Brown-Sequard Syndrome: Difference between revisions
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<div class="editorbox"> '''Original Editor '''- [[User: | <div class="editorbox"> '''Original Editor '''- [[User:Cindy John-Chu|Cindy John-Chu]] <br> | ||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> | ||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
Brown-Sequard Syndrome (BSS) is a neurological condition that results from a hemisection to the spinal cord<ref name=":0">Shams S, Arain A. [https://www.ncbi.nlm.nih.gov/books/NBK538135/#_NBK538135_pubdet_ Brown Sequard Syndrome.] [Updated 2020 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2021.</ref>. It typically presents with paralysis on the side of the lesion and a loss of pain and temperature sensation contralateral to the lesion.<br> | Brown-Sequard Syndrome (BSS), an [[Overview of spinal cord injuries|incomplete spinal cord injury]], is a neurological condition that results from a hemisection to the spinal cord<ref name=":0">Shams S, Arain A. [https://www.ncbi.nlm.nih.gov/books/NBK538135/#_NBK538135_pubdet_ Brown Sequard Syndrome.] [Updated 2020 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2021.</ref> on either side, typically in the cervical and thoracic spinal cord region. This lesion leads to interruption of normal function of nerve tracts in one half of the spinal cord<ref name=":1">Ranga U, Aiyappan SK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277151/#_ffn_sectitle Brown-Séquard syndrome]. The Indian Journal of Medical Research 2014; 140(4): 572-573.</ref>. It typically presents with paralysis (hemiparaplegia) on the side of the lesion due to compromise to the lateral corticospinal tracts; loss of proprioception and vibration sense on the same side from damage to the dorsal column and a loss of pain and temperature sensation (hemianaesthesia) contralateral to the lesion owing to injury to the lateral [[spinothalamic tract]]. | ||
See the video below to further understand the anatomy of the spinal cord in relation to BSS.<br> | |||
{{#ev:youtube|tSkocizPFAA|250}} <div class="text-right"><ref>Dr Matt & Mike. Brown Sequard Syndrome. Available from: http://www.youtu.be/tSkocizPFAA [last accessed 21/4/2021]</ref></div> | |||
== Mechanism of Injury / Pathological Process == | == Mechanism of Injury / Pathological Process == | ||
Line 14: | Line 17: | ||
* Gunshot wound to the spine | * Gunshot wound to the spine | ||
* Motor vehicular accident | * Motor vehicular accident | ||
* Fractured vertebra from a | * Fractured vertebra resulting from a fall<br> | ||
'''Non-traumatic mechanisms could include:''' | '''Non-traumatic mechanisms could include:''' | ||
* Vertebral disc herniation | * Vertebral disc herniation | ||
* Tumours | * Tumours | ||
* Cervical spondylosis | * [[Cervical Spondylosis|Cervical spondylosis]] | ||
* Multiple sclerosis | * [[Multiple Sclerosis (MS)|Multiple sclerosis]] | ||
* Radiation | * Radiation | ||
* Cystic disease<ref name=":0" /> | * [[Cystic Fibrosis|Cystic disease]]<ref name=":0" /> | ||
* Tuberculosis | |||
* [[Meningitis]] | |||
* Herpes zoster | |||
== Clinical Presentation == | == Clinical Presentation == | ||
BSS is characterized by: | BSS is characterized by: | ||
* Ipsilateral lower motor neuron paralysis in the segment of the lesion. | * Ipsilateral lower motor neuron paralysis in the segment of the lesion. This is due to lesion to the lateral corticospinal tract at the level of the lesion, which transmits motor information from the cerebral cortex to the posterior horn of the spinal cord. | ||
* Contralateral loss of pain and temperature sensations below the level of the lesion<ref>Wright R, Simpson EP. [https://www.sciencedirect.com/science/article/pii/B9780323057127000088 Myelopathies]. In: Rolak, AL editor. Neurology Secrets (Fifth Edition). Mosby 2010. p131-140.</ref>. | * Contralateral loss of [[Pain Assessment|pain]] and temperature sensations below the level of the lesion<ref>Wright R, Simpson EP. [https://www.sciencedirect.com/science/article/pii/B9780323057127000088 Myelopathies]. In: Rolak, AL editor. Neurology Secrets (Fifth Edition). Mosby 2010. p131-140.</ref>. This is due to the lesion to the lateral spinothalamic tract which decussates at the level of the spinal cord. | ||
