS) presenting as Brown-Séquard syndrome is very rare. We present a case of hemicord myelitis which presented as Brown-Séquard syndrome as a first manifestation, which was later diagnosed as MS during subsequent relapses.

Cervical fracture from chronic steroid usage presenting as a stroke: A case report

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This case highlights the important fact that stroke mimics can require the same urgency in care and diagnosis as strokes themselves.

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Such a case demonstrates that clinicians should carefully examine imaging of the cervical spine in cases of hemiparesis, even in cases where there is no recent history of trauma.

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The case of several cervical spine fractures resulting from a simple head tilt perhaps implicates that the bone mineral density of patients on long-term steroid use should be monitored starting at an early age and that a certain threshold of bone density should be impermissible.

Introduction

Misdiagnosis of Brown-Séquard-like presentations can delay treatment; potentially endangering the positive outcomes a patient might otherwise have had. Stroke mimics can be perceived as signaling the end of urgent investigation and care once stroke is ruled out; however, stroke mimics themselves can require prompt care. Herein, we discuss an extremely rare case where stroke was ruled out, resulting in a lapse in care that lead to an exacerbated hemiparesis over the following week.

Presentation of case

We present a patient with an occult cervical spine fracture with extension of the neck, caused by reduced bone density from a chronic steroid regimen. Nine days after the initial onset of her neurological symptoms, the patient presented to the ED with the complaint of left sided weakness and right-sided sensory loss. She was determined to have a left- sided Brown Séquard syndrome, which resolved following anterior cervical discectomy and fusion at C4-C6 and a laminectomy from C4-C6.

Discussion

This case indicated that patients with dangerously low bone density should be weaned off chronic steroid therapy to prevent the onset of osteoporotic symptoms early in adulthood. Furthermore, this case emphasizes the importance of continued investigation of symptoms if a stroke is ruled out and the need for more diligent monitoring of bone density of chronic steroid users.

Conclusion

Stroke mimics can require the same urgency in care and diagnosis as strokes themselves.

Spinal cord injury after blunt cervical spine trauma: correlation of soft-tissue damage and extension of lesion

BACKGROUND AND PURPOSE

In patients with spinal cord injury after blunt trauma, several studies have observed a correlation between neurologic impairment and radiologic findings. Few studies have been performed to correlate spinal cord injury with ligamentous injury. The purpose of this study was to retrospectively evaluate whether ligamentous injury or disk disruption after spinal cord injury correlates with lesion length.

MATERIALS AND METHODS

We retrospectively reviewed 108 patients diagnosed with traumatic spinal cord injury after cervical trauma between 1990-2011. Plain films, CT, and MR imaging were performed on patients and then reviewed for this study. MR imaging was performed within 96 hours after cervical trauma for all patients. Data regarding ligamentous injury, disk injury, and the extent of the spinal cord injury were collected from an adequate number of MR images. We evaluated anterior longitudinal ligaments, posterior longitudinal ligaments, and the ligamentum flavum. Length of lesion, disk disruption, and ligamentous injury association, as well as the extent of the spinal cord injury were statistically assessed by means of univariate analysis, with the use of nonparametric tests and multivariate analysis along with linear regression.

RESULTS

There were significant differences in lesion length on T2-weighted images for anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum in the univariate analysis; however, when this was adjusted by age, level of injury, sex, and disruption of the soft tissue evaluated (disk, anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamentum flavum) in a multivariable analysis, only ligamentum flavum showed a statistically significant association with lesion length. Furthermore, the number of ligaments affected had a positive correlation with the extension of the lesion.

CONCLUSIONS

In cervical spine trauma, a specific pattern of ligamentous injury correlates with the length of the spinal cord lesion in MR imaging studies. Ligamentous injury detected by MR imaging is not a dynamic finding; thus it proved to be useful in predicting neurologic outcome in patients for whom the MR imaging examination was delayed.

