Brown Sequard Syndrome | Internal Medicine 💊

right today we are going to talk about Brown Squad syndrome Brown Squad syndrome is a clinical situation which is produced by the Hemy section of the spinal cord uh even though Brony cord syndrome in a classical sense is not very common right but still it appears very frequently in exams why it appears in exams so frequently because to truly understand the brown SE quad syndrome uh examiner is checking that do you know what what are the tracks on one side of the spinal cord what are ascending system descending system what is the position of the track what is their function and when those tracks are damaged or crushed or injured what changes in the body appear right so let's start uh discussing from the normal structure of spinal cord very briefly right that what is the normal structure of spinal cord uh we draw it here I make our transaction of the spinal cord and here is your gray matter spinal canal this is which is this part poster hor Anor horn posterior horn and Anor horn and there can be lateral depending upon the level of spinal cord section and here is okay just a minute yes this is yes dorsal column what is this dorsal column and right and left and here is your lateral column or funiculus lateral funiculus and here is interior funiculus and naturally here are interior Roots right and here are posterior root with dorsal root gangon right now what really happens in uh Bron seart syndrome that there is damage to the half Hemi section of the spinal cord or half of the spinal cord let's suppose damages in this area right why such kind of damage should be there classical example is stabbed wound right or there can be injury by a bullet injury or there can be Dart or kick or any type of fracture here in vertebral spine which basically dislocated fracture damages half of the spinal cord so when half of the spinal cord is damaged the clinical situation is called Brown sart syndrome this is also called hemisection of the spinal cord but complete hemisection is rare most of the patient who come to your clinical practice they have a partial damage to the half of the spinal cord so we can say Brown seart syndrome can be complete Brown sequart syndrome when there's a complete hemisection of spinal cord or it can be partial what partial Brown seart syndrome when there is a damage to one half of one half side of the spinal cord but not completely now what will happen to the patient after this once half of the damage card is half of the spinal cord is damaged let's start system by System right that we have a patient and one system or second or third when they're damaged what happen let's suppose here is a a draw person this is cerebral cortex midbrain pawns Medela and here is spinal cord and let's suppose that of course this is the center of the spinal cord interior what is this interior spinal interior median fissure right now let's suppose that there's damage in the cervical cord and this has damaged yes of course there's no such clean cut leens but we just think of that that this damage to spinal segment C5 6 7 8 and T1 you know that this interior RI from this area Supply the breakel plexes or they Supply the Upper Limb let's suppose someone got bullet injury a stab wound here right and this part of the spinal cord has been crushed or damaged now what will be the changes in patients sensory and the motor system right for understanding that let's start that normal how in spinal cord system goes up we talk about first of all dorsal column system right I will draw it here dorsal column system now let's suppose this is supplying the lower limb the supply is coming from the lower limb and here is let's suppose it is upper LM now in dorsal column which Sensations go actually fine touch yes fine touch vibration proprioception proprioception propioception which goes from the Doral system this is basically conscious propioception first of all what is prop reception what is proception position a sense of position right for example with your closed eyes you know which part of the body which limp in the air is in which position right so this is the sensations are coming through a system which is called propioception propioception is or we can say the sensations which are coming from locom motor system Sensations which are coming classically from the muscles and from the joints and from the ligaments tendons right uh muscle spindles they all comprise of the proprioception classical example of proprioception I can tell you that your brain knows all the time what is the position of different parts of the body in the air all the time either you are consciously aware or not for example when you walking did you take your both legs off the ground sometime try to take both when you're walking the central nervous systems understand which part of the leg is it in with position if one is is going to the ground other is lifted up is that right so all the sensations which are coming from the locomotive system we call them proprioception and there are two types of proprioception some part of the proception go to cerebral cortex this is called conscious proception for example when a woman is doing Cat Walk she's very much aware of her movements am I right so that is to that is conscious proception is that right then another part lot of protic information is going to the cerebellum