Brown-Sequard syndrome: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
The hemisection of the cord results in a lesion of each of the three main neural systems: | The hemisection of the cord results in a lesion of each of the three main neural systems: | ||
* the principal [[upper motor neuron]] pathway of the [[corticospinal tract]] | |||
* one or both [[dorsal column]]s | *the principal [[upper motor neuron]] pathway of the [[corticospinal tract]] | ||
* the [[spinothalamic tract]] | *one or both [[dorsal column]]s | ||
*the [[spinothalamic tract]] | |||
As a result of the injury to these three main brain pathways the patient will present with three lesions. | As a result of the injury to these three main brain pathways the patient will present with three lesions. | ||
* The corticospinal lesion produces spastic paralysis on the same side of the body (the loss of moderation by the [[Upper motor neuron|UMN]]). | *The corticospinal lesion produces spastic paralysis on the same side of the body (the loss of moderation by the [[Upper motor neuron|UMN]]). | ||
* The lesion to [[fasciculus gracilis]] or [[fasciculus cuneus]] results in ipsilateral loss of vibration and [[proprioception]] (position sense). | *The lesion to [[fasciculus gracilis]] or [[fasciculus cuneus]] results in ipsilateral loss of vibration and [[proprioception]] (position sense). | ||
* The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. At the lesion site all sensory modalities are lost on the same side, and also an ipsilateral flaccid paralysis. | *The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. At the lesion site all sensory modalities are lost on the same side, and also an ipsilateral flaccid paralysis. | ||
==Causes== | ==Causes== | ||
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==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
Common complications of '''Brown -sequard syndrome''' include hypotension, spinal shock,'''[[UTI]]''' and '''[[pneumonia]]''',[[hypercalcemia]],[[osteoporosis]],'''[[vertebral artery dissection]]''',pressure ulcers and [[bowel impaction]]. These complications could be due to the trauma causing 'BSS or the overall problem in the body . Also patients with the pathology in their cervical or upper thorax spine need respiratory support.<ref>{{https://brownsequardsyndrome.org/}}</ref> | Common complications of '''Brown -sequard syndrome''' include hypotension, spinal shock,'''[[UTI]]''' and '''[[pneumonia]]''',[[hypercalcemia]],[[osteoporosis]],'''[[vertebral artery dissection]]''',pressure ulcers and [[bowel impaction]]. These complications could be due to the trauma causing 'BSS or the overall problem in the body . Also patients with the pathology in their cervical or upper thorax spine need respiratory support.<ref><nowiki>{{</nowiki>https://brownsequardsyndrome.org/<nowiki>}}</nowiki></ref> | ||
==Diagnosis== | ==Diagnosis== | ||
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===History and Symptoms=== | ===History and Symptoms=== | ||
The majority of patients with '''Brown-Sequard Syndrome''' experience this syndrome following a trauma to their neck or back region. First symptoms are usually loss of pain and temperature sensation in dermatomes below the traumatized region ,which is due to the decussation of '''[[antero- lateral fibers]]''' within spinal tract through [[white commissure]] resulting in contralateral loss of pain and temperature sensation. Also ,decussation of '''[[corticospinal tract]]''' at medulla leads to ipsilateral spastic paresis and ipsilateral of vibration and proprioception sensation.<ref>{{https://www.wikem.org/wiki/Brown-Séquard_syndrome]]</ref> | The majority of patients with '''Brown-Sequard Syndrome''' experience this syndrome following a trauma to their neck or back region. First symptoms are usually loss of pain and temperature sensation in dermatomes below the traumatized region ,which is due to the decussation of '''[[antero- lateral fibers]]''' within spinal tract through [[white commissure]] resulting in contralateral loss of pain and temperature sensation. Also ,decussation of '''[[corticospinal tract]]''' at medulla leads to ipsilateral spastic paresis and ipsilateral of vibration and proprioception sensation.<ref><nowiki>{{</nowiki>https://www.wikem.org/wiki/Brown-Séquard_syndrome]]</ref> | ||
===Physical Examination=== | ===Physical Examination=== | ||
