Brown sequard syndrome Nithika MP 2 Final.pptx

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1. A 42-year-old woman was brought into the emergency department after a stab injury on the right side of the posterior neck from a knife . The patient complained of hemiparesis of the right-side extremities. Neurological examination showed ipsilateral hypoesthesia of the right side and contralateral loss of pain and temperature sensation. MRI showed spinal cord hemisection at the level of C5,C6. Spinal cord was slightly swollen at the site of penetration what could be the probable diagnosis ? CASE HISTORY

2. BROWN SEQUARD SYNDROME NITHIKA MP 1ST YEAR MBBS 2023-2024

3. SYNOPSIS Introduction History Causes Clinical features Complications Management Diagnosis

4. Also known as transverse hemisection syndrome or Hemiplegia syndrome What Is brown sequard syndrome ? Functional hemisection of the spinal cord involving one of its lateral half

5. through an observation of a sea captain who had been stabbed in the neck HISTORY Discovered by Brown sequard in 1849

6. Non traumatic Causes: Disc herniation cyst Cervical tumor Multiple Sclerosis Radiation Decompression sickness CAUSES Traumatic causes : Gunshot wounds Stab wound Motor vehicle accident Blunt trauma Fractured vertebrae

7. CLINICAL FEATURES At three levels Above the level of lesion At the level of lesion Below the level of lesion Four pathways Dorsal column -medial leminscal pathway Anterolateral Spinothalamic Pathway Spinocerebellar tract Pyramidal tract

8. DORSAL COLUMN MEDIAL LEMINSCAL PATHWAY Carries sensations of Fine touch Vibration Pressure Proprioception Two point discrimination Crossing over to the opposite side at the level of lower medulla

9. Site of lesion First order neurons Nucleus gracilis and cuneatus DORSAL COLUMN MEDIAL LEMINSCAL PATHWAY Ipsilateral loss of sensation at and below the level of lesion

10. Crossing over to the opposite side at the level of next 2 or 3 spinal segment itself SPINOTHALAMIC PATHWAY Carriers sensations of Pain Temperature Crude touch Tickle and itch sensations

11. Site of lesion First order neurons 2nd order neuron Contralateral loss of sensation below the level of lesion(2or 3 segments below the actual level) SPINOTHALAMIC PATHWAY

12. SPINOCEREBELLAR TRACT Carries non sensory proprioception impulses from muscles , tendons and joints Ventral Dorsal Crosses at the level of spinal cord to the anterior white column and the ascends Ascends through the dorsal part of the lateral white column

13. First order neurons Dorsal Site of lesion 2nd order neuron As each tract carries impulses from both the sides There is no complete loss of sensation SPINOCEREBELLAR TRACT Ventral

14. DESCENDING TRACT PYRAMIDAL TRACT Carries motor impulses for the initiation of voluntary movement Crossing over to the opposite side at the level of lower medulla

15. PYRAMIDAL TRACT Site of lesion First order neurons 2nd order neuron First order neuron -Upper motor neuron 2nd order neuron -Lower motor neuron At the level of lesion -Flaccid paralysis ,muscles hypotonic,decreased power and tone Below The level of lesion - Spastic paralysis,clasp knife type of rigidity,Exaggerated deep reflexes.

16. ABOVE THE LEVEL OF LESION Band of cutaneous hyperaesthesia on the the same side of lesion due to irritation of sensory fibres Twitching of muscles

17. AT THE LEVEL OF LESION O n the same side Sensory changes Co mplete anaesthesia occurs Motor changes Autonomic Changes Complete lower motor neuron paralysis Complete and permanent vasomotor paralysis

18. On the opposite side Sensory changes Motor changes Some loss of pain ,temperature and crude touch sensation nil AT THE LEVEL OF LESION

19. Pain ,temperature and crude touch remain unaffected On the same side Sensory changes Motor changes Temporary loss of vasomotor tone BELOW THE LEVEL OF LESION Spastic type of paralysis(upper motor neuron paralysis) Sense of position ,movement, vibration and tactile discrimination are lost on the same side Autonomic Changes

20. On the opposite side Sensory changes Complete loss of pain ,temperature and crude touch Kinesthetic sensation, fine touch, tactile localization, tactile discrimination remain unaffected Motor changes No paralysis of muscles BELOW THE LEVEL OF LESION

21. Touch - Below the level of lesion Touch fibers have dual pathway in the spinal cord Fine touch ,tactile localisation ,tactile discrimination by Tract of Goll and Burdach hence they are lost in the same side of,lesion Crude touch by Spinothalamic tract ,which is lost on the opposite side There is no complete loss of touch in the same side ,but it is impaired on both the sides

22. Constriction of pupil on the same side - p u pillary dilator fibers coming from the medulla are damaged REGIONAL PECULARITIES Hemisection of the cervical region Paralysis of the diaphragm on the same side -phrenic nerve involvement. Loss of biceps ,triceps , supinator and pronator jerk - C5,C6,C7 segments are involved

23. Hemisection in the lumbar region Loss of knee jerk - involvement of L3,4 spinal segment Disturbances in micturition Hemisection in the lumbosacral region Loss of control over sphincters of urinary bladder and anus

24. Horner’syndrome When the lesion of spinal cord above T1 spinal segment, sympathetic chain may be affected resulting in Horner syndrome

25. COMPLETE SECTION BROWN SEQUARD SYNDROME Complete loss of sensation below the level of lesion Complete loss of voluntary movements below the level of lesions Loss is immediate and permanent Partial loss of sensation on each side below the level of lesions Ipsilateral loss of voluntary movements below the level of lesion The onset is slow and the symptoms appear gradually

26. 1.Trauma history 2.Physical examination 3.Laboratory investigations Purified protein derivative and sputum for acid-fast bacilli test chest-X-ray MRI DIAGNOSIS

27. Urinary stasis + paralysis of the urinary bladder causes stones, precipitates urinary tract infection . COMPLICATIONS Decubitus (postural) ulcers develop due to compression of skin circulation Negative protein balance due to breakdown of protein Calcium withdrawal from bone lead to hypercalcemia, hypercalciuria

28. Prevention of infection of urinary bladder by periodic catheterization 2 . Administration of large doses of glucocorticoid preparation, to help reduce inflammation 3 . Rehabilitation, physiotherapy of muscles and counselling Management

29. Functional hemi-section of spinal cord Summary At the level of lesion Complete anesthesia Lower motor neuron paralysis Above the level of lesion Cutaneous Hyperesthesia Below the level of lesion Partial loss of sensation Upper motor neuron paralysis

30. 1.Guyton and Hall textbook of medical physiology – 3r d South Asian Edition 2.GK Pal textbook of physiology - 3 rd Edition 3.Ganong Review of medical physiology – 26 th edition 4.Berne and levy physiology – 7 th edition 5.AK Jain textbook of physiology – 10 th edition 6.Sarada Subrahmanyam Textbook – 6 th edition REFERENCES