where automatic calculations are going on about the body part positions and tension in different muscles tension in ligaments and tension in the GGI tendon organs right that is called unconscious proception now in dorsal column conscious proper reception go we determine the sense of position right when you are aware of your postural posture then not only fine Touch goes by dorsal column system sense of vibration goes sense of property reception goes what else goes by dorsal column system two point discrimination yes two point discrimination twoo discrimination is actually very fine sense when you stimulate let's suppose on my hand if you stimulate at two points if I'm with the closed eyes and you stimulate with two pins right of course if the significant distance between the pins I will know that I'm being stimulated or touched at two points but you keep on bringing the two points of stimulation closer and closer in the end nervous system will perceive as one stimulation or one touch point right so ability of nervous system to differentiate that two points on the skin are touched very closely but there are two not one point this is called two point discrimination right this two Point discrimination is very high in the on the lips tongue that is why so sens so many Sensations from this area right and also from the fingertips and two point discrimination is very poor on the back is that right as much you enjoy kissing the lips you don't enjoy kissing the back why yes why Sensations are less here sensory nerve endings are very high concentration highly dense the fingertips highly dense but in some other area it is less so what I'm saying that fine touch or tactile stimulation can be perceived and when there are two tactile stimulations very close to each other but you still perceive them as two independent stimulations we call it two point discrimination then another information which goes from the dorsal column that is form perception let me tell you what is form perception please you come here do your hand like this and close your eyes and can you tell me what I have put in your hand uh this is a board eraser okay it is whiteboard eraser good keep your eyes closed can you tell me what is now uh marker marker now how did he do he was not only feeling the touch of the substance right he was feeling the touch pressure he could feel the form texture all this information is going by the dorsal colum system all this information is going by the D colum system in central of system in cerebral cortex it is processed and after the processing he can he's able to recognize familiar subject objects or subjects familiar objects right what is put in his hand right so this is also dependent on dorsal column system is it right please sit this is also called stereognosis this sensation is also called stereognosis so from the dorsal column what are the sensation fine touch two point discrimination vibration sense of position of proper reception and and form perception now all these are going by the dorsal column is that right let me show how it goes let's suppose from the leg these first order neurons come here and from here first order neurons goes upward and they are traveling upward and they will end up into nuclei in the lower Mida is there lower mid from the legs this is fulus graus going and this will end up into nucleus graus from here second order neurons will go to the opposite side and they will go upward and in the what is this ventrolateral nucleus of Thalamus ventrolateral nucleus of Thalamus and third out neuron eventually take the information to somato sensory cortex is that right now you can see that this information ascended ipsilaterally within the spinal cord from dorsal root ganglion right the information which was supposed to go to right go to the higher level it was traveling ially this was from the lower part of the body let's suppose this is from Upper Limb and this will also add first order neurons and second order neurons and from here third order neuron now you see actually from lower LM this is fulus graus going on from upper LM this is or upper upper part of the body it is fulus patus fulus patus am I clear similarly from the other side information will come from the left side and it will enter here and it will first neuron Ascend I laterally and here they will end up into the nuclei and they will cross on the opposite side and in the same way eventually they will read right and this is from where upper part of the body and this is also going in the same fashion and cross and reach upward now what we see dorsal colon system this dorsal colum system within the spinal cord is ascending ipsilaterally and second order neuron these are the nuclei uh what is this nucleus nucleus graus and what is this nucleus catus right graus fulus Gress from the graceful legs from the graceful legs right so anyway so these Crossing is called internal arade FIB fibers and eventually reach here now you imagine if you cut let's suppose there's damage on this side of the spinal cord right here in this diagram now I can show that from the right side this is the fulus what is this gracas and what is here vus catus and in the same way graculus and catus right now actually these are dorsal column system and they are taking information from if lateral side right column is bringing information from the right