Journal of Korean Society of Spine Surgery Brown-Séquard Syndrome and Cervical Vertebral Fractures after Blunt Cervical Trauma in a Traffic Accident - A Case Report - Seung-Pyo Suh, M.D., Won Rak Choi, M.D., Chang-Nam Kang, M.D. Ph.D. J Korean Soc Spine Surg 2017 Dec;24(4):252-256. Originally published online December 31, 2017; https://doi.org/10.4184/jkss.2017.24.4.252 Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: +82-2-483-3413 Fax: +82-2-483-3414 Copyright 2017 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.krspine.org/doix.php?id=10.4184/jkss.2017.24.4.252 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.krspine.org
Case Report J Korean Soc Spine Surg. 2017 Dec;24(4):252-256. https://doi.org/10.4184/jkss.2017.24.4.252 Brown-Séquard Syndrome and Cervical Vertebral Fractures after Blunt Cervical Trauma in a Traffic Accident - A Case Report - Seung-Pyo Suh, M.D.*, Won Rak Choi, M.D., Chang-Nam Kang, M.D. Ph.D. Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea *Department of Orthopaedic Surgery, Sung-Ae Hospital, Seoul, Korea Study Design: Case report Objectives: To report a case of Brown-Séquard syndrome after blunt cervical trauma. Summary of Literature Review: Brown-Séquard syndrome is a rare disease characterized by hemisection of the spinal cord, and it shows the best prognosis of the various types of incomplete spinal cord injuries. Materials and Methods: A patient with Brown-Séquard syndrome that occurred after a traffic accident was followed up for 2 years and 6 months. Results: We observed normal recovery of motor strength, but sensory impairment and deep tendon hyperreflexia remained. Conclusions: Brown-Séquard syndrome is known to have a good prognosis, but in this case, the neurological abnormality did not fully recover; therefore, we report this rare case and present a review of the literature. Key words: Brown séquard syndrome, Cervical vertebrae, Fracture, Spinal cord injury 브라운-세카르증후군은척수의반절단을특징으로하며가장흔하게는척추외상및종양질환에서발견된다. 척수손상측의편마비, 고유수용감각손상과반대측의통각, 온도감각의손상을특징으로한다. 발생원인으로는척수압박을일으키는외상, 추간판탈출, 경막외혈종, 종양및혈관손상등이있다. 발생빈도는전체외상성척수손상의약 3% 를차지한다. 1) 저자들은 25세여자환자에서탑승자교통사고로인해발생한경추골절과동반된브라운-세카르증후군에대해정기적추시관찰중으로 2년 6개월추시결과를보고하고자한다. spinal injury association; ASIA) 에따른운동신경등급은좌측 30점, 우측 50점에해당하였다. 우측제 5경추이하피부분절의촉각, 통각및온도감각의저하와우측항문주위감각저하가관찰되어 ASIA 침통각검사 (pin prick score) 는좌측 56점, 우측 31 점이었고 ASIA 가벼운촉각검사 (light touch score) 는좌측 56 점, 우측 31점에해당하였다 (Fig. 1). 이외좌측상완이두건및좌측슬개건의심부건반사가항진되어있었다. 단순방사선촬영및전산화단층촬영상제 3경추는추체, 좌측후관절, 후궁및극돌기골절이있었고, 제 4경추는추체, 양 증례보고 기저질환이없는 25세여자환자가내원당일교통사고로발생한경추부통증및좌측상지운동약화를주소로응급실에내원하였다. 교통사고당시운전자뒷자석탑승자로사고당시상황은기억하지못했다. 과거력상외상병력, 선천성기형및종양등은없었으며, 이학적검사상후경추부의전반적인압통을보였다. 