Brown-Séquard syndrome in a 11-year-old girl due to penetrating glass injury to the thoracic spine

Injuries in children are one of the most frequent causes of high morbidity and mortality, and they present a challenge to the treating physician. Fortunately, spinal trauma in pediatric patient is relatively rare. Brown-Séquard syndrome is a rare form of incomplete spinal cord injury consisting of ipsilateral upper motor neuron paralysis (hemiplegia) and loss of proprioception with contralateral pain and temperature sensation deficits resulting from hemisection or lateral injury to the spinal cord. A 11-year-old girl was admitted to our Pediatric Trauma Emergency Department after she had suffered a penetrating back injury. Neurological examination demonstrated left lower extremity paresis and moderate spastic paralysis of the right lower extremity. The examination showed loss of temperature sensation contralateral to and below the lesion. The examination of the pain sensation was difficult because the patient was in pain shock, but it was diminished on the side opposite to the damage. Multislice spiral computed tomography (MSCT) demonstrated a triangular foreign body in spinal canal at the level of the Th11–Th12. After a Th₁₁–L₂ laminectomy and retrieval of foreign bodies, dura repair was performed. Patient was discharged from the hospital with partial recovery. Operative decompression of the neural elements in case of spinal canal compromise is the treatment of choice. Indication for surgical intervention in existing cerebrospinal fluid fistula includes closure of the dura and reducing neural elements compression and lowering the risk of infectious complications by removing bone or foreign body fragments. Patients with Brown-Séquard syndrome have good prognosis for functional recovery.

Intramedullary lesion expansion on magnetic resonance imaging in patients with motor complete cervical spinal cord injury

OBJECT

The authors performed a study to determine if lesion expansion occurs in humans during the early hours after spinal cord injury (SCI), as has been established in rodent models of SCI, and to identify factors that might predict lesion expansion.

METHODS

The authors studied 42 patients with acute cervical SCI and admission American Spinal Injury Association Impairment Scale Grades A (35 patients) and B (7 patients) in whom 2 consecutive MRI scans were obtained 3-134 hours after trauma. They recorded demographic data, clinical information, Injury Severity Score (ISS), admission MRI-documented spinal canal and cord characteristics, and management strategies.

RESULTS

The characteristics of the cohort were as follows: male/female ratio 37:5; mean age, 34.6 years; and cause of injury, motor vehicle collision, falls, and sport injuries in 40 of 42 cases. The first MRI study was performed 6.8 ±2.7 hours (mean ± SD) after injury, and the second was performed 54.5 ± 32.3 hours after injury. The rostrocaudal intramedullary length of the lesion on the first MRI scan was 59.2 ± 16.1 mm, whereas its length on the second was 88.5 ± 31.9 mm. The principal factors associated with lesion length on the first MRI study were the time between injury and imaging (p = 0.05) and the time to decompression (p = 0.03). The lesion's rate of rostrocaudal intramedullary expansion in the interval between the first and second MRI was 0.9 ± 0.8 mm/hour. The principal factors associated with the rate of expansion were the maximum spinal cord compression (p = 0.03) and the mechanism of injury (p = 0.05).

CONCLUSIONS

Spinal cord injury in humans is characterized by lesion expansion during the hours following trauma. Lesion expansion has a positive relationship with spinal cord compression and may be mitigated by early surgical decompression. Lesion expansion may be a novel surrogate measure by which to assess therapeutic effects in surgical or drug trials.

Clinical diagnosis and prognosis following spinal cord injury

Spinal cord injury (SCI) is a sudden, life-altering event. Injury severity and accompanying recovery vary considerably from individual to individual. The most important determinant of prognosis is whether an injury is clinically complete or incomplete. While approximately 10-20% of complete injuries convert to incomplete during the first year post-injury, the magnitude of motor recovery following complete SCI is limited or absent. Robust functional motor recovery (e.g., weight-bearing, ambulation) distal to the zone of injury is rare. Recovery following incomplete SCI is particularly variable, and anywhere from 20% to 75% of individuals will recover some degree of walking capacity by 1 year post-injury. This is related to presenting injury severity (American Spinal Injury Association Impairment Scale grade); however, even 20-50% of individuals who present as motor complete, sensory incomplete will walk in some capacity by 1 year post-injury. Regardless, for both complete and incomplete injuries, the majority of recovery is observed during the initial 9-12 months, with a relative plateau reached by 12-18 months post-injury. Magnetic resonance imaging (MRI) provides valuable adjunct information when a bedside clinical assessment cannot be completed. The presence of intramedullary hemorrhage and extended segments of edema have been associated with clinically complete SCI.

