Brown-Sequard syndrome

We describe a rare herniation of the disc at the C2/C3 level in a 73-year-old woman. It caused hemicompression of the spinal cord and led to the Brown-Sequard syndrome. The condition was diagnosed clinically and by MRI six months after onset. Discectomy and fusion gave complete neurological resolution.

J Bone Joint Surg [Br] 1999;81-B:462-3.

Received 26 May 1998; Accepted after revision 6 August 1998

A variety of pathological processes affecting the spinal cord can lead to the Brown-Sequard syndrome (BSS)1-3 which is characterised by ipsilateral loss of motor function, proprioception and vibratory sense, combined with contralateral loss of sensitivity to both pain and temperature.4 It occurs most often after injury to the spinal cord.5

Herniation of a cervical disc has rarely been considered to be a cause of BSS. Since 19281-3,5,6 there have been only 14 reports of a herniated disc causing a hemicord syndrome. In no case did this involve herniation of the C2/C3 disc, itself very rare.

Case Report

An otherwise healthy 73-year-old woman developed sharp pain in the neck radiating to the right scapular region. It responded to oral analgesics. She complained that her right arm had grown progressively weaker over the previous six months with paraesthesiae and numbness. She had numbness and decreased thermal sensitivity on the left side.

Physical examination showed a diminished vibratory sense and proprioception in the right leg, as well as weakness and spasticity. The gait was stiff and spastic. The plantar response was extensor on both sides.

MRI showed a large posterior right paramedian herniated disc at the C2/C3 level which was causing focal right-sided compression of the cord (Fig. 1).

Anterior cervical discectomy was carried out with fusion using an iliac graft.7-10 A large amount of herniated disc material was found to be compressing the right side of the cord. We achieved complete decompression.

Postoperatively, the patient improved rapidly, with the pain resolving first, followed by the numbness and weakness. An early paresis of the hypoglossal nerve recovered spontaneously within a few weeks.

After nine months, MRI revealed minimal epidural bulging. The numbness and weakness had disappeared. The hyper-reflexia had improved and the patient's gait was normal.

Discussion

Intervertebral herniation of a disc is generally believed to be a consequence of a long-term degenerative process in the disc. Herniation of a cervical disc, as a cause of BSS, has rarely been reported since Stookey first observed an association in 1928 (Table I). In the literature the incidence of disc herniation between C2 and C3 is less than 1% (Table II). No association with BSS at this level has previously been reported. We believe that this condition is underdiagnosed. Our patient's symptoms could have been mistaken for those of myelopathy secondary to cervical spondylosis.

As in our case, Stookey'sl patients presented with neck pain. The three patients reported by Finelli et al had numbness of the hand. Classical radicular symptoms were absent, probably because the compression affects the cord itself rather than the nerve root.

Since MRI can indicate accurately the presence or absence of a herniated disc, we advocate its use in all patients with BSS, as well as in those with unexplained hypoaesthesia of a limb.6,12 Even when there are no other symptoms the possibility of a cervical disc syndrome should be kept in mind.5,12 We recommend early surgical intervention.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References

1. Stookey B. Compression of the spinal cord due to ventral extradural cervical chondromas: diagnosis and surgical treatment. Arch Neurol Psychiatry 1928;20:275-91.

2. Jabbari B, Pierce JF, Boston S, Echols DM. Brown-Sequard syndrome and cervical spondylosis. J Neurosurg 1977;47:556-60. 3. Jomin M, Lesoin F, Lozes G, et al. Herniated cervical discs: analysis

of a series of 230 cases. Acta Neurochir Wien 1986;79:107-13. 4. Brown-Sequard CE. De la transmission des impressions sensitives par la moelle epiniere. CR Soc Biol 1849;1:192-4. 5. Rumana CS, Baskin DS. Brown-Sequard syndrome produced by cervical disc herniation: case report and literature review. Surg Neurol 1996;45:359-61.

6. Finelli PF, Leopold N, Tarras S. Brown-Sequard syndrome and

herniated cervical disc. Spine 1992;17:598-600. 7. Espersen JO, Buhl M, Eriksen EF, et al. Treatment of cervical disc disease using Cloward's technique. I. General results, effect of different operative methods and complications in 1106 patients. Acta Neurochir Wien 1984;70:97-114.

8. Klaiber RD, von Ammon K, Sarioglu AC. Anterior microsurgical approach for degenerative cervical disc disease. Acta Neurochir Wien 1992:114:36-42.

9. Lunsford LD, Bissonette DJ, Jannetta PJ, Sheptak PE, Zorub DS. Anterior surgery for cervical disc disease. I. Treatment of lateral cervical disc herniation in 253 cases. J Neurosurg 1980;5:1-11. 10. Mosdal C. Cervical osteochondrosis and disc herniation: eighteen years' use of interbody fusion by Cloward's technique in 755 cases. Acta Neurochir Wien 1984;70:207-25.

11. Murphey F, Simmons JC, Brunson B. Surgical treatment of laterally ruptured cervical disc: review of 648 cases, 1939 to 1972. J Neurosurg 1973;38:679-83.

12. Rosenberg WS, Rosenberg AE, Poletti CE. Cervical disc herniation presenting as a mass lesion posterior to the odontoid process. J Neurosurg 1991;75:954-9.

13. Dubuisson A, Lenelle J, Stevenaert A. Soft cervical disc herniation: a retrospective study of 100 cases. Acta Neurochir Wien 1993;125: 115-9.

14. Houser OW, Onofrio BM, Miller GM, Folger WN, Smith PL.

Cervical disc prolapse. Mayo Clin Proc 1995;70:939-45. 15. Gaetani P, Tancioni F, Spanu G, Rodriguez Y, Baena R. Anterior cervical discectomy: an analysis on clinical long-term results in 153 cases. J Neurosurg Sci 1995:39:211-8.

From the Hospital de Sabadell, Barcelona, Spain

P A. Antich, MD, Senior Orthopaedic Registrar A. C. Sanjuan, MD, Consultant Orthopaedic Registrar F. M. Girvent, MD, Consultant Orthopaedic Registrar Spine Surgery Department

J. D. Simo, Consultant Surgeon Registrar Head and Neck Surgery Department

Hospital de Sabadell, Parc Tauli s/n, DP 08208 Sabadell, Barcelona, Spain.

Correspondence should be sent to Dr P. A. Antich.

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