Although there are various cause for '''Brown-Sequard Syndrome''', the main cause is due to traumatic injury.So initial examination for these patients should follow the ABCDE protocol suggested by '''[[advanced trauma life support]]'''.cervical spine should be immobilized. furthermore,Rectal exam should be done and '''[[ASIA]]''' score should be evaluated'Also other important causes of this syndrome such as '''infection''','''mass effect''','''[[stroke]]''' and '''[[multiple sclerosis]]''' should be ruled out. | Although there are various cause for '''Brown-Sequard Syndrome''', the main cause is due to traumatic injury.So initial examination for these patients should follow the ABCDE protocol suggested by '''[[advanced trauma life support]]'''.cervical spine should be immobilized. furthermore,Rectal exam should be done and '''[[ASIA]]''' score should be evaluated'Also other important causes of this syndrome such as '''infection''','''mass effect''','''[[stroke]]''' and '''[[multiple sclerosis]]''' should be ruled out. | ||
The majority of patients with this syndrome ,usually experience classic '''[[hemi -cord syndrome]]''',ipsilateral motor paralysis and loss of vibration and proprioception sense .IN addition loss of pain and temperature sense on the other side.Loss of bowel and bladder control may be seen.<ref>{{https://www.orthopaedicsone.com/display/Main/Brown-Sequard+syndrome}}</ref> | The majority of patients with this syndrome ,usually experience classic '''[[hemi -cord syndrome]]''',ipsilateral motor paralysis and loss of vibration and proprioception sense .IN addition loss of pain and temperature sense on the other side.Loss of bowel and bladder control may be seen.<ref><nowiki>{{</nowiki>https://www.orthopaedicsone.com/display/Main/Brown-Sequard+syndrome<nowiki>}}</nowiki></ref> | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
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===Medical Therapy=== | ===Medical Therapy=== | ||
'''[[corticosteroids]]''' are used in acute treatment of '''[[SCI]]''' through reducing the spinal cord inflammation .Also drugs that control muscle spasms may be prescribed to control muscle symptoms. Supportive treatments including braces, hand splits and wheelchairs may be essential to help the affected population to resume their daily activities.<ref>{https://rarediseases.org/rare-diseases/brown-sequard-syndrome/}</ref> | '''[[corticosteroids]]''' are used in acute treatment of '''[[SCI]]''' through reducing the spinal cord inflammation .Also drugs that control muscle spasms may be prescribed to control muscle symptoms. Supportive treatments including braces, hand splits and wheelchairs may be essential to help the affected population to resume their daily activities.<ref>{https://rarediseases.org/rare-diseases/brown-sequard-syndrome/}</ref> | ||
However, there are some resources recommending not to use '''[[corticosteroids]]''' .<ref>{{https://www.wikem.org/wiki/Brown-Séquard_syndrome}}</ref> | However, there are some resources recommending not to use '''[[corticosteroids]]''' .<ref><nowiki>{{</nowiki>https://www.wikem.org/wiki/Brown-Séquard_syndrome<nowiki>}}</nowiki></ref> | ||
===Surgery=== | ===Surgery=== | ||
surgery for those patients with '''BSS''' with specific underlying causes such as [[acute disc herniation]] or '''tumors''' is associated with good surgical outcome.<ref>{{https://pubmed.ncbi.nlm.nih.gov/31720278/}}</ref> | surgery for those patients with '''BSS''' with specific underlying causes such as [[acute disc herniation]] or '''tumors''' is associated with good surgical outcome.<ref><nowiki>{{</nowiki>https://pubmed.ncbi.nlm.nih.gov/31720278/<nowiki>}}</nowiki></ref> | ||
Also, surgery is recommended in patients with '''[[progressive neurologic deficits]]''' and '''[[unstable spine fracture]]'''.<ref>{{ttps://www.wikem.org/wiki/Brown-Séquard_syndrome | Also, surgery is recommended in patients with '''[[progressive neurologic deficits]]''' and '''[[unstable spine fracture]]'''.<ref>{{ttps://www.wikem.org/wiki/Brown-Séquard_syndrome | ||
Revision as of 16:22, 16 July 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mandana Safakhah, MD[2]
Synonyms and keywords: Brown-Séquard's hemiplegia; Brown-Séquard's paralysis
| Brown-Sequard syndrome | |
 | |
|---|---|
| Brown-Sequard syndrome is bottom diagram | |
| ICD-10 | G83.8 |
| ICD-9 | 344.89 |
| DiseasesDB | 31117 |
| MeSH | D018437 |
Overview
'Brown-Séquard syndrome is a loss of motricity (paralysis and ataxia) and sensation caused by the lateral hemisection of the spinal cord. Other synonyms are crossed hemiplegia, hemiparaplegic syndrome, hemiplegia et hemiparaplegia spinalis and spinal hemiparaplegia.