* Ipsilateral loss of tactile discrimination, vibratory and proprioceptive sensations below the level of the lesion. | * Ipsilateral loss of tactile discrimination, vibratory and proprioceptive sensations below the level of the lesion. This is due to the lesion to the Dorsal Column of the spinal cord. | ||
* Contralateral partial loss of tactile sensation below the level of the lesion. | * Contralateral partial loss of tactile sensation below the level of the lesion. | ||
* Ipsilateral spastic paralysis below the level of the lesion.<br> | * Ipsilateral [[Spasticity|spastic]] paralysis below the level of the lesion.<br> | ||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
* A detailed history should be taken to determine possible causes of the damage i.e. whether the lesion is traumatic or infectious. | |||
* An extensive examination should be carried out to ascertain the extent of neurological damage and what deficits to expect, depending on the level of injury. This examination should involve a detailed motor and sensory evaluation. | |||
* Laboratory tests should be carried out when infections are suspected. | |||
* Diagnostic imaging especially, magnetic resonance imaging(T2-Weighted image) to ascertain the aetiology and level of cord hemisection. <ref>Urrutia J, Fadic R. Cervical disc herniation producing acute Brown-Sequard syndrome: dynamic changes documented by intraoperative neuromonitoring. European Spine Journal. 2012 Jun;21:418-21.</ref><br> | |||
== Outcome Measures == | |||
The following outcome measures will be useful in the assessment and management of BSS. | |||
* [[American Spinal Cord Injury Association (ASIA) Impairment Scale|American Spinal Injury Association (ASIA) Impairment Scale]] | |||
* [[Functional Independence Measure (FIM)]] | |||
* [[Spinal Cord Independence Measure (SCIM)]] | |||
== Management / Interventions == | |||
Management approaches to choose for BSS are dependent on the underlying aetiology. The decision to opt for either conservative or surgical management depends on the patient's neurological and radiological findings<ref name=":1" />. However, all forms of management are geared towards achieving independence in activities of daily living and overall quality of life<ref name=":0" />. | |||
===== Physiotherapy Management ===== | |||
The goals of physiotherapy in the management of BSS include: | |||
== | * To maintain [[Strength Training in Spinal Cord Injury|strength]] in neurologically intact muscles | ||
* To normalize the [[Spasticity|tone]] of the muscles. | |||
* To maintain [[Range of Motion|range of motion]] in all affected joints and to prevent damage in them due to immobility. | |||
* To prevent damage to skin through proper positioning and transitions at regular intervals | |||
* To maintain a clear airway and maintain normal ventilation. This includes [[Diaphragmatic Breathing Exercises|Breathing exercises]] | |||
* To achieve early mobilization to enhance ambulation initially using an assistive device and then progress to independent walking depending upon the capacity of the patient<ref name=":3">Vandenakker-Albanese C, Brown-Sequard Syndrome [Internet]. 2020 [cited 20 May 2021]. Available from: https://emedicine.medscape.com/article/321652-overview</ref> | |||
* To provide emotional support to patients and their relatives | |||
===== Medical Management ===== | |||
Medical management is the treatment of choice where aetiology of BSS is either infective or demyelinating<ref name=":1" />. It may include: | |||
* Wound debridement and closure in the case of open an open injury | |||
* Anti-tetanus prophylaxis | |||
* Antibiotics<ref name=":2">Toluse A, Adeyemi T, Angaye E, Alimi M. [https://www.njotonline.org/text.asp?2020/19/2/77/303434 Brown-sequard syndrome: A case series from a regional hospital in Nigeria.] Niger J Orthop Trauma 2020;19:77-9</ref><ref name=":3" /> | |||
