Traumatic Brown-Sequard Syndrome due to a Stab Injury

Case Study

European Journal of Trauma

Traumatic Brown-Sequard Syndrome due to a Stab Injury Case Report and Review of the Literature Ricardo Galvez1, Philippe Hantson1, Xavier Wittebole1, Thierry Duprez2, Jean-Michel Guérit3, Antonios Liolios1

Abstract We report a case of Brown-Sequard syndrome (BSS) caused by a penetrating knife injury in a 31-year-old woman who was involved in a fight and was stabbed on her occiput and on her back. Neurological examination on admission suggested the BSS. Cervical magnetic resonance imaging (MRI) and evoked potentials confirmed the diagnosis. The patient’s hemiparesis gradually improved and she underwent rehabilitation. The pertinent literature is reviewed and discussed. Key Words Brown-Sequard · Knife injury · Magnetic resonance · Evoked potentials Eur J Trauma 2004;30:398–402 DOI 10.1007/s00068-004-1419-4

Case Report A 31-year-old woman was involved in a fight and was stabbed with a knife on her occiput and on her back. On arrival to the Emergency Department the patient was found to have five stab wounds and three knife blades in place in the posterior cervical area. The patient was alert and oriented and had stable vital signs. Plain radiography revealed the presence of three metallic knife blade at the level of the right parascapular region, left

posterior paravertebral thoracic and middle central posterior cervical area (Figure 1). Neurological examination revealed a paralysis of voluntary movements in the right side, anesthesia to touch and pain and changes temperature sensation and hyperesthesia in the left side along with paralysis of the muscular sense in the right side. Methylprednisolone infusion was started immediately according to the protocol for spinal cord injury (bolus dose 30 mg/kg and subsequently 5.4 mg/kg/hour for 23 hours). The computed tomography (CT) examination demonstrated that the metallic knife blade transected the spinal cord canal. The tip of the knife blade reached the soft tissue space between the vertebral body and esophagus at the C3–C4 level. There was bilateral cervical emphysema. The knife did not penetrate the thoracic wall. Localized emphysema was observed on the left thoracic wall, but no pneumothorax, pleural effusion or hemomediastinum were seen. The magnetic resonance imaging (MRI) of the cervical area showed a normal vertebro-cranial junction with the presence of a linear lesion corresponding to the blade’s course in the posterior cervical region. The right lateral area of the spinal cord was injured by the fractured body of the C3 vertebra (Figure 2). The MRI also showed abnormal signal intensity within the right parasagittal segment of the spinal cord parenchyma and within the parasagittal right soft tissue near the spinal process, reflecting tissue laceration due to the penetration of the blade.

1

Department of Intensive Care, Department of Neuroradiology, and 3 Laboratory of Neurophysiology, Cliniques universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium. 2

Received: March 10, 2004; accepted: July 5, 2004.

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Surgical removal of the three blades was performed under local anesthesia in the operating room. After admission to the Intensive Care Unit, the patient underwent somatosensory evoked potentials testing which supported the diagnosis of the Brown-Sequard syndrome (BSS) (Figure 3). The patient’s hemiparesis gradually improved and she underwent rehabilition. 6 months after admission the patient was able to walk without assistance. Discussion BSS, or hemisection of the spinal cord, was first described in 1849 by Charles-Edouard Brown-Sequard. The most common cause of the anatomic hemisection is penetrating traumatic injury of the spinal cord [1]. The classic BSS or hemisection of the spinal cord is considered a testing ground for the knowledge of clinical spinal cord anatomy. Characteristically, the patient presents with ipsilateral and contralateral symptoms. Ispilaterally there is spastic paralysis below the level of the lesion and Babinski sign (which may be absent in the first hours after acute injury) due to the interruption of the lateral corticospinal tracts. Additionally, there is loss of tactile discrimination, vibratory, and position sensation below the level of the lesion due to interruption of the posterior white column. When the BSS results from an extramedullary lesion, there may be segmental lower motor neuron and sensory signs at the level of the lesion due to damage to the roots and anterior horn cells, and these signs are the most reliable indication of the level of the lesion. Contralaterally, there is loss of pain and temperature sensation caudal to the lesion due to the interruption of the lateral spinothalamic tracts (the deficit begins usually 2–3 segments below the level of the lesion). The BSS is a rare syndrome and most cases have been sporadic and in general traumatic or neoplastic in origin. In a study from Senegal during the war, in 16 patients with gunshot and stab injuries three developed the BSS [3]. In another single-center study, 1,600 patients with spinal cord injury were seen during 13 years. Of these, patients with spinal cord stab wounds accounted for over one-quarter of the total population. Half of these patients developed findings consistent with the BSS [4]. Stab wounds to the neck have been associated with the development of the BSS in several other studies [5, 10]. Additionally, BSS due to traumatic brachial plexus root avulsion and cervical spine vertebral fracture has been described [11–13].

