Brown-Sequard Syndrome due to Cervical Disc Herniation
Review written by: James Demetrious, DC, DABCO
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Summary
Brown-Sequard syndrome (BSS) is a rare neurological condition characterized by a lesion in the spinal cord which results in weakness or paralysis (hemi-paraplegia) on one side of the body and a loss of sensation (hemianesthesia) on the opposite side. While most commonly associated with traumatic spinal injury, spinal cord neoplasms, and epidural hematomas, cervical disc herniation is a very rare cause of BSS. In this Clinical Pearl, we will discuss two recent case reports.
Recent Cases
Case #1: In their paper, Meng et. al report the case of a 51-year old female who developed BSS and Horner syndrome following cervical disc herniation. The patient presented with neck pain, right hemiparesis, difficulty ambulating, numbness in the lower trunk and limbs on the left side. MRI of the cervical spine revealed a large central and right-sided extradural C5–6 herniation and a small C3–4 disc herniation. T2 weighted images provided visualization of high signal intensity of the underlying spinal cord.
Case #2: In their recent paper, Walker et. al report the history of a 29-year-old male who developed sudden onset BSS after self-manipulation of his neck. The authors reported that the gentleman forcefully bent his neck laterally while rotating his chin to the opposite shoulder until he felt an audible “crack.” The patient presented with shooting pain down his neck, right hemiparesis with decreased vibratory sense, and left-sided decrease of sensation. MRI of the cervical spine revealed large disc herniations at C4-5 and C5-6 with severe cord compression and increased signal within the cord on T2 weighted images.
Insight
In practice, it is of vital importance to quickly identify signs and symptoms that may reflect spinal cord compromise. Progressive BSS requires emergent neurosurgical referral and intervention.
Brief Review
While extraordinarily rare, the C5/6 vertebral level is most susceptible to discogenic BSS. The assessment of BSS requires comprehensive understanding of spinal cord anatomy to interpret associated clinical signs, symptoms and pathologic processes.
Due to hemi-section or hemi-compression of the spinal cord, BSS may feature ipsilateral deficits including:
- upper motor neuron paralysis (hemiplegia) due to corticospinal tract compromise;
- loss of proprioception with possible gait disturbance, altered light touch and vibration sense due to posterior column involvement;
- disruption of the dorsal spinocerebellar tract may lead to ipsilateral dystaxia;
- Horner’s syndrome may present due to autonomic deficits and disruption of second-order sympathetic fibers.
Contralateral effects may include:
- pain, temperature and crude touch sensation from spinothalamic tract dysfunction;
- disruption of the ventral spinocerebellar tract may produce contralateral dystaxia.
More commonly, incomplete-BSS or partial-BSS may present with variable clinical elements described above.
Chiropractic Takeaway…
BSS represents a neurosurgical emergency. Early referral and intervention can greatly benefit patients. The high prevalence of disc herniation and spinal stenosis in the asymptomatic population requires introspection. Practitioners must keep in mind the extraordinarily rare occurrence of BSS associated with disc herniation and spinal manipulation. However, review of the subject is of importance. Awareness and understanding provides the ability to identify burgeoning spinal cord compromise. Such critical insight may lead to timely and emergent neurosurgical referrals.
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