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Brown-Séquard's Syndrome

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Brown-Séquard's syndrome results from a lesion in one (lateral) half of the spinal cord (for example, hemisection or lateral injury of the cord). It often occurs in the cervical cord region. It was first described in the 1840s by Dr Charles-Édouard Brown-Séquard (1817-94).1

The syndrome is rare and comprises ipsilateral hemiplegia with contralateral pain and temperature sensation deficits (because of the crossing of the fibres of the spinothalamic tract).

Pathophysiology

The pure Brown-Séquard's syndrome reflecting hemisection of the cord is rarely seen. However, a clinical picture with some of the features of the syndrome is more common. The hemisection syndrome may also occur with additional symptoms and signs. Interruption of the lateral corticospinal tracts, the lateral spinothalamic tract, and occasionally the posterior columns clinically cause a spastic weak leg with brisk reflexes and a strong leg with loss of pain and temperature sensation. Spasticity and hyperactive reflexes may not be present with an acute lesion.

Aetiology

The causes of this syndrome are:

  • Most commonly, trauma (penetrating or blunt).2,3
  • Neoplasia (spinal cord tumour - either metastatic or primary).
  • Multiple sclerosis.
  • Degenerative (such as herniation of discs and cervical spondylosis).4
  • Cysts5 and cystic diseases.
  • Idiopathic spinal cord herniation6 (spinal cord herniation can also occur after trauma7).
  • Vascular causes:
    • Haemorrhage (including spinal subdural/epidural and haematomyelia).
    • Ischaemia.
  • Infectious causes:
  • Other causes include gnathostomiasis (helminthic parasitic disease rarely seen outside the tropics where it may be associated with itch, fever, nausea, vomiting, abdominal pain, non-pitting oedema, and finger swelling), and tropical spastic paraplegia (HTLV-1).
  • Rollercoaster riding and chiropractic manipulation8 may be a contributing factor if there is a predisposition (such as a cyst).3

Presentation

Presenting features of Brown-Séquard's syndrome

  • There is a total ipsilateral loss of sensation (analgesia and thermoanaesthesia) with flaccid paralysis at the level of the lesion.
  • There is contralateral loss of pain and temperature beginning a few segments below the lesion (because the spinothalamic tracts enter the cord and travel ipsilaterally for a few segments before decussating). No plantar response on this side because of loss of pain sensation.
  • There is ipsilateral spastic paraparesis with loss of vibration and joint-position sense (destruction of ipsilateral dorsal column fibres) below the lesion. Reflexes are brisk with upgoing plantar reflex.
  • There may be an ipsilateral Horner's syndrome if the sympathetic fibres are damaged (in the neck).9,10
  • There are also sphincter disturbances.

Incomplete forms of the syndrome commonly occur, usually caused by vascular impairment secondary to compression of the cord, with sparing of the dorsal columns (separate vascular supply); or inflammatory lesions (for example, multiple sclerosis).

Differential diagnosis

Diagnosis of Brown-Séquard's syndrome is made on the basis of neurological history and physical examination. Most cases will be caused by trauma. It is important when there is no history of trauma to consider:

  • Multiple sclerosis
  • Spinal cord Infections
  • Stroke

Investigations

  • Laboratory studies may be useful with nontraumatic causes. Overall they are not usually necessary for diagnosis. They may be useful in monitoring a clinical course.
  • Imaging:
    • Spinal plain radiographs (for bony injury in penetrating or blunt trauma)11.
    • MRI scanning can help to define the extent of spinal cord injury. It is particularly helpful when evaluating nontraumatic causes. MRI may be needed in traumatic cases when there is neurological deterioration.12
    • CT myelography (useful if MRI is contra-indicated).

Management

  • Initially, a thorough evaluation, including neurological examination, is performed to establish the level of injury.
  • Careful cervical spine/dorsal spine immobilisation is necessary.
  • No movement of the neck should be permitted.
  • It is important to identify cases (such as spinal cord herniation) where surgical intervention can improve prognosis.4,13,14

Complications

Early and late complications associated with spinal injury may occur. These may include:

  • Hypotension ('spinal shock').
  • Pulmonary embolism (prophylaxis needed).
  • Infection (lungs, urine, etc.).
  • Depression (common with spinal cord injuries).

Prognosis

The prognosis for Brown-Séquard's syndrome is generally poor although it may be better than other froms of spinal cord injury.15 Aetiology can have a bearing on prognosis. Early treatment with high-dose steroids has shown benefit in some cases.