side and left column is taking information from the left side now very simple thing if you make a cut here what will happen it's very simple what will happen that if cut has been made here then if see laterally these columns are taking information from the same side let's suppose my right hemisection is done here if right side hem section is done here what will happen the dorsal column system on the right side is cut and right side which fulus are cut fulus gulus and fulas and then information coming from lower part of the body and upper part of the body going to the dorsal column cannot be taken to the central nervous system and these patient will lose these Sensations if see laterally is that right below the level of Lon right come here on this diagram so we can say if this was the leg not very romantic leg but anyway it is just a leg and this is suppose are upper upper limbs right so you can look at here now this was your dorsal column system going up it is cut over here and what is this dorsal column system on the opposite side and here was the dorsal column system coming ipsilaterally and D dorsal column system coming on the other side now you can see one thing they were supposed to cross from this side and this which was coming here here they were supposed to cross on this side now what you can see when this is this part of the spinal cord at cervical level is crushed right this actually uh these Sensations are lost from which LM not to the contralateral LM but only to the ipsilateral LM right so what we say in brown SE cord syndrome or in the Hem section of the spinal cord when dorsal column is damaged or it is cut or it is traumatized then if see laterally below the level of Leon here is the Le below the level of lean patient will lose which Sensations dorsal simply dorsal column Sensations dorsal column Sensations now what are the dorsal column Sensations patient will lose ha touch fine touch vibration sense sense of position two point discrimination and form recognition so if I'm the patient and if my this part of the spinal cord is damaged then in for example right lower LM there's loss of dorsal column Sensations am I clear to everyone this is one thing in opposite limb dorsal column Sensations are intact is that right yes what is your question is the stereognosis same thing as form form perception yes yes stereognosis and form perception is the same right now let's come back so what this is one thing clear right now we talk about the another pathway which is let spinothalamic pathway now spinothalamic pathway is different than the dorsal column pathway spinothalamic track I'm going to show here by the there are two spinothalamic track which which are taking information from the spinal cord to the thalamus spinothalamic tract one is lateral and other is Interior right so here I draw the lateral spinothalamic track I will tell you exactly what it how it is formed and what it is doing here is lateral spinothalamic track and here is in this interior of funiculus there is yes interior interior spinal thalmic track now these green these are spinothalamic track first we'll see how they are formed and then we'll see what they're doing and then we'll see once they're injured what happen is that right so let's We Draw It Here spinothalamic track again here is your what lower Lim and here are your upper lims now what you can see here actually first of all I will show you the pain pathway pain and temperature pathway pain and temperature pathway from lower LM first order neurons are coming here they enter dorsal root gangan they enter here and terminate from the level of Entry very right second order neurons start and they cross to the opposite side they cross to the opposite side and from here this fiber will go upward right they will end up into Thalamus vpl nucleus and go contralateral side it means these pain fibers pain and temperature fibers which are ascending into what is this lateral spinothalamic tra right these pain and temperature fibers they entered from here now it's from Upper Limb right and from here also they crossed and went up right so left side fibers will cross at the level of entry in the spinal cord wherever the enter in spinal cord they slightly go obliquely upward I will show you later right they go upward and cross and Ascend on the contralateral side in the same way if we talk about the right lower LM the five p and temperature fibers will come from here right they will enter yes and cross to the opposite side and then go upward from upper LM from the right side now the fiber similarly come they end up here and cross opposite side and go upward now what is the important thing to understand that in lateral cortical spino sorry spinothalamic pathway and lateral spinothalamic pathway pain and temperature is information is modalities are taken up but pain and temperature fibers again I'm repeating at the point of entry right what happen the fibers cross contralaterally so they ascend contralaterally is that right so pain and temperature from the right lower limb will enter in spinal cord and Ascend which part of the spinal cord left side of spinal cord and in the same way pain and temperature from left side of the body will enter in the final card but the crossover at the level of Entry or one or two segment up and then they will Ascend on the right side so it is