Neurology · Year 3 · from Neurology

Case 2: Brown-Sequard Syndrome - Spinal Cord Hemisection

Patient Demographics

  • Age: 34 years
  • Sex: Female
  • Occupation: Construction worker

Chief Complaint

"I can't feel temperature on my right leg, and my left leg is weak."

History of Present Illness

The patient was involved in a workplace accident where a metal rod penetrated her upper back on the left side. She immediately noticed weakness in her left leg and an unusual sensation in her right leg. She describes that she cannot feel hot or cold on her right leg but can still feel touch. The left leg feels "normal" but won't move properly.

Neurological Examination Findings

Mental Status:

  • Alert, oriented, appropriate

Cranial Nerves:

  • All cranial nerves intact (II-XII)

Motor Examination:

  • Left lower extremity: 2/5 hip flexion, 3/5 knee extension, 2/5 ankle dorsiflexion
  • Right lower extremity: 5/5 throughout
  • Upper extremities: 5/5 bilateral

Sensory Examination:

  • Left side: Loss of vibration and proprioception below T6 level
  • Left side: Light touch intact
  • Right side: Loss of pain and temperature below T8 level
  • Right side: Vibration and proprioception intact

Reflexes:

  • Left lower extremity: 3+ (hyperreflexia)
  • Left Babinski positive
  • Right lower extremity: 2+
  • Right Babinski negative

Coordination:

  • Impaired heel-to-shin on left (due to proprioceptive loss)
  • Right side normal

Localization

Lesion Location: Left spinal cord hemisection at T6 level (Brown-Sequard Syndrome)

  • Ipsilateral (left) motor weakness - corticospinal tract
  • Ipsilateral (left) loss of vibration/proprioception - dorsal columns
  • Contralateral (right) loss of pain/temperature - spinothalamic tract (crosses 1-2 levels below entry)
  • UMN signs ipsilaterally below lesion

Neuro Workup

  • MRI Spine with contrast: Left hemicord signal abnormality at T6 level with associated cord edema
  • CT Spine: Metallic foreign body trajectory through left posterior elements at T6
  • Somatosensory evoked potentials: Delayed responses from left lower extremity

Diagnosis

Traumatic Brown-Sequard Syndrome at T6 level secondary to penetrating spinal cord injury

Management

  1. Emergent neurosurgical consultation for foreign body removal and decompression
  2. High-dose methylprednisolone (controversial but considered)
  3. Maintain spinal precautions
  4. DVT prophylaxis
  5. Foley catheter for neurogenic bladder
  6. Aggressive rehabilitation program
  7. Prognosis: Brown-Sequard has best prognosis among incomplete spinal cord injuries

Clinical Image

Image Description: MRI T2-weighted image of the thoracic spine demonstrating hemicord hyperintensity consistent with cord contusion.

Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Brown-Sequard_syndrome.svg

All cases for this lecture as Markdown