Solving the puzzle of Brown-Séquard syndrome.

ABSTRACT: Incomplete spinal cord injury is challenging to diagnose and treat. This overview of Brown-Séquard syndrome outlines key assessment and nursing considerations important to enhancing recovery outcomes.

Comparative biomechanical analysis of gait in patients with central cord and Brown-Séquard syndrome.

PURPOSE: This is a pilot study with the aim to highlight the use of kinematic and kinetic analyses as an adjunct to the assessment of individual patients with central cord syndrome (CCS) and hemisection or Brown-Séquard syndrome (BSS) and to discuss their possible consequences for clinical management. METHODS: The sample studied consisted of 17 patients with CCS, 13 with BSS and 20 control subjects (control group (CG)). Data were obtained using a three-dimensional motion analysis system and two force plates. Gait differences were compared between CCS, BSS walking at a self-selected speed and CG at both a self-selected and a similar speed to that of the patient groups. RESULTS: The most relevant findings involved the knee and ankle, especially in the sagittal plane. In patients with CCS, knee flexion at initial contact was increased with respect to those in the BSS group (p < 0.01). The ankle in the BSS group made initial contact with a small degree of plantar flexion. CONCLUSION: The use of gait biomechanical analysis to detect underlying impairments can help the physician to set a specific rehabilitation program in each CCS and BSS walking patient. In this group of patients, rehabilitation treatment should aim to improve gait control and optimise ankle positioning at initial contact. Implications for Rehabilitation In this study, gait differences between patients with CSS and BSS were evaluated with biomechanical equipment. The most remarkable differences were found in the knee and ankle sagittal plane due to ankle position at initial contact. In this group of patients, rehabilitation treatment should aim to improve gait control and to get a better ankle positioning at initial contact.

[Postraumatic epidural arachnoid spinal cyst: case report]. / Quiste aracnoideo espinal epidural postraumático: presentación de un caso.

INTRODUCTION: Extradural arachnoid spinal cysts are unfrequent lesions that are associated with spinal trauma, surgery and less frequently with congenital anomalies. The clinical manifestations are similar to those seen with other compressive spinal cord lesions. Magnetic resonance techniques allow to diagnose correctly this pathology and to define its thopographic situation. The pathologic history of the patient is essencial to establish the ethiology. Surgery is the elective treatment in most cases. CLINICAL CASE: The patient is a 35 years old man who has a medical history of penetrating spinal trauma two years ago. In that instance he suffered an unilateral spinal cord section at D2-D3 level with the corresponding Brown Sequard syndrome. A small wound was detected at the skin dorsal level and it was closed without difficulties. At the beginning, he improved his motor right leg function with rehabilitation and vitamins. After two years of good recovery he came to our hospital suffering a neurological deterioration of six months of evolution. The physical examination revealed an spastic paraparesis. Magnetic resonance was performed demonstrating a cystic extradural collection compressing the spinal cord at D3-D4 level. Surgical decompressive treatment allowed to excise the cyst and it was possible to define a dural tear that was closed successfully. The outcome was good with restoration of the initial motor function that he had after the spinal trauma. CONCLUSIONS: Surgical management of postraumatic epidural arachnoid spinal cyst allows to detect the meningeal tear and to close it, which is highly effective on these kinds of lesions.

Brown-Séquard-plus syndrome because of penetrating trauma in children.

Brown-Séquard syndrome is an uncommon condition involving incomplete spinal cord injury, with ipsilateral motor and proprioception loss, contralateral pain, and decreased temperature. Brown-Séquard-plus syndrome is associated with additional neurologic findings involving the eyes, bowel, or bladder. We describe an adolescent with Brown-Séquard-plus syndrome attributable to a stab injury. Our patient's clinical features of spinal and neurogenic shock overlapped at presentation. He was managed with high-dose steroids, along with intense physiotherapy and rehabilitation, resulting in good neurologic recovery. Appropriate medical (and surgical, when indicated) management usually results in good to complete recovery of neurologic function, depending on the level and grade of injury. With the increasing incidence of gunshot wounds and stab injuries in children, pediatricians, including pediatric neurologists and emergency physicians, are more likely to encounter these types of spinal cord injuries in children.

Brown-Sèquard syndrome caused by type III odontoid fracture: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: To present the second case of Brown-Sèquard syndrome (BSS) produced by type III odontoid fracture managed by conservative treatment. SUMMARY OF BACKGROUND DATA: The occurrence of BSS due to odontoid fracture is scarce. So far 6 cases have been reported, and only 1 is produced by type III odontoid fracture. The possible pathophysiology, clinical course and treatment outcome have been rarely discussed. METHODS: A 39-year-old man presented with weakness of his left arm and leg, mild neck pain, and impaired proprioceptive and light touch sensations below the left C2 dermatome. There were decreased pain and temperature sensations below the right C4 dermatome too. Computerized tomography showed odontoid type III fracture with posterior displacement at that level. Magnetic resonance imaging presented focal hyperintensity around the C2 vertebral level. High dose of prednisolone, close reduction with Gardner-Wells tong skull traction, following external stabilization by Halo-Vest and rehabilitation therapy were applied. RESULTS: Complete resolution of neck pain and significant improvement of motor and sensory functions, i.e., light touch and proprioception, were shown 2 months after spinal injury. Impaired temperature discrimination persisted, however. CONCLUSION: BSS is rarely caused by type III odontoid fracture and this is the second report. Conservative intervention is advantageous for both type III odontoid fracture and BSS which is consistent with previous results.