very important thing that dorsal column modalities dorsal column modalities they came enter into spinal cord and they ascended upward ifil laterally dorsal column modalities dorsal column Sensations enter into spinal cord and they did not cross over they ascend ipsilaterally but pain and temperature Sensations when they enter into spinal cord they cross over and Ascend contralaterally this is very important point to understand is that right this is one thing secondly there is crude touch I told you dorsal column sensation was taking which sensation fine touch fine touch you can feel with the pin and crude touch crude touch can be patient can perceive it by the cotton ball you touch right crew touch Sensations come from one limb enter into spinal cord and they also go contralaterally but interior funiculus where in interior yes funiculus so it means crude touch fibers right they also when they enter they cross over at the level of Entry but they ascend upward through interior funiculus right don't call it gross touch it is not gross touch it is crude touch if you tell a woman about gross touch she will not be very happy so talk about crude touch it is taken from which fibers interior spinothalamic now come here so this was your what was this lateral spinothalamic and this was interior spinothalamic lateral were taking which Sensations pain and temperature and interior taking crud touch now you have seen that this this is called spinothalamic system interior and lateral together they are just called spinothalamic system so we can say spinothalamic system can take pain in temperature and crude touch is that right and spinothalamic fibers which are going upward they're taking information from the contralateral side as in information entered and crossed over clear now we come over here in this diagram in this patient let's suppose this is spinothalamic information coming what is this information coming spinothalamic now it will cross from here and then go upward Contra laterally and pain and temperature and crud touch entered from the lower limb from here and again it crossed and then went contralaterally upward now you can see in browny Quad syndrome what will happen when dorsal columns and dorsal column are traumatized there is loss of below the level of Leon look at this below the level of Leon dorsal column Sensations are lost ipsilaterally but pain and temperature Sensations or spinothalamic Sensations or we can say pain in temperature and crude touch Sensations crude to touch along with tickle and itch spinothalamic system classically we can say it takes P paint temperature and gross not gross crud tou okay but if you really want to be more additions you can say spinothalamic system takes not only pain temperature and crude touch but it also takes the itching sensations of itch and also tickling tickling tickling Sensations right okay now come back here so when there is half of there's Leon on half of spinal cord hemisection on the right side right and right spinothalamic system is damaged this is right spinothalamic system is ascending fibers are damaged here but these fibers are originally coming from the opposite side so pain and temperature sense pain and temperature sense along with the crude touch will be lost in contralateral side below the level of Le below the level of Leon pain temperature and crude touch will be lost on contralateral side am I clear now let's talk about here is the Leon and what happened below the Leon in Sensations only I'm going to talk about only sensory system right again if see laterally what were these fibers dorsal column system dorsal column medial lisal system right now dorsal column sensation they are lost if see laterally right on other side from from right limb Leon is on right side right limb you lose dorsal column sensation in left limb dorsal column Sensations will be intact why because from the left limb Sensations are going laterally and they escape the Leon because they are on the other side they escape the Leon so this will be very strange situation in my right lower limb I cannot feel fine touch I cannot feel the vibrations I cannot feel the sense of position right and I cannot feel the two point discrimination or form perceptions fine modalities the dorsal column modalities but dorsal column modalities on the left side will be intact because both came and went if see laterally here on the right side it is damaged but left side it escaped the Leon but when we talk about pain and temperature and crude touch and tickling and itching these are spinal going through spinal helic track at the point of entry they cross over so right Sensations go to the left side and left uh spinothalamic sensation come to the right side left come to the right side and when they're ascending upward if Leon is here so what will happen Sensations spinothalamic Sensations from lateral C spinothalamic tract and interior spinothalamic tract when they are cut on the right side Sensations are lost on the left side so left limb will lose pain and temperature crude touch itching tickling things like that and crude right opposite to that in the right limb pain and temperature fibers have escaped on the opposite side so escape the Leon crude touch will also escape the Leon so in the right limb if see laterally what Sensations will be intact pain and temperature will be intact