KISEP

CASE REPORT
J Korean Neurosurg Soc 38 :

Brown Sequard Syndrome Resulting from Cervical

Disc Herniation Treated by Anterior Foraminotomy
Yeon-Seong Kim, M.D., Jung-Kil Lee, M.D., Sung-Pil Joo, M.D., Soo-Han Kim, M.D.
Department of Neurosurgery, Chonnam National University Hospital & Medical School, Gwangju, Korea

The authors describe two cases of Brown-Sequard syndrome associated with cervical disc herniation. In both cases, magnetic
resonance images of the cervical spine showed a large paramedian disc herniation at C5-C6 with ipsilateral severe spinal
cord compression. Microsurgical removal of the herniated disc via anterior foraminotomy was performed and complete
decompression of the spinal cord was achieved. Postoperatively, the neurological symptoms recovered rapidly and both
patients experienced a complete remission of their symptoms. Although Brown-Sequard syndrome is rarely associated with
degenerative cervical spine disease, cervical disc herniation should be kept in mind and prompt evaluations are mandatory.
To the best of our knowledge, these are the first reported case of Brown-Sequard syndrome produced by cervical disc
herniation which was treated by anterior foraminotomy.

KEY WORDS : Brown-Sequard syndrome Cervical disc herniation Cervical foraminotomy.

Introduction which was managed conservatively. He was admitted to the

Department of Neurology and treated under the diagnosis

B rown-Sequard syndrome(BSS) involves corticospinal

tract compression resulting in ipsilateral loss of motor
function and spinothalamic tract dysfunction resulting in
of focal infarction, because the brain magnetic resonance
(MR) images showed the presence of a multifocal lacunar
infarction in both basal ganglia, the centrum semiovale and
contralateral loss of pain and temperature sensation. BSS is the periventricular white matter. There was no history of
observed most frequently in association with traumatic trauma to the head or neck. On admission, motor examination
injuries to the spinal cord and extramedullary spinal cord revealed right hemiparesis (grade 4/5), with particular weakness
tumors15,16,18). On the other hand, cervical disc herniation of the intrinsic muscles of the right hand (grade 2/5). On the
has rarely been considered to be a cause of BSS, and only day following admission, his right hemiparesis worsened
27cases have been reported. We report two cases of disc progressively with significant weakness developing in the
herniation at the C5-C6 level with severe hemicompression right leg. Difficulty in urinating was then noted and catheter
of the spinal cord, resulting in BSS. To the best of our insertion became necessary. Finally, 4days after his admission,
knowledge, these are the first reported cases of BSS caused by the patient was referred to our department after the cervical
cervical disc herniation, which were successfully treated by MR images were checked. On admission to our department, a
anterior foraminotomy. neurologic examination revealed diminished sensation to
pain and temperature on the left side below the T10 dermatome.
Case Report Right-arm weakness had progressed to a grip strength of
grade 1/5, and the patient was unable to ambulate because
Case 1 of significant weakness in the right leg, which was consistent
A 56-year-old man suffering from a sudden onset of right with a diagnosis of BSS. The patellar tendon reflexes were
hemiparesis was brought to the emergency room. During the hyperactive bilaterally. Cervical spine X-rays showed diffuse
4days prior to admission, he experienced right shoulder pain, spondylosis, which was most marked at C5-C6. MR images

Received March 2, 2005 Accepted March 25, 2005

Address for reprints Jung-Kil Lee, M.D., Department of Neurosurgery, Chonnam National University Hospital & Medical School, 8 Hak-dong,
Dong-gu, Gwangju 501-757, Korea Tel : +82-62-220-6602, Fax : +82-62-224-9865, E-mail : jklee0261@[Link]