신경학적검사상좌측주관절굴곡, 신전, 수근관절신전, 수지굴곡및외전모두 MRC 기준척도 (medical research council) 등급 1로관찰되어미국척수손상협회 (american Received: July 6, 2017 Revised: July 12, 2017 Accepted: November 14, 2017 Published Online: December 31, 2017 Corresponding author: Chang-Nam Kang, M.D., Ph.D. ORCID ID: Chang-Nam Kang: https://orcid.org/0000-0002-4633-3391 Seung-Pyo Suh: https://orcid.org/0000-0002-1457-8984 Won Rak Choi: https://orcid.org/0000-0002-0854-7567 Department of Orthopaedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04753, South Korea TEL: +82-2-2290-8485, FAX: +82-2-2299-3774 E-mail: cnkang65@hanyang.ac.kr 252 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Korean Society of Spine Surgery Brown-Séquard Syndrome after Blunt Cervical Trauma Fig. 1. The patient s medical record with an assessment using the American Spinal Injury Association (ASIA) impairment scale at the initial visit. A B Fig. 2. Simple radiographs of the cervical spine. The anteroposterior view (A) shows a fracture of the left superior articular process of C3 (arrow). The lateral view (B) shows fractures of the body of C4 (arrow) and the spinous process of C4 (arrowhead). www.krspine.org 253
Seung-Pyo Suh et al Volume 24 Number 4 December 31 2017 A B Fig. 3. Computed tomography of the cervical spine. The axial view of C3 (A) shows fractures of the body (arrow), left superior articular process, and lamina (arrowhead). The axial view of C4 (B) shows fractures of both lamina (arrow). The midsagittal view (C) shows fractures of the body of C4 (arrow) and the spinous process of C4 (arrowhead). There was no spinal canal encroachment. C 측후궁및극돌기골절, 제 5경추와제 6경추는우측추궁근골절이관찰되었으나척추관침범은관찰되지않았다 (Fig. 2, 3). 자기공명영상 T2 강조영상에서제 3경추-제 4경추간좌측척수내부고신호강도병변이관찰되어척수손상을시사하였다 (Fig. 4). 임상양상및방사선학적검사상외상에의한좌측제 3경추- 제 4경추간척수손상으로발생한브라운-세카르증후군에합당하였다. 2) 다발성경추골절에대하여수상후 1일째윤조끼보조기고정을시행하여수상후 8주째까지유지하였다. 브라운-세카르증후군에대하여는응급실내원시좌측 ASIA 운동등급은 30점에서 30분경과시점까지 38점으로호전되어빠른신경학적회복을보이고있어서고용량스테로이드요법은시행하지않고, nefopam 30 mg intravenous injection daily, tramadol/acetaminophen 18.75/162.5 mg per oral, twice daily 및 pregabalin 300 mg per oral, twice daily 를통한약물치료를시행하면서면밀히경과관찰하였다. 수상 5주째운동저하는모두 MRC 기준척도 (medical research council) 5로회복되었으나우측제 8경추이하피부분절의촉각, 통각및온도감각저하가지속되었고, 제 2흉추-제 10흉추간피부분절의촉각및통각은회복되었다. 수상 8주째전산화단층촬영추시상골유합진행을확인하고윤조끼보조기를제거하였으며, 우측제 2 흉추-제 12흉추피부분절의촉각및통각이회복되었다. 수상 6개월째전산화단층촬영추시하여골유합을확인하였고, 우측제 8경추-제 2흉추피부분절의촉각, 통각은부분적으로회복되었으나온도감각저하는지속되었으며, 제 2흉추-제 4요추슬관절상방피부분절의촉각, 통각이회복되었다. 수상 1년째우측하지의촉각및통각은모두회복되었으나우측제 8경추피부분절이하온도감각저하및제 8경추-제 2흉추피부분절 A B Fig. 4. The axial (A) and midsagittal (B) view of T2-weighted magnetic resonance images. The arrow indicates high signal intensity in the left side of the spinal cord at the C3-C4 level. 의촉각및통각의부분저하는지속되었으며이는수상 2 년 6 개월추시까지도계속유지되었으며, 좌측상완이두건및슬개 254 www.krspine.org
Journal of Korean Society of Spine Surgery Brown-Séquard Syndrome after Blunt Cervical Trauma 건심부건반사의항진역시호전되지않고지속되었다. 고찰 브라운-세카르증후군은 1849년 Charles-Edward Brown- Séquard 에의해처음기술되었다. 3) 손상동측의운동, 고유및진동감각소실과손상반대측의통증, 온도감각소실을특징으로한다. 운동소실과고유및진동감각소실은각각피질척수로, 배측주의손상에의한것으로이는하부연수에서교차하기때문에척수손상동측에서나타난다. 통증및온도감각소실은척수시상로손상에의한것으로, 이는각신경절의척수로이행하는부위의 1~2분절상방에서교차하기때문에척수손상반대편에서나타난다. 4) 손상부위는흉추부에서 75% 로가장흔하며, 경추부에서 17%, 요추부에서 8% 의빈도를보인다. 5) 예후는모든척수손상형태중가장좋은것으로알려져있으며, 약 75~90% 의환자들이퇴원시자립보행의회복을보인다. 1,6) 외상성인경우가장흔한원인은관통상이며, 둔상에의해서도드물게발생한다. 관통상인경우기능및신경학적손상의회복이둔상에의한경우보다좋지않은예후를보인다. 7,8) Roth 등에의하면, 상지및하지의운동약화의분포가기능회복에가장중요한예측인자였으며, 상지에서하지보다운동약화가심한경우퇴원시보행확률이높고, 일상생활기능점수가더높았다. 6) Little 과 Halar 는수상 1~6개월째수의근력및보행의회복을보인다고발표하였다. 