* Analgesics | |||
* Antispasmodics | |||
* Laxatives<ref name=":3" /> | |||
== Management | ===== Surgical Management ===== | ||
Surgery is recommended in cases of trauma where cerebrospinal leakage, retention of foreign objects and signs of external cord compression are present<ref name=":1" />. Surgical intervention may include: | |||
* Decompressive surgery | |||
* Spinal immobilization | |||
<br> | |||
== Prognosis == | |||
Patients with BSS have been reported to have better outcomes of improvement when compared to those with other [[Spinal cord anatomy|spinal cord]] syndromes<ref>Mckinley W, Santos K, Meade M, Brooke K. [https://doi.org/10.1080/10790268.2007.11753929 Incidence and Outcomes of Spinal ord Injury Clinical Syndromes]. The Journal of Spinal Cord Medicine 2007; 215-224.</ref><ref name=":2" />. | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
These should include: | |||
* [[Stroke]] | |||
* [[Multiple Sclerosis (MS)|Multiple sclerosis]] | |||
* [[Anterior Cord Syndrome|Anterior cord syndrome]] | |||
* Posterior cord syndrome | |||
* [[Syringomyelia]] <ref name=":0" /> | |||
* Transverse myelitis | |||
* [[Hemiplegia|Hemiplegia <br>]] | |||
== Resources == | == Resources == | ||
{{#ev:youtube|WpjGmKnGv1c|300}}<ref>Neurology Analogy. Brown Sequard Syndrome/Animation/Explained Conceptually. Available from: https://youtu.be/WpjGmKnGv1c [last accessed 20/5/2021]</ref> | |||
== References == | == References == | ||
<references /> | <references /> | ||
[[Category:Spinal Cord Injuries]] |
Latest revision as of 18:01, 21 June 2023
Top Contributors - Cindy John-Chu, Kim Jackson, Hetvi Gala, Stacy Schiurring and Ahmed M Diab
Clinically Relevant Anatomy[edit | edit source]
Brown-Sequard Syndrome (BSS), an incomplete spinal cord injury, is a neurological condition that results from a hemisection to the spinal cord[1] on either side, typically in the cervical and thoracic spinal cord region. This lesion leads to interruption of normal function of nerve tracts in one half of the spinal cord[2]. It typically presents with paralysis (hemiparaplegia) on the side of the lesion due to compromise to the lateral corticospinal tracts; loss of proprioception and vibration sense on the same side from damage to the dorsal column and a loss of pain and temperature sensation (hemianaesthesia) contralateral to the lesion owing to injury to the lateral spinothalamic tract.
See the video below to further understand the anatomy of the spinal cord in relation to BSS.
Mechanism of Injury / Pathological Process[edit | edit source]
The mechanism of injury in BSS can either be traumatic or non-traumatic with traumatic being more common[1].
Tramatic causes of BSS are as follows:
- Stab injury to the cervical region
- Gunshot wound to the spine
- Motor vehicular accident
- Fractured vertebra resulting from a fall
Non-traumatic mechanisms could include:
- Vertebral disc herniation
- Tumours
- Cervical spondylosis
- Multiple sclerosis
- Radiation
- Cystic disease[1]
- Tuberculosis
- Meningitis
- Herpes zoster
Clinical Presentation[edit | edit source]
BSS is characterized by:
- Ipsilateral lower motor neuron paralysis in the segment of the lesion. This is due to lesion to the lateral corticospinal tract at the level of the lesion, which transmits motor information from the cerebral cortex to the posterior horn of the spinal cord.
- Contralateral loss of pain and temperature sensations below the level of the lesion[4]. This is due to the lesion to the lateral spinothalamic tract which decussates at the level of the spinal cord.
- Ipsilateral loss of tactile discrimination, vibratory and proprioceptive sensations below the level of the lesion. This is due to the lesion to the Dorsal Column of the spinal cord.
- Contralateral partial loss of tactile sensation below the level of the lesion.
- Ipsilateral spastic paralysis below the level of the lesion.
Diagnostic Procedures[edit | edit source]
- A detailed history should be taken to determine possible causes of the damage i.e. whether the lesion is traumatic or infectious.