136
 Cervical Disc Herniation YS Kim, et al.

of the cervical sp- nths later, the nu-

ine showed a la- mbness and we-
rge disc herniati- akness had disa-
on at the C5-C6 ppeared and the
level causing fo- patient was able
cal right-sided to return to his fo-
cord compression rmer job as a me-
(Fig. 1A, B). Right dical doctor.
anterior forami-
notomy was per- Case 2
formed to deco- A 47-year-old
mpress the spinal man presented
cord. Using an with a 2-week
operating micros- history of num-
cope, a 5 8mm bness in the left
hole was made hand and left shoulder pain, which subsequently developed
medial to the un- into left hemiparesis. He was then managed conservatively
cal joint with a at a local hospital under the diagnosis of a cerebrovascular
drill. There was a accident, until progressive left leg weakness and ataxia led him
large tear in the to be transferred to our hospital. There was no history of
right posterolat- trauma to the head or neck. The motor examination revealed
eral annulus. A mild weakness of the left arm and a moderate weakness in
large amount of herniated disc material, which had hernia- the left leg with a spastic gait. The patient presented dimini-
ted posterior to the annulus, was found to be compressing shed sensation to pain and temperature in the right arm and
the right side of the cord. The herniated disc fragments were leg, hypesthesia and hypalgesia in the left arm and hyperreflexia
gently removed with a microforceps and complete decomp- of the lower extremities, which were consistent with BBS
ression of the spinal cord was achieved. It was confirmed with combined with radicular symptoms. MR images of the cervical
a blunt nerve hook that no more disc material was remained, spine revealed a large left extradural paramedian disc herniation
and the small hole was packed with thin gelatin sponge. Pos- at the C5-C6 level, with ipsilateral severe spinal cord compres-
toperatively, the patient improved rapidly and was discharged sion and high signal intensity within the spinal cord adjacent
on the 7th postoperative day. One month later, the patient to the herniated disc (Fig. 3 A, B). The patient underwent a
was able to walk without assistance and was found to have left anterior foraminotomy following the same procedure as
slowly regained strength in his right arm. The postoperative that described above. We removed six large disc fragments,
MR images, obtained 1month after surgery, showed complete which had herniated through the annulus tear and complete
removal of the disc fragment and satisfactory decompression decompression of the spinal cord was obtained. The posto-
of the spinal cord (Fig. 2). At the follow-up examination 5mo- perative course was uneventful, with gradual improvement

137
J Korean Neurosurg Soc 38 August 2005

of the patient’s neurological function being observed. The occurs most often after traumatic injury to the spinal cord1).
patient regained normal motor strength and sensation at 2months However, other reports have described the syndrome in
after surgery. Postoperative computed tomograms showed com- association with spinal cord ischemia, infectious and infla-
plete decompression of the spinal cord through the small tunnel mmatory causes including multiple sclerosis, spinal hemo-
(Fig. 4). A follow-up examination at 3months demonstrated rrhages including hematomyelia, and subdural and epidural
only mild left shoulder pain. hematoma18). Cervical disc herniation has rarely been rep-
orted as a cause of BSS. Since the first three cases of BSS
Discussion caused by cervical disc herniation reported by Stookey in
1928, 29cases including our own have been described in

BSS was first described in a patient with hemisection of

the spinal cord as a consequence of a knife injury in
1849. BSS is characterized by ipsilateral loss of motor function,
the literature1-5,7,10,15,16,18-24). According to Jomin et al., the
frequency of BSS caused by cervical disc herniation is 2.6%,
but details were not mentioned in this report14). Another
proprioception and vibratory sense, combined with contra- case was cited by Jabbari et al. in their series, but no details
lateral loss of pain and temperature sensation. Complete for this case were given11). In reviewing the literature, we could
hemisection with classic clinical features of pure BSS, is rare find only 27cases of BSS caused by cervical disc herniation,
and incomplete hemisection causing BSS plus other signs and so our present cases raises the total to 29cases (Table. 1).
and symptoms is more common18). Spasticity and hyperactive Among these 29cases, there were 19males and 10females,
reflexes may not be present in the case of an acute lesion. It whose ages ranged from 25 to 73years (mean 45.1years). The

Table 1. Summary of cases of Brown-Sequard syndrome caused by cervical disc herniation reported in the literature*