Outcome after incomplete spinal cord injury: central cord versus Brown-Sequard syndrome.

STUDY DESIGN: A retrospective analysis of prospectively collected data. OBJECTIVE: A hemisection of the spinal cord is a frequently used animal model for spinal cord injury (SCI), the corresponding human condition, that is, the Brown-Sequard syndrome (BS), is relatively rare as compared with the central cord syndrome (CC). The time course of neurological deficit, functional recovery, impulse conductivity and rehabilitation length of stay in BS and CC subjects were compared. SETTING: Nine European Spinal Cord Injury Rehabilitation Centers. METHODS: Motor score, walking function, daily life activities, somatosensory evoked potentials and length of stay were evaluated 1 and 6 months after SCI, and were compared between age-matched groups of tetraparetic BS and CC subjects. RESULTS: For all analyzed measures no difference in the time course of improvement was found in 15 matched pairs. CONCLUSION: In contrast to the assumption of a better outcome of subjects with BS, no difference was found between the two incomplete SCI groups. This is of interest with respect to the different potential mechanisms leading to a recovery of functions in these two SCI subgroups.

Spinal decompression sickness presenting as partial Brown-Sequard syndrome and treated with robotic-assisted body-weight support treadmill training.

OBJECTIVE: To describe the rehabilitation outcome of a case of spinal decompression sickness presenting as partial Brown-Sequard syndrome treated with robotic-assisted body-weight support treadmill training. STUDY DESIGN: Case report. BACKGROUND: Type II decompression sickness patients commonly suffer from myelopathy with gait disturbances necessitating rehabilitation. Robotic-assisted body-weight support treadmill training has been shown to improve the rehabilitation outcome of incomplete spinal cord injury. Its usefulness has not been described in decompression sickness myelopathy. METHODS: Robotic-assisted body-weight support treadmill training was administrated using the Lokomat. Primary outcomes were American Spinal Cord Association scale, Spinal Cord Independence Measurement, Berg Balance Test, and Walking Index for Spinal Cord Injury. RESULTS: The patient was admitted 3 weeks after the diving injury, with severe paraparesis and a T11 sensory neurological level, resembling partial Brown-Sequard syndrome. After 3 months of rehabilitation including 18 Lokomat sessions, American Spinal Cord Association score improved from C to D, Spinal Cord Independence Measurement improved from 50 to 90 out of 100. Berg Balance Test improved from 35 to 43 out of 56 and Walking Index for Spinal Cord Injury improved from 1 to 15 out of 20. Upon discharge he could walk with one crutch for more than 1 km. CONCLUSION: Robotic-assisted body-weight support treadmill training for spinal decompression sickness rehabilitation might be beneficial.

Incidence and outcomes of spinal cord injury clinical syndromes.

BACKGROUND/OBJECTIVE: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). DESIGN: Retrospective review. SETTING: Tertiary care, level 1 trauma center inpatient rehabilitation unit. PARTICIPANTS: Eight hundred thirty-nine consecutive admissions with acute SCIs. MAIN OUTCOMES MEASURES: Functional independence measure (FIM), FIM subgroups (motor, self-care, sphincter control), length of stay (LOS), and discharge disposition. RESULTS: One hundred seventy-five patients (20.9%) were diagnosed with SCI clinical syndromes. CCS was the most common (44.0%), followed by CES (25.1%) and BSS (17.1%). Significant differences (P < or = 0.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant differences (P < or = 0.01) with respect to age (39.7 vs 53.2 years) and a trend toward significance (P < or = 0.05) with regard to self-care admission and discharge FIM. No significant differences (P < or = 0.01) were found when comparing CMS to CES. CONCLUSIONS: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation, with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Patients with cervical BSS seem to achieve higher functional improvement by discharge compared with patients with CCS. Patients with CMS and CES exhibit similar functional outcomes. Patients with ACS and PCS show functional gains with inpatient rehabilitation, with patients with ACS displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI.

Blowdart injury resulting in Brown-Séquard plus syndrome.

This report presents an interesting and unusual case of an injury sustained from a blowgun dart. The dart penetrated zone 2 of the neck, resulting in a neurological deficit consistent with a variant of Brown-Sequard syndrome referred to as "Brown-Sequard plus syndrome."

Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients.

OBJECTIVE: To develop an objective and uniform means for classifying patients with incomplete spinal cord injury (SCI) according to SCI syndromes. DESIGN: Criteria for assigning the syndromes (defined by the International Standards for Neurological and Functional Classification of SCI Patients) were operationalized by means of sensory and motor scores and were incorporated into a set of six independent algorithms and two composite algorithms. SETTING: A regional SCI rehabilitation center in Canada. PATIENTS: SCI patients (n = 56) with incomplete injuries (American Spinal Injury Association classes B, C, D) and stable neurologic deficits. RESULTS: Individual algorithms allowed the highest classification rate but with some patients meeting the criteria for more than one syndrome. A composite, differential allocation algorithm, with selected thresholds at decision nodes, yielded a classification rate approximating that of the individual algorithms but without double classifications. CONCLUSIONS: The composite algorithm provided an objective and standardized means of assigning patients to syndromes based on clinically measurable sensory and motor scores. The thresholds used to implement criteria and the order of decision nodes greatly influenced the outcomes and may be adjusted to suit the needs of the classification, that is, embracing liberal or stringent criteria. Controversy remains about the interpretation of some syndromes, and many patients remain unclassifiable because of mixed clinical presentation.