Brown-Sequard Syndrome

Original Editor - Cindy John-Chu
Top Contributors - Cindy John-Chu, Kim Jackson, Hetvi Gala, Stacy Schiurring and Ahmed M Diab

Clinically Relevant Anatomy

Brown-Sequard Syndrome (BSS), an incomplete spinal cord injury, is a neurological condition that results from a hemisection to the spinal cord 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. 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

The mechanism of injury in BSS can either be traumatic or non-traumatic with traumatic being more common.

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
• Tuberculosis
• Meningitis
• Herpes zoster

Clinical Presentation

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. 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

• 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.
  

Outcome Measures

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

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. However, all forms of management are geared towards achieving independence in activities of daily living and overall quality of life.

Physiotherapy Management

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
• 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. It may include:

• Wound debridement and closure in the case of open an open injury
• Anti-tetanus prophylaxis
• Antibiotics
• Analgesics
• Antispasmodics
• Laxatives

Surgical Management

Surgery is recommended in cases of trauma where cerebrospinal leakage, retention of foreign objects and signs of external cord compression are present. Surgical intervention may include:

• Decompressive surgery
• Spinal immobilization

Prognosis

Patients with BSS have been reported to have better outcomes of improvement when compared to those with other spinal cord syndromes.

Differential Diagnosis

These should include:

• Stroke
• Multiple sclerosis
• Anterior cord syndrome
• Posterior cord syndrome
• Syringomyelia
• Transverse myelitis
• Hemiplegia