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Figure 1. Profile cervical spine X-ray examination in the operating room showing one of the knife blades still in place at the C4 level.

BSS has been associated with numerous other conditions: tumors, infections, hematomas, vasculitides and several other conditions able to compromise blood flow to the spinal cord have been associated with it. More specifically, BSS has been associated with the following conditions: after rapid acceleration and deceleration in theme parks (roller-coaster rides) [14, 15], cervical disk herniation [1, 16, 17], spinal epidural Figure 2. Right parasagittal T2-weighted fast spin echo MR image showing parenchymal damage within the cord at the C4 with edema (hypersignal intensity) up and down the linearily damaged area and the presence of fresh deoxyhemoglobin along the cutted edge (hyposignal intensity).

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hematoma [18–21], after the intralesional injection of alcohol for the treatment of vertebral hemangioma [22], after chiropractic manipulation [23], with spontaneous spinal cord herniation [24, 25], subarachnoid hemorrhage [26, 27], vertebral artery dissection [28], transverse myelitis after influenza and rabies vaccination [29– 31], after heroin abuse [32], after methamphetamine injection into the neck [33], with tumors [34, 35], with intramedullary spinal cord infiltration from Hodgkin’s disease [36], after radiation chemotherapy for breast cancer and cancer of the nasopharynx [36, 37], with systemic lupus erythematosus (SLE) [38–40|, Sjögren’s syndrome [41], thoracic neurenteric cyst [42], neurofibromatosis [42], Chiari I malformation [42], multiple sclerosis [43, 44], infections as intramedullary tuberculosis [45], syphilitic gummas [46], cryptic vascular malformations of the spinal cord [47], Lyme’s disease [48], soft tissue infections in immunocompromised patients [38], blastomycosis of the cervical spine [49], spinal histoplasmic granuloma [50], painless thoracic epidural empyema [51]. Also with cervical spondylosis [52], esophageal sclerotherapy and crack cocaine abuse [53], post-traumatic arachnoiditis [54], aortic coarctation with subsequent aneurysm of the anterior radicular artery [55, Figure 3. Somatosensory evoked potentials. Upper recording: right and left median 56], paraneoplastic subacute necrotic mynerve stimulation (wrist). The morphology of the sensory nerve action potential (Erb’s elopathy [57], and after coronary artery point) is well structured on both sides. Subcortical and cortical activities are absent after left median nerve stimulation. The parietal N20 is present, although diminished bypass graft surgery [58]. after right median nerve stimulation. Note that cervical leads and readings could not Diagnosis is generally straightforward be obtained because of local trauma. Lower recording: right and posterior tibial nerve with the use of spinal MRI and the assisstimulation (ankle). The sensory nerve action potential (SNAP) and the lumbar N24 are tance of evoked potentials [59]. Evoked normal and symmetrical, cortical activities are bilaterally well-structured but there is a marked P1 latency delay after left ankle stimulation. potentials provided valuable assistance in our patient. al., it is reported that 70% of patients with BSS become Outcome is encouraging. BSS syndrome has the independent in daily living and 80–90% regain bowel best prognosis of any of the incomplete spinal cord and bladder function [62]. syndromes. In a study by Poolard et al. in 412 paAlthough the classical BSS is seldom seen and a tients with traumatic, incomplete, cervical spinal cord variant of BSS (often called BSS plus) is more commoninjuries, and an average follow-up period of 2 years, ly observed, good knowlegde of the local anatomy and younger patients and patients with the BSS had a betpathophysiology may lead to rapid identification and ter prognosis [60]. Similar favorable results have been treatment [63]. reported previously by Peacock et al. and Roth et al. [4, 61]. In a review of the literature by Kirschblum et

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Address for Correspondence Philippe Hantson, MD, PhD Department of Intensive Care Cliniques universitaires St-Luc Avenue Hippocrate, 10 1200 Brussels Belgium Phone (+32/2) 764-2743, Fax -8928 e-mail: [email protected]

European Journal of Trauma 2004 · No. 6 © Urban & Vogel