Sciwora na população pediátrica após traumatismo cervical

OBJETIVO: Avaliar a incidência e as características das lesões tipo SCIWORA nos indivíduos até os 16 anos, da área de um hospital central entre 1989 e 2009, após traumatismo cervical. MÉTODOS: Estudo retrospectivo de consulta processual. RESULTADOS: Nove (10,5%) de 86 crianças apresentavam achados clínicos e radiológicos compatíveis com o diagnóstico de SCIWORA. A média de idades foi de 10,7 anos. A causa mais frequente foi o acidente de trânsito. Seis indivíduos eram classificáveis como Frankel D. Os restantes três casos eram Frankel C. Em três doentes a RMN mostrou imagem de lesão. Sete efetuaram metilprednisolona endovenosa e todos mantiveram imobilização com colar cervical até a primeira consulta de seguimento, às 2 semanas. Na alta, os seis doentes que apresentavam Frankel D à entrada melhoraram para um grau E. Dos doentes com Frankel C à entrada, um melhorou até Frankel D e os restantes dois mantiveram-se inalterados em Frankel C. CONCLUSÃO: Em um hospital de referência traumatológica, SCIWORA representa cerca de 10% das lesões cervicais pediátricas. Os défices neurológicos à entrada e a RMN têm valor prognóstico de recuperação. A corticoterapia em dose elevada não está formalmente indicada e não é consensual o tempo de utilização de imobilização ou a sua indicação em todos os SCIWORA.

Fraturas de odontoide tipo III com necessidade de tratamento cirúrgico: estudo de série de casos e revisão de literatura

OBJETIVO: Analisar uma série de pacientes com fraturas de odontoide do tipo III, instáveis, tratados cirurgicamente. MÉTODOS: Análise retrospectiva de uma série de 5 casos consecutivos de pacientes com fratura de odontoide do tipo III, submetidos a tratamento cirúrgico. RESULTADOS: Três pacientes foram tratados inicialmente com halo-veste e, nos casos de falha, foram submetidos a osteossíntese cirúrgica. Dois pacientes, um com grande instabilidade radiológica em flexão e compressão medular e outro com comprometimento neurológico, foram submetidos a tratamento cirúrgico primário. A técnica cirúrgica foi individualizada para cada caso. Não ocorreram complicações graves; quatro pacientes evoluíram assintomáticos e somente um paciente desenvolveu dor cervical não incapacitante. A tomografia computadorizada (TC) mostrou consolidação da fratura em 2 casos, os demais não realizaram TC de controle. O seguimento médio foi de 1,9 anos. CONCLUSÕES: Fraturas de odontoide do tipo III nem sempre são lesões benignas, sendo importante individualizar seu tratamento sempre que alguma característica incomum for identificada. Existem critérios de instabilidade e indicação de tratamento cirúrgico para pacientes com este tipo de lesão.