- An extensive examination should be carried out to ascertain the extent of neurological damage and what deficits to expect, depending on the level of injury. This examination should involve a detailed motor and sensory evaluation.
- Laboratory tests should be carried out when infections are suspected.
- Diagnostic imaging especially, magnetic resonance imaging(T2-Weighted image) to ascertain the aetiology and level of cord hemisection. [5]
Outcome Measures[edit | edit source]
The following outcome measures will be useful in the assessment and management of BSS.
- American Spinal Injury Association (ASIA) Impairment Scale
- Functional Independence Measure (FIM)
- Spinal Cord Independence Measure (SCIM)
Management / Interventions[edit | edit source]
Management approaches to choose for BSS are dependent on the underlying aetiology. The decision to opt for either conservative or surgical management depends on the patient's neurological and radiological findings[2]. However, all forms of management are geared towards achieving independence in activities of daily living and overall quality of life[1].
Physiotherapy Management[edit | edit source]
The goals of physiotherapy in the management of BSS include:
- To maintain strength in neurologically intact muscles
- To normalize the tone of the muscles.
- To maintain range of motion in all affected joints and to prevent damage in them due to immobility.
- To prevent damage to skin through proper positioning and transitions at regular intervals
- To maintain a clear airway and maintain normal ventilation. This includes Breathing exercises
- To achieve early mobilization to enhance ambulation initially using an assistive device and then progress to independent walking depending upon the capacity of the patient[6]
- To provide emotional support to patients and their relatives
Medical Management[edit | edit source]
Medical management is the treatment of choice where aetiology of BSS is either infective or demyelinating[2]. It may include:
- Wound debridement and closure in the case of open an open injury
- Anti-tetanus prophylaxis
- Antibiotics[7][6]
- Analgesics
- Antispasmodics
- Laxatives[6]
Surgical Management[edit | edit source]
Surgery is recommended in cases of trauma where cerebrospinal leakage, retention of foreign objects and signs of external cord compression are present[2]. Surgical intervention may include:
- Decompressive surgery
- Spinal immobilization
Prognosis[edit | edit source]
Patients with BSS have been reported to have better outcomes of improvement when compared to those with other spinal cord syndromes[8][7].
Differential Diagnosis[edit | edit source]
These should include:
- Stroke
- Multiple sclerosis
- Anterior cord syndrome
- Posterior cord syndrome
- Syringomyelia [1]
- Transverse myelitis
- Hemiplegia
Resources[edit | edit source]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 Shams S, Arain A. Brown Sequard Syndrome. [Updated 2020 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2021.
- ↑ 2.0 2.1 2.2 2.3 Ranga U, Aiyappan SK. Brown-Séquard syndrome. The Indian Journal of Medical Research 2014; 140(4): 572-573.
- ↑ Dr Matt & Mike. Brown Sequard Syndrome. Available from: http://www.youtu.be/tSkocizPFAA [last accessed 21/4/2021]
- ↑ Wright R, Simpson EP. Myelopathies. In: Rolak, AL editor. Neurology Secrets (Fifth Edition). Mosby 2010. p131-140.
- ↑ Urrutia J, Fadic R. Cervical disc herniation producing acute Brown-Sequard syndrome: dynamic changes documented by intraoperative neuromonitoring. European Spine Journal. 2012 Jun;21:418-21.
- ↑ 6.0 6.1 6.2 Vandenakker-Albanese C, Brown-Sequard Syndrome [Internet]. 2020 [cited 20 May 2021]. Available from: https://emedicine.medscape.com/article/321652-overview
- ↑ 7.0 7.1 Toluse A, Adeyemi T, Angaye E, Alimi M. Brown-sequard syndrome: A case series from a regional hospital in Nigeria. Niger J Orthop Trauma 2020;19:77-9
- ↑ Mckinley W, Santos K, Meade M, Brooke K. Incidence and Outcomes of Spinal ord Injury Clinical Syndromes. The Journal of Spinal Cord Medicine 2007; 215-224.
- ↑ Neurology Analogy. Brown Sequard Syndrome/Animation/Explained Conceptually. Available from: https://youtu.be/WpjGmKnGv1c [last accessed 20/5/2021]