9) 본증례에서는경추부둔상에의한브라운-세카르증후군환자였다는점, 하지근력은정상이었으며상지근력저하만보였다는점이좋은예후를예측할수있는인자였으며, 수상 5주째정상근력으로의회복을관찰할수있었다. 척수내가측피질척수로 (lateral corticospinal tract) 및가측척수시상로 (lateral spinothalamic tract) 내부에는내측에서외측으로경추, 흉추, 요추, 천추신경다발이순서대로위치한다. 10) 본증례에서근력저하가상지에만국한된점, 2년 6개월추시에서통각및온도감각의저하가상지에서더뚜렷하며완전회복이되지않았던점에서좌측척수내에서주로내측손상이발생했던것으로해석된다. 본증례에서저자들은경추부둔상에의해드물게발생하는브라운-세카르증후군환자 1예를경험하였고, 수상 5주째근력의정상회복을관찰하였으나우측제 8경추피부분절이하온도감각, 촉각및통각의저하와우측상완이두건및슬개건의심부건반사항진은 2년 6개월추시까지도회복되지않아서문헌고찰과함께증례를보고하는바이다. REFERENCES 1. McKinley W, Santos K, Meade M, et al. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007;30(3):215-24. DOI: 10.1080/10790268.2007.11753929. 2. Miranda P, Gomez P, Alday R, et al. Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. Eur Spine J. 2007 Aug;16(8):1165-70. DOI: 10.1007/s00586-007-0345-7. 3. Brown-séquard E. Experimental and Clinical Researches on the Physiology and Pathology of the Spinal Cord, and some other parts of the Nervous Centres. Am J Med Sci. 1855 Jul ;30(59):161-5. DOI: 10.1097/00000441-185507000- 00023. 4. Johnson S, Jones M, Zumsteg J. Brown-Séquard syndrome without vascular injury associated with Horner s syndrome after a stab injury to the neck. J Spinal Cord Med. 2016;39(1):111-4. DOI: 10.1179/2045772314Y.0000000297. 5. Garcia-Manzanares M, Belda-Sanchis J, Giner-Pascual M, et al. Brown-Sequard syndrome associated with Horner s syndrome after a penetrating trauma at the cervicomedullary junction. Spinal Cord. 2000 Nov;38(11):705-7. DOI: 10.1038/sj.sc.3101062. 6. Roth EJ, Park T, Pang T, et al. Traumatic cervical Brown- Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes. Paraplegia. 1991 Nov;29(9):582-9. DOI: 10.1038/sc.1991.86. 7. Mataliotakis GI, Tsirikos AI. Spinal cord trauma: pathophysiology, classification of spinal cord injury syndromes, treatment principles and controversies. Orthop Trauma. 2016;30(5):440-9. DOI: 10.1016/j.mporth.2016.07.006. 8. Oller D, Boone S. Blunt cervical spine Brown-Séquard injury. A report of three cases. Am Surg. 1991 Jun;57(6):361-5. 9. Little JW, Halar E. Temporal course of motor recovery after Brown-Sequard spinal cord injuries. Spinal Cord. 1985 Feb;23(1):39-46. DOI: 10.1038/sc.1985.7. 10. Lim E, Wong Y, Lo Y, et al. Traumatic atypical Brown- Sequard syndrome: case report and literature review. Clin Neurol Neurosurg. 2003 Apr;105(2):143-5. DOI: 10.1016/s0303-8467(03)00009-x. www.krspine.org 255
Case Report J Korean Soc Spine Surg. 2017 Dec;24(4):252-256. https://doi.org/10.4184/jkss.2017.24.4.256 교통사고로발생한경추부둔상에의한경추골절과브라운 - 세카르증후군 - 증례보고 - 서승표 * 최원락 강창남한양대학교의과대학정형외과학교실, * 성애병원정형외과연구계획 : 증례보고목적 : 경추부둔상에의해발생한브라운-세카르증후군증례를보고하고자한다. 선행연구문헌의요약 : 브라운-세카르증후군은척수반절단을특징으로하는드문질환으로, 불완전척수손상중가장좋은예후를보인다. 대상및방법 : 교통사고로발생한브라운-세카르증후군환자를 2년 6개월간추시하였다. 결과 : 근력은정상으로회복되었으나감각저하와심부건반사항진은지속되었다. 결론 : 브라운-세카르증후군은좋은예후를보이는것으로알려져있으나본증례에서는신경학적이상이완전회복되지않아서문헌고찰과함께증례를보고하는바이다. 색인단어 : 브라운세카르증후군, 경추, 골절, 척수손상 약칭제목 : 경추부둔상에의한브라운 - 세카르증후군 접수일 : 2017년 7월 6일 수정일 : 2017년 7월 12일 게재확정일 : 2017년 11월 14일 교신저자 : 강창남 서울시성동구왕십리로 222 한양대학교의과대학정형외과학교실 TEL: 02-2290-8485 FAX: 02-2299-3774 E-mail: cnkang65@hanyang.ac.kr 256 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.