The role of magnetic resonance imaging in the management of acute spinal cord injury

Magnetic resonance imaging (MRI) has become the gold standard for imaging neurological tissues including the spinal cord. The use of MRI for imaging in the acute management of patients with spinal cord injury has increased significantly. This paper used a vigorous literature review with Downs and Black scoring, followed by a Delphi vote on the main conclusions. MRI is strongly recommended for the prognostication of acute spinal cord injury. The sagittal T2 sequence was particularly found to be of value. Four prognostication patterns were found to be predictive of neurological outcome (normal, single-level edema, multi-level edema, and mixed hemorrhage and edema). It is recommended that MRI be used to direct clinical decision making. MRI has a role in clearance, the ruling out of injury, of the cervical spine in the obtunded patient only if there is abnormality of the neurological exam. Patients with cervical spinal cord injuries have an increased risk of vertebral artery injuries but the literature does not allow for recommendation of magnetic resonance angiography as part of the routine protocol. Finally, time repetition (TR) and time echo (TE) values used to evaluate patients with acute spinal cord injury vary significantly. All publications with MRI should specify the TR and TE values used.

Brown-Sèquard syndrome caused by type III odontoid fracture: a case report and review of the literature

STUDY DESIGN

Case report.

OBJECTIVE

To present the second case of Brown-Sèquard syndrome (BSS) produced by type III odontoid fracture managed by conservative treatment.

SUMMARY OF BACKGROUND DATA

The occurrence of BSS due to odontoid fracture is scarce. So far 6 cases have been reported, and only 1 is produced by type III odontoid fracture. The possible pathophysiology, clinical course and treatment outcome have been rarely discussed.

METHODS

A 39-year-old man presented with weakness of his left arm and leg, mild neck pain, and impaired proprioceptive and light touch sensations below the left C2 dermatome. There were decreased pain and temperature sensations below the right C4 dermatome too. Computerized tomography showed odontoid type III fracture with posterior displacement at that level. Magnetic resonance imaging presented focal hyperintensity around the C2 vertebral level. High dose of prednisolone, close reduction with Gardner-Wells tong skull traction, following external stabilization by Halo-Vest and rehabilitation therapy were applied.

RESULTS

Complete resolution of neck pain and significant improvement of motor and sensory functions, i.e., light touch and proprioception, were shown 2 months after spinal injury. Impaired temperature discrimination persisted, however.

CONCLUSION

BSS is rarely caused by type III odontoid fracture and this is the second report. Conservative intervention is advantageous for both type III odontoid fracture and BSS which is consistent with previous results.

Case report: Brown-Séquard syndrome resulting from a ski injury in a 7-year-old male

Cervical spine and spinal cord injuries are rare in pediatric trauma victims. The majority result from blunt trauma. Spinal cord injury without radiographic abnormality has been reported to be more common among young children than adults. The Brown-Séquard syndrome is rarely seen as the result of blunt trauma. We present the case of young boy who suffered spinal cord injury without radiographic abnormality resulting in the Brown-Séquard syndrome and review the controversy surrounding the use of high-dose corticosteroids in the treatment of pediatric spinal cord injury. Current data do not support the use of corticosteroids as 'standard of care' for this population.

Brown-Sèquard syndrome produced by C3-C4 cervical disc herniation: a case report and review of the literature

STUDY DESIGN

The article presents a case in which Brown-Sèquard syndrome resulted from a painless C3-C4 disc herniation.

OBJECTIVE

To raise spinal surgeons' awareness of this unusual clinical problem.

SUMMARY OF BACKGROUND DATA

Brown-Sèquard syndrome involves ipsilateral loss of motor function combined with contralateral loss of pain and temperature sensation. Brown-Sèquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely it can be caused by a herniated cervical disc.

METHODS

A 46-year-old man presented with progressive numbness and weakness in the left arm, mild neck pain, and reduced temperature sensation on the right side of the body. There was weakness in left arm and leg and proximal right lower limb. Magnetic resonance imaging showed large C3-C4 disc herniation compressing the spinal cord at that level. Anterior cervical discectomy and fusion with iliac crest bone graft was performed.

RESULTS

Follow-up showed complete resolution of the neck pain, normal sensory function, and complete recovery of motor power in the left upper and right lower limb. There was a slight residual weakness in the left leg.

CONCLUSION

Brown-Sèquard syndrome is rarely caused by a cervical disc herniation. This etiology may be underdiagnosed but has a more favorable outcome in those cases where rapid diagnosis is followed by spinal cord decompression.