138
 Cervical Disc Herniation YS Kim, et al.

disc herniation involved one interspace in 27cases and two of the compressive pathological lesion, while preserving the
contiguous interspaces in 2cases. The disc herniation was at remaining disc as much as possible. The remaining disc can
C2-C3 in 2cases, at C3-C4 in 3cases, at C4-C5 in 5cases, at still function as a mobile unit along with the facet joints12,13).
C5-C6 in 16cases and at C6-C7 in 5cases. There were 10cases Additionally, anterior foraminotomy eliminates the bone fusion
of intradural herniation and 19cases of extradural herniation. or postoperative immobilization13). Although the symptoms of
Intradural disc herniation is very rare and accounts for less BSS were quite severe in our patients, a 5 8mm hole was suf-
than 0.3% of all disc herniations and only 3% occurs in the ficient for adequate decompression of the spinal cord and root,
cervical region2). Only 17cases of cervical intradural disc resulting in a favorable outcome.
herniation have been reported in the literature and BSS was The safety and resolution of MR imaging clearly demonstrates
observed in 10 of these 17cases10). As regards the treatment, its usefulness in evaluating degenerative cervical spine disease17).
all patients underwent surgery after diagnosis. 6patients were Because of the ready availability of MR imaging, the number
treated by laminectomy or hemilaminectomy, 4patients by of contemporary reports of BSS has been increased. Since
anterior discectomy without interbody fusion, 14patients by MR imaging can accurately indicate the presence or absence
anterior discectomy with interbody fusion, 2patients by of a disc herniation, MR imaging is indispensable for the
anterior corpectomy and interbody fusion, 1patient by diagnosis of all patients with BSS, as well as in patients with
anterior discectomy with interbody fusion and laminectomy extremity numbness of unknown etiology. Although BSS is
and our own 2patients by anterior foraminotomy. The pos- rarely associated with degenerative cervical spine disease,
toperative evaluation of the patient's motor and sensory cervical disc herniation should be kept in mind and early
deficits were favorable in most cases, although minor residual evaluation is mandatory, even in the absence of pain or sig-
deficits sometimes were remained. The outcomes of the cases nificant spine radiographic abnormalities. Sometimes BSS
of extradural disc herniation were better than those of intradural can be misdiagnosed as a cerebrovascular accident and diag-
disc herniation. Complete recovery occurred in 9 of the 19 nostic workup can be delayed, because of the similar motor
extradural cases and 3 of the 10 intradural cases. Intradural weakness, as shown in our own cases. Because serious symp-
disc herniation may have a worse effect on the spinal cord toms can progress rapidly, early accurate diagnosis and imm-
than extradural disc herniation, because the intradural fragment ediate surgical treatment should be recommended to prevent
can cause hemispinal cord damage directly. serious morbidity.
In our cases, we performed anterior foraminotomy and
obtained good decompression of the spinal cord. Anterior Conclusion
discectomy followed by bone fusion, with or without a
cervical plate, is the standard surgical treatment for cervical
disc herniation, because it allows easier exposure of and a
direct approach to the pathology, as well as less frequent
B ased on our cases, we emphasize the need for early dia-
gnosis and prompt surgical intervention, in order for
the patients involved to have the best chance of functional
epidural bleeding than the posterior foraminotomy approach13). neurological recovery in cases of BSS associated with cervical
However, the main drawback of this procedure is that the disc herniation. Cervical disc herniation should be considered
functioning motion segment is lost. Consequently, it has in the differential diagnosis of patients with BSS, even in the
been postulated that fusion of the cervical segments produces absence of the typical symptoms. Anterior foraminotomy
an acceleration of degenerative changes at adjacent segments. suffices for the removal of a cervical disc protrusion, without
The common findings of the adjacent segments in the MR the risk of consequent adjacent-segment disease.
images are intervertebral disc herniations, spinal malalign-
ment in both the superior and inferior directions, hypertrophy References
of the yellow ligaments and ossification of the posterior 1. Antich PA, Sanjuan AC, Girvent FM, Simo JD : High cervical disc
longitudinal ligaments8). The rate of symptomatic adjacent- herniation and Brown-Sequard syndrome. A case report and review
of the literature. J Bone Joint Surg Br 81 : 462-463, 1999
segment disease following anterior cervical fusion ranges 2. Borm W, Bohnstedt T : Intradural cervical disc herniation. Case report
from 8 to 25%6,9). Cervical canal stenosis is the most common and review of the literature. J Neurosurg Spine 92 : 221-224, 2000
3. Clatterbuck RE, Belzberg AJ, Ducker TB : Intradural cervical disc
finding in the cervical spine X-rays of patients with BSS herniation and Brown-Sequard’s syndrome. Report of three cases and
produced by cervical disc herniation15). In patients with review of the literature. J Neurosurg Spine 92 : 236-240, 2000
4. Durig M, Zdrojewski B : Intrathecal herniation of a cervical disc : a
cervical spondylotic radiculopathy or myelopathy, anterior case report. Arch Orthop Unfallchir 87 : 151-157, 1977
foraminotomy leads to an excellent outcome without bone 5. Eisenberg RA, Bremer AM, Northup HM : Intradural herniated cervical
disk : a case report and review of the literature. AJNR Am J Neuroradiol
fusion and eliminates the risk of consequent adjacent-segment 7 : 492-494, 1986
disease. Anterior foraminotomy provides direct elimination 6. Emery SE, Bohlman HH, Bolesta MJ, Jones PK : Anterior cervical