Historical footnote

Charles-Édouard Brown-Séquard (1817-94) was a very remarkable and eminent neurologist who worked in England, France and the United States of America. He was one of the founding physicians at the Institute of Neurology in London. He published 577 papers. He initially intended to be a writer, but became a medical student when his manuscripts were rejected repeatedly. He first published the findings which became "Brown-Séquard's syndrome" in 1849 and he later described a typical case of his syndrome to the British Medical Association's annual meeting in 1862 - that of a sea captain stabbed in the neck. He also performed notable work in the emerging field of endocrinology.1,16,17,18,19,20

Document references

  1. Laporte Y; Charles-Edouard Brown-Sequard: an eventful life and a significant contribution to the study of the nervous system. C R Biol. 2006 May-Jun;329(5-6):363-8. Epub 2006 May 3. [abstract]
  2. McCarron MO, Flynn PA, Pang KA, et al; Traumatic Brown-Sequard-plus syndrome. Arch Neurol. 2001 Sep;58(9):1470-2. [abstract]
  3. Bateman DE, Pople I; Brown-Sequard at a theme park. Lancet. 1998 Dec 12;352(9144):1902.
  4. Lee JK, Kim YS, Kim SH; Brown-Sequard syndrome produced by cervical disc herniation with complete neurologic recovery: report of three cases and review of the literature. Spinal Cord. 2007 Nov;45(11):744-8. Epub 2007 Feb 6. [abstract]
  5. Cheng WY, Shen CC, Wen MC; Ganglion cyst of the cervical spine presenting with Brown-Sequard syndrome. J Clin Neurosci. 2006 Dec;13(10):1041-5. [abstract]
  6. Parmar H, Park P, Brahma B, et al; Imaging of idiopathic spinal cord herniation. Radiographics. 2008 Mar-Apr;28(2):511-8. [abstract]
  7. Francis D, Batchelor P, Gates P; Posttraumatic spinal cord herniation. J Clin Neurosci. 2006 Jun;13(5):582-6. [abstract]
  8. Domenicucci M, Ramieri A, Salvati M, et al; Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine. 2007 Nov;7(5):571-4. [abstract]
  9. Garcia-Manzanares MD, Belda-Sanchis JI, Giner-Pascual M, et al; Brown-Sequard syndrome associated with Horner's syndrome after a penetrating trauma at the cervicomedullary junction. Spinal Cord. 2000 Nov;38(11):705-7. [abstract]
  10. Edwards A, Andrews R; A case of Brown-Sequard syndrome with associated Horner's syndrome after blunt injury to the cervical spine. Emerg Med J. 2001 Nov;18(6):512-3. [abstract]
  11. Miranda P, Gomez P, Alday R, et al; Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. Eur Spine J. 2007 Aug;16(8):1165-70. Epub 2007 Mar 30. [abstract]
  12. Jacobsohn M, Semple P, Dunn R, et al; Stab injuries to the spinal cord: a retrospective study on clinical findings and magnetic resonance imaging changes. Neurosurgery. 2007 Dec;61(6):1262-6; discussion 1266-7. [abstract]
  13. Uhl E, Holtmannspotter M, Tonn JC; Improvement of Brown-Sequard syndrome after surgical repair of an idiopathic thoracic spinal cord herniation. J Neurol. 2008 Jan;255(1):125-6. Epub 2008 Jan 22.
  14. Massicotte EM, Montanera W, Ross Fleming JF, et al; Idiopathic spinal cord herniation: report of eight cases and review of the literature. Spine. 2002 May 1;27(9):E233-41. [abstract]
  15. McKinley W, Santos K, Meade M, et al; Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30(3):215-24. [abstract]
  16. Aminoff MJ; Historical perspective Brown-Sequard and his work on the spinal cord. Spine. 1996 Jan 1;21(1):133-40. [abstract]
  17. Aminoff MJ; Brown-Sequard and his syndrome. J Hist Neurosci. 1996 Apr;5(1):14-20. [abstract]
  18. Tattersall RB; Charles-Edouard Brown-Sequard: double-hyphenated neurologist and forgotten father of endocrinology. Diabet Med. 1994 Oct;11(8):728-31. [abstract]
  19. Tyler HR, Tyler KL; Charles Edouard Brown-Sequard: professor of physiology and pathology of the nervous system at Harvard Medical School. Neurology. 1984 Sep;34(9):1231-6. [abstract]
  20. Goetz CG; Battle of the titans: Charcot and Brown-Sequard on cerebral localization. Neurology. 2000 May 9;54(9):1840-7. [abstract]

Acknowledgements

EMIS is grateful to Dr Richard Draper for writing this article and to Dr Huw Thomas for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2010.
Document ID: 1891
Document Version: 21
Document Reference: bgp1217
Last Updated: 19 Sep 2010
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