(Kiosk 3) Atypical Presentation of Brown-sequard Syndrome Secondary to Cervical Manipulation

Case Diagnosis: 53-year-old female with vertebral artery dissection and epidural hematoma causing Brown-Sequard Syndrome after receiving cervical traction at home.

Case Description or Program Description: 53-year-old female presented to ED complaining of neck pain, right arm weakness and numbness that began after her husband performed cervical traction to her neck. CTA brain/carotid demonstrated left vertebral artery dissection at C5-C7 level. Follow-up MRI cervical spine revealed large dorsal epidural hematoma from C4 to T2 resulting in severe compression of the right hemicord. Patient subsequently underwent hematoma evacuation and posterior decompressive laminectomies and fusion by neurosurgical team.

Setting: Acute inpatient rehabilitation

Assessment/Results: On admission to acute inpatient rehab, physical exam showed right sided hemiparesis involving both the upper (1/5) and lower extremity (0/5), as well as loss of proprioception to the right hallucis. She was also found to have loss of pain, temperature, and light touch on the left side from T1 and below. Her physical exam was consistent with Brown-Sequard Syndrome and ASIA exam confirmed diagnosis of incomplete C2 ASIA D quadriplegia. Functionally, she was non-ambulatory and max for ADLs and transfers.

Discussion (relevance): Brown-Sequard Syndrome is a rare neurological injury secondary to hemisection of the spinal cord with characteristic physical exam findings including ipsilateral weakness paired with contralateral loss of pain, temperature, and light touch. The most common causes include penetrating trauma, ischemia, or tumors. Our patient’s presentation of Brown Sequard Syndrome was unique in that her symptoms began after receiving cervical manipulation at home by her husband. The cervical traction that was applied to her neck likely led to her vertebral artery dissection, causing her initial neck pain. Following the dissection, an epidural hematoma formed and compressed the right half of her spinal cord, which explains her gradual onset of right arm and leg numbness/weakness. Fortunately for our patient, with intensive therapy she regained strength of her right side and became modified independent with ADLs and ambulation.

Conclusions: In conclusion, this case report serves to raise awareness of the dangers of manual manipulation of the cervical spine in a setting where the individual is not a trained medical provider, as this may lead to severe neurological injury.