139
J Korean Neurosurg Soc 38 August 2005

decompression and arthrodesis for the treatment of cervical spondylotic review of the literature. Spine J 3 : 530-533, 2003
myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg 80A : 16. Kohno M, Takahashi H, Yamakawa K, Ide K, Segawa H : Postoperative
941-951, 1998 prognosis of Brown-Sequard-type myelopathy in patients with cervical
7. Finelli PF, Leopold N, Tarras S : Brown-Sequard syndrome and herniated lesions. Surg Neurol 51 : 241-246, 1999
cervical disc. Spine 17 : 598-600, 1992 17. Kulkarni V, Rajshekhar V, Raghuram L : Accelerated spondylotic changes
8. Goto S, Mochizuki M, Watanabe T, Hiramatu K, Tanno T, Kitahara H, adjacent to the fused segment following central cervical corpectomy :
et al. : Long-term follow-up study of anterior surgery for cervical magnetic resonance imaging study evidence. J Neurosurg Spine 100 : 2-
spondylotic myelopathy with special reference to the magnetic resonance 6, 2004
imaging findings in 52cases. Clin Orthop 291 : 142-153, 1993 18. Mastronardi L, Ruggeri A : Cervical disc herniation producing Brown-
9. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH : Sequard syndrome : case report. Spine 29 : E28-31, 2004
Radiculopathy and myelopathy at segments adjacent to the site of a previous 19. Roda JM, Gonzalez C, Blazquez MG, Alvarez MP, Arguello C : Intradural
anterior cervical arthrodesis. J Bone Joint Surg 81A : 519-528, 1999 herniated cervical disc. Case report. J Neurosurg 57 : 278-280, 1982
10. Iwamura Y, Onari K, Kondo S, Inasaka R, Horii H : Cervical intradural 20. Rumana CS, Baskin DS : Brown-Sequard syndrome produced by
disc herniation. Spine 26 : 698-702, 2001 cervical disc herniation : case report and literature review. Surg Neurol
11. Jabbari B, Pierce JF, Boston S, Echols DM : Brown-Sequard syndrome 45 : 359-361, 1996
and cervical spondylosis. J Neurosurg 47 : 556-560, 1977 21. Schneider SJ, Grossman RG, Bryan RN : Magnetic resonance imaging of
12. Jho HD : Microsurgical anterior cervical foraminotomy for radiculopathy : transdural herniation of a cervical disk. Surg Neurol 30 : 216-219, 1988
a new approach to cervical disc herniation. J Neurosurg 84 : 155-160, 1996 22. Shin MS, Chung BS, Choi HK : A Brown-Sequard Syndrome Resulting
13. Jho HD, Kim WK, Kim MH : Anterior microforaminotomy for from a Ruptured Cervical Disc Herniation. A Case Report. J Korean
treatment of cervical radiculopathy : part 1--disc-preserving “functional Neurosurg Soc 25 : 2365-2367, 1996
cervical disc surgery”. Neurosurgery 51 : S46-53, 2002 23. Sprick C, Fegers S : Intradural sequestration of cervical intervertebral
14. Jomin M, Lesoin F, Lozes G, Thomas CE 3rd, Rousseaux M, Clarisse disk displacement. Nervenarzt 62 : 133-135, 1991
J : Herniated cervical discs. Analysis of a series of 230 cases. Acta 24. Stookey B : Compression of the spinal cord due to ventral extradural
Neurochir (Wien) 79 : 107-113, 1986 cervical chondromas : diagnosis and surgical treatment. Arch Neurol
15. Kobayashi N, Asamoto S, Doi H, Sugiyama H : Brown-Sequard Psychiatry 20 : 275-291, 1928
syndrome produced by cervical disc herniation : report of two cases and

140