Brown-Séquard Syndrome

Physical Examination

Inspection

• Observe for any muscle wasting, asymmetry, or abnormalities in posture or gait

• Look for abnormal movements, such as spasms or twitches

Motor Examination

Tone

• Increased muscle tone (spasticity) on the side of the body ipsilateral to the lesion

Power

• Motor weakness observed ipsilateral to the lesion

Reflex

• Hyperreflexia and a positive Babinski's sign on the side of the body ipsilateral to the lesion

Cerebellar Examination

• No anticipated cerebellar signs in Brown-Séquard syndrome

Sensory Examination

Soft touch

• Loss of soft touch sensation on the side of the body ipsilateral to the lesion

Pin Prick

• Loss of pain and temperature sensation contralateral to the lesion (starting a couple of segments below the lesion)

Vibration and Proprioception

• Loss of vibration and proprioception sensation ipsilateral to the lesion

Additional Examination

• Spinal examination to look for a possible site of lesion

• Full neurological examination to identify other signs consistent with the condition or related conditions

• Consider examining for signs of trauma, including looking for penetrating injuries, as Brown-Séquard syndrome is often caused by traumatic injury to the spinal cord

• Anal tone assessment and bladder examination

Investigations

Laboratory Tests

• Complete blood count (CBC), renal functional test, coagulation profile, inflammatory markers

• Specific tests if suspected infectious cause (TB, HIV, syphilis serology, Lyme disease): As these infections can affect the spinal cord

Imaging

• Magnetic Resonance Imaging (MRI) spine: Gold standard for detecting spinal cord lesions, it can help identify the location, extent of lesion and the underlying cause (tumor, abscess, disc prolapse, hemorrhage, ischemia)

• CT scan: If MRI is contraindicated or unavailable; less sensitive for spinal cord lesions but useful for bone pathology

• Chest X-ray: If TB or lung cancer (that could metastasize to the spine) is suspected

Invasive

• Lumbar puncture with CSF analysis: If infection or inflammation (like meningitis, TB, multiple sclerosis) is suspected. It can also be useful in suspected cases of spinal cord tumour for cytology.

• Biopsy: If a spinal tumor is suspected on imaging

Other tests

• Electromyography (EMG) and nerve conduction studies: To rule out peripheral nerve or muscle disorders

• Urodynamic studies: If there's any suspicion of bladder involvement (common in spinal cord disorders) to evaluate the degree of dysfunction.

Management

General Management

• Rehabilitation: Physiotherapy for muscle strengthening, occupational therapy for daily living skills

• Patient education: Information on the condition, prognosis, and self-care strategies

• Psychological support: Mental health services for coping with diagnosis and changes in lifestyle

Medical Management

• Pain control: Use of analgesics, antispasmodics for muscle spasms

• Control of other symptoms: Medications for urinary and bowel control if needed

• Steroids: In case of inflammation, or in acute phase to reduce edema

• Anticoagulation: If the cause is related to thrombosis

• Antibiotics: If the cause is infectious

Surgical Management

• Decompression surgery: If the cause is a compressive lesion like a tumor or abscess

• Stabilization procedures: In case of unstable fractures or spinal instability

• Shunt placement: If there is hydrocephalus

Other Management

• Mobility aids: Wheelchairs, braces, or other devices as needed

• Bladder and bowel management: Catheterization or bowel programme if necessary

• Social services involvement: Assistance with housing modifications, support groups, or vocational services

• Regular follow-ups: Monitoring progress and response to treatment, adjustment of treatment plan as needed

Notes

The spinal cord has several tracts that carry different types of sensory information to the brain, and motor commands from the brain to the body. In the context of Brown-Séquard Syndrome, we will focus on three primary tracts: the corticospinal tract, the dorsal column-medial lemniscus pathway, and the spinothalamic tract.

Corticospinal Tract

• It is the primary motor tract, also known as the pyramidal tract.

• It originates in the cerebral cortex and travels down the brainstem and spinal cord.

• The corticospinal tract decussates (crosses over) in the lower part of the medulla oblongata, an area known as the pyramidal decussation.

• This means that the left cerebral cortex controls motor function on the right side of the body, and the right cerebral cortex controls the left side.

Dorsal Column-Medial Lemniscus Pathway

• This pathway is responsible for transmitting fine touch, vibration sense, and proprioception (awareness of the position of one's body).

• The primary neurons enter the spinal cord and ascend ipsilaterally (on the same side) in the dorsal columns.

• These neurons then synapse with secondary neurons in the nucleus gracilis and nucleus cuneatus in the medulla oblongata.

• It's here that the fibers decussate and become the medial lemniscus, continuing to the thalamus.

Spinothalamic Tract

• This tract carries pain and temperature sensation.

• Primary neurons enter the spinal cord and synapse with secondary neurons in the dorsal horn.

• These secondary neurons then decussate at the level of the spinal cord itself, usually within one or two levels of the point of entry, and ascend contralaterally (on the opposite side) in the spinothalamic tract to the thalamus.

In Brown-Séquard Syndrome, a hemisection (partial cut) of the spinal cord results in damage to these tracts on one side. The clinical presentation reflects this damage: ipsilateral loss of fine touch, vibration, and proprioception (due to damage to the dorsal columns), contralateral loss of pain and temperature sense (due to damage to the spinothalamic tract), and ipsilateral motor weakness and spasticity (due to damage to the corticospinal tract).