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Traumatic Brown-Séquard–Plus Syndrome
Mark O. McCarron, MA, MRCP, MD;
Peter A. Flynn, MRCP, FRCR;
Kiang A. Pang, FRCP;
Stanley A. Hawkins, FRCP
Arch Neurol. 2001;58:1470-1472.
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).
INTRODUCTION
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.
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Figure 1. A, Right-sided neck stab wound;
B, left-sided Horner syndrome.
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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.
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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).
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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, 4, 5, 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.
AUTHOR INFORMATION
Accepted for publication May 14, 2001.
From the Departments of Neurology (Drs McCarron and Hawkins), Neurophysiology
(Dr Pang), and Neuroradiology (Dr Flynn), Royal Victoria Hospital, Belfast,
Northern Ireland.
Corresponding author: Mark McCarron, MA, MRCP, MD, Department of
Neurology, Quin House, Royal Victoria Hospital, Belfast BT12 6BA, Northern
Ireland (e-mail: mark.mccarron{at}royalhospitals.n-i.nhs.uk).
REFERENCES
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1. Aminoff MJ. Historical perspective: Brown-Séquard and his work on the spinal
cord. Spine. 1996;21:133-140.
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2. Firlik AD, Welch WC. Images in clinical medicine: Brown-Séquard syndrome. N Engl J Med. 1999;340:285.
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3. Roth EJ, Park T, Pang T, Yarkony GM, Lee MY. Traumatic cervical Brown-Séquard and Brown-Séquard–plus
syndromes: the spectrum of presentations and outcomes. Paraplegia. 1991;29:582-589.
PUBMED
4. Garcia-Manzanares MD, Belda-Sanchis JI, Giner-Pascual M, Miguel-Leon I, Delgado-Calvo M, Alio 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.
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5. Shen CC, Wang YC, Yang DY, Wang FH, Shen BB. Brown-Séquard syndrome associated with Horner's syndrome in
cervical epidural hematoma. Spine. 1995;20:244-247.
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6. Koehler PJ, Endtz LJ. The Brown-Séquard syndrome: true or false? Arch Neurol. 1986;43:921-924.
ABSTRACT
7. Taylor RG, Gleave JRW. Incomplete spinal cord injuries—with Brown-Séquard phenomena. J Bone Joint Surg Br. 1957:39:438-450.
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