Historical Perspective
It was first described in 1850 by the historically famous British neurologist Charles Édouard Brown-Sequard (1817-1896), who studied the anatomy and physiology of the spinal cord. [1][2] Brown-Sequard was quite a controversial and eccentric figure, and is also known for self-reporting "rejuvinated sexual prowess after eating extracts of monkey testis". The response is now thought to have been a placebo effect, but apparently this was "sufficient to set the field of endocrinology off and running."[3]
Interestingly, many nations claim him as their own, he was the son of an American sea captain and a French woman, living in a British territory. He studied in the US, France, as well as the UK. He described this injury which resulted from caning knives trauma in Mauritius.
Classification
Pathophysiology
The hemisection of the cord results in a lesion of each of the three main neural systems:
- the principal upper motor neuron pathway of the corticospinal tract
- one or both dorsal columns
- the spinothalamic tract
As a result of the injury to these three main brain pathways the patient will present with three lesions.
- The corticospinal lesion produces spastic paralysis on the same side of the body (the loss of moderation by the UMN).
- The lesion to fasciculus gracilis or fasciculus cuneus results in ipsilateral loss of vibration and proprioception (position sense).
- The loss of the spinothalamic tract leads to pain and temperature sensation being lost from the contralateral side beginning one or two segments below the lesion. At the lesion site all sensory modalities are lost on the same side, and also an ipsilateral flaccid paralysis.
Causes
Brown-Sequard syndrome may be caused by a spinal cord tumor, trauma (such as a gunshot wound or puncture wound to the neck or back), ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosis.
Differentiating Brown-Sequard syndrome from Other Diseases
Brown -Sequard syndrome must be differentiated from other diseases that cause poor muscle tone, muscle weakness, muscle spasticity and areflexia such as Motor neuron disease, Progressive spinal muscular atrophy, Primary lateral sclerosis and stroke.[4].
Epidemiology and Demographics
Brown sequard syndrome affects both male and female equally. The incidence of this disease is 2% of all traumatic spinal cord injury. [5]
In 2007, the prevalence of brown- sequard syndrome was estimated to be 17.1% of patients diagnosed with spinal cord injuries admitted to Virginia commonwealth university,Virginia,USA.[6].
Risk Factors
There is no established risk factor for Brown -sequard syndrome.
Screening
There is insufficient evidence to recommend routine screening for [brown -sequard syndrome].
Natural History, Complications, and Prognosis
Common complications of Brown -sequard syndrome include hypotension, spinal shock,UTI and pneumonia,hypercalcemia,osteoporosis,vertebral artery dissection,pressure ulcers and bowel impaction. These complications could be due to the trauma causing 'BSS or the overall problem in the body . Also patients with the pathology in their cervical or upper thorax spine need respiratory support.[7]
Diagnosis
Diagnostic Criteria
There are no established criteria for the diagnosis of Brown-Sequard Syndrome.
