Journal of Orthopaedic Surgery 2013;21(3):372-4

Cervical epidural haematoma causing BrownSequard syndrome: a case report
Arvind G Kulkarni,1,2 Kushal Nag,1 Sambhav Shah1,2
1
2

Saifee Hospital, Mumbai, India
Bombay Hospital, Mumbai, India

ABSTRACT
Brown-Sequard syndrome secondary to compression
of the spinal cord by an epidural haematoma following
minor trauma is rare. A 65-year-old woman presented
with neck pain and sudden onset hemiplegia with
contralateral anaesthesia. Magnetic resonance
imaging showed a haematoma in the epidural space
in the C3 to C5 levels. She underwent open-door
laminoplasty for evacuation of the haematoma. At the
2-year follow-up, she had regained normal sensations
and a neurological grade of 5/5.
Key words: Brown-Sequard syndrome; hematoma,
epidural, spinal

INTRODUCTION
Brown-Sequard syndrome is characterised by motor
paralysis on the same side as the spinal cord lesion
and deficits in pain and temperature sensation on the

opposite side. This is known as ipsilateral hemiplegia
and contralateral pain and temperature sensation
deficits (anaesthesia). The loss of sensation is caused
by the sensory nerve fibres of the spinothalamic tract
crossing the spinal cord. The most common cause is
penetrating trauma such as a gunshot wound or stab
wound to the spinal cord. Other causes are tumours,
epidural haematomas, tuberculosis, and multiple
sclerosis. We report on a 65-year-old woman with
Brown-Sequard syndrome secondary to a cervical
epidural haematoma following minor trauma.
CASE REPORT
In October 2008, a 65-year-old woman presented
with sudden-onset hemiplegia of the right side and
anaesthesia of the left side. The patient did not have
any previous trauma or medical co-morbidities (such
as hypertension or diabetes mellitus), but gave a
history of sudden voluntary hyperextension of the
neck.
On clinical examination, the motor power of the
right-side limbs was grade 0/5. There was anaesthesia

Address correspondence and reprint requests to: Dr Arvind G Kulkarni, Bombay Hospital, New Wing, Medical Research Centre,
Room Nos. 206, 2nd Floor, 12, New Marine Lines, Mumbai, 400020, India. Email: drarvindspines@gmail.com

Vol. 21 No. 3, December 2013

Cervical epidural haematoma causing Brown-Sequard syndrome 373

Figure
T2-weighted magnetic resonance images showing an epidural haematoma (arrows) extending from the C3 to C5
levels compressing the spinal cord.

of the left side below C3. The patient had spasticity
with hyper-reflexia and positive Babinski reflex on
the right side. Her bladder and bowel functions were
normal. She was initially examined by a neurologist
and suspected to have a cerebrovascular incident.
Computed tomography (CT) of the brain was normal.
Magnetic resonance imaging (MRI) of the cervical
spine showed an isointense mass extending from
the C3 to C5 levels compressing the right side of the
spinal cord (Fig.).
The patient underwent open-door laminoplasty.
The spinal cord was compressed by the haematoma
extending from the C3 to C5 levels laterally to the
foramen. The haematoma was evacuated, and
palpations in the spinal cord were immediately
appreciated. Postoperatively, the patient was
immobilised with a hard cervical collar, and
physiotherapy was started. At the 2-year follow-up,
the patient had regained normal sensory functions
and a power of 5/5 in all 4 limbs.
DISCUSSION
About 40% of cervical epidural haematomas do not
have any demonstrable aetiology and are referred to
as idiopathic and spontaneous.1 The diagnosis must
exclude other causes such as neoplasm and systemic
diseases,2 anticoagulant therapy,1 hypertension,3
pregnancy,4 and vascular malformations.3 Cervical

epidural haematoma occurs most commonly in
patients aged 50 to 80 years,5 and rarely in those
younger than 16 years.6 The male-to-female ratio is
1.5:1.5
There is controversy as to whether the source of
the haematoma is arterial or venous. Proponents of
a venous origin maintain that the sudden increase in
intrathoracic and intra-abdominal pressure leads to
the rupture of the thin-walled epidural veins. Injury
to the epidural veins may occur during coughing,
sneezing, defecation, micturition, vomiting, and
coitus.7–9 However, as the epidural venous pressure
is less than the intrathecal pressure, the haematoma
is unlikely to cause Brown-Sequard syndrome.1 In
addition, extreme movements at the cervicodorsal
junction could result in tearing of the arteries. The
high arterial pressure can lead to compression of the
dural sac and clinical syndromes,1 and even an active
bleeding arterial haematoma.10
Acute onset of radiating neck pain is the most
common symptom; the location depends on the
involvement of specific nerve roots and the spinal
cord. The second most common symptom is
gradual weakness of the limbs below the level of
compression.11 Brown-Sequard syndrome as a result
of cervical epidural haematoma is rare.12
Myelography used to be the diagnostic modality
of choice,13,14 but there is a risk of lumbar puncture
and its results are non-specific.15,16 MRI is the
diagnostic tool of choice.17 Spinal angiography may

Journal of Orthopaedic Surgery

374 AG Kulkarni et al.

be useful in planning surgery for patients with a
vascular anomaly. The differential diagnoses include
neoplasia, transverse myelitis, aortic aneurysm,
epidural abscesses, and acute cervical disc herniation.
Hemiparesis at presentation may be confused with a
cerebrovascular incident.18
Prompt diagnosis and surgical decompression
is vital to facilitate neurological recovery, although
recovery without any surgical intervention has

been reported.19,20 Laminectomy is the preferred
procedure; hemilaminectomy or laminoplasty can
also be used depending on the extent and location of
the haematoma.21
DISCLOSURE
No conflicts of interest were declared by the authors.

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