History and Symptoms
The majority of patients with Brown-Sequard Syndrome experience this syndrome following a trauma to their neck or back region. First symptoms are usually loss of pain and temperature sensation in dermatomes below the traumatized region ,which is due to the decussation of antero- lateral fibers within spinal tract through white commissure resulting in contralateral loss of pain and temperature sensation. Also ,decussation of corticospinal tract at medulla leads to ipsilateral spastic paresis and ipsilateral of vibration and proprioception sensation.[8]
Physical Examination
Although there are various cause for Brown-Sequard Syndrome, the main cause is due to traumatic injury.So initial examination for these patients should follow the ABCDE protocol suggested by advanced trauma life support.cervical spine should be immobilized. furthermore,Rectal exam should be done and ASIA score should be evaluated'Also other important causes of this syndrome such as infection,mass effect,stroke and multiple sclerosis should be ruled out. The majority of patients with this syndrome ,usually experience classic hemi -cord syndrome,ipsilateral motor paralysis and loss of vibration and proprioception sense .IN addition loss of pain and temperature sense on the other side.Loss of bowel and bladder control may be seen.[9]
Laboratory Findings
There are no diagnostic laboratory findings associated with Brown-Sequard Syndrome unless the disesase is due to spinal cord infections.
Imaging Findings
MRI is the imaging of choice in spinal cord lesions.The features of MRI in any case depends on the underlying cause. However, all of them may show unilateral pathology.
Treatment
Like any other diseases, treatment of Brown-Sequard Syndrome is based upon the underlying cause. As the most common cause of this syndrome is due to spinal cord injuries,the first step in the management would be dealing with injury then proceeding to BSS management . There are various options for treatment plan of BSS, such as medical,physical,occupational,recreational and surgical but there isn't any specific choice for it's treatment. Early intervention is usually associated with good prognosis. Although, in severe motor injury there is a low chance of improvement.
Medical Therapy
corticosteroids are used in acute treatment of SCI through reducing the spinal cord inflammation .Also drugs that control muscle spasms may be prescribed to control muscle symptoms. Supportive treatments including braces, hand splits and wheelchairs may be essential to help the affected population to resume their daily activities.[10] However, there are some resources recommending not to use corticosteroids .[11]
Surgery
surgery for those patients with BSS with specific underlying causes such as acute disc herniation or tumors is associated with good surgical outcome.[12]
Also, surgery is recommended in patients with progressive neurologic deficits and unstable spine fracture.[13]
Prevention
There are no established measures for the primary prevention of Brown -Sequard Syndrome.
References
- ↑ Template:WhoNamedIt
- ↑ C.-E. Brown-Séquard: De la transmission croisée des impressions sensitives par la moelle épinière. Comptes rendus de la Société de biologie, (1850)1851, 2: 33-44.
- ↑ The Practice of Neuroscience, p. 199-200, John C.M. Brust (2000).
- ↑ {{https://rarediseases.org/rare-diseases/brown-sequard-syndrome/}}
- ↑ {{https://rarediseases.org/rare-diseases/brown-sequard-syndrome/}}
- ↑ {{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031952/}}
- ↑ {{https://brownsequardsyndrome.org/}}
- ↑ {{https://www.wikem.org/wiki/Brown-Séquard_syndrome]]
- ↑ {{https://www.orthopaedicsone.com/display/Main/Brown-Sequard+syndrome}}
- ↑ {https://rarediseases.org/rare-diseases/brown-sequard-syndrome/}
- ↑ {{https://www.wikem.org/wiki/Brown-Séquard_syndrome}}
- ↑ {{https://pubmed.ncbi.nlm.nih.gov/31720278/}}
- ↑ Template:Ttps://www.wikem.org/wiki/Brown-Séquard syndrome