gross touch no crude touch will be intact right is it clear now I want to just make a little test from you now be alert okay I have a injury on cervical cord hem section on the right side right dorsal column Sensations will be lost on which side below the Leon where below the Leon right side and pain and temperature sensation and crude touch below the Leon will be lost left side left side very good and if I have Leon on the left side then dorsal column Sensations are lost on the left side very good left lower LM and if Leon is on the left side then pain and temperature are lost on the right side clear this is one way to look another way to look at this that let's suppose I'm the patient hem section of the right spinal cord at cervical level hemisection of right now if you what are the findings in the right limb s sensory findings and what are the findings on the left limb I will say if right L is there first of all dorsal columns and sessions on the right side are lost but pain and temperature and crw touch or right side are intact on left side in this patient on the left side dorsal column Sensations are intact and pain and temperature Sensations and crw touches lost am I clear there's no problem right now look at the level of Leon I'm just dealing with the sensory system now right level of Leon what happened below the level of Leon we have seen what happened at the level of Leon at the level of the Leon what was these fibers entering what were these D dorsal column and here was pain and temperature which was supposed to go to the opposite side but actually at the level of Leon whatever Sensations were entering here they are crushed compl so at the level of not only dorsal column Sensations are lost but spinothalamic Sensations are also lost is that right let me tell you that at the level of Leon I'll make it a more clear diagram for you okay I'm just making a very simple diagram this is the dorsal column system going yes if laterally dorsal column system going if laterally am I clear this is spinothalamic system which crossed and went contralaterally and from here spinothalamic system crossed and went contra laterally is it clear yes is it right now lateral C now in this area supp this is lower limb Upper Limb here were dorsal root gangon now this point you need to understand these were two dorsal column Sensations coming right and they were supposed to go to the same side here is it right and these are your pain and temperature Sensations which are supposed to cross over to the opposite side but actually because there is damage here what will happen all the sensations which are entering here all the sensations which are entering at the level of the Leon they are damaged so at the level of Leon patient will have what problem complete complete loss of Sensations dorsal column Sensations are lost as well as pain and temperature Sensations are lost now we come back if I'm that patient and cervical Leon is there C5 to T1 the1 now what will happen all the sensations which are coming from my Upper Limb dorsal column Sensations as well as pain temperature and crude touch at the point of entry they are damaged so will I have any Sensations in Upper Limb No so at the level of Leon there will be complete anesthesia Ipsy laterally there will be complete cutaneous anesthesia it laterally am I clear so in this patient what we have learned the right hemisection at cical level now only we are talking about sensory system at the level of Leon there's complete anesthesia below the level of Leon if see laterally dorsal colum sensation lost right and below the level of Leon contralaterally pain and temperature and crude touch lost any question it's clear Thank God now we come to another thing there's another system which is concerned with the unconscious property reception and that system is called spino Cal system right let's talk about that spino cerebral system now if we talk about spinal cerebral system let me make a diagram here let's suppose here is your brain stem midbrain pawns medella and here I enlarge okay and here is your now here is your cerebelum what is it cerebelum and here are your cereal pental Superior cereal pental yes middle cereal penal and inferior cereal penal is it right now how the sensations go from the spinos cereal from spinal cord Sensations go to the cereum AL actually there are two Pathways here behind here is dorsal spino cere barel and here it is interior spino cere barel here it is yes dorsal spinos barrel and here it is interior spinal Barrel right now how the sensations go these Sensations are again proceptive Sensations right which are coming from the locomotor system but they are unconscious property reception remember through dorsal column the property reception which was going upward that was conscious proception but in spinal cereal system proprioceptive information going to the cere Alum ISC unconscious prop reception now fibers come here this is dorsal spino cereal tra here fibers enter right fibers enter and from here second order neurons start which go ipsilaterally they go ipsilaterally and from here they will go upward and through the what was it inferior CLE fiber will go to theum it means the unconscious prop perception which is going upward through dorsal or posterior spinos barel track that is going ipsilaterally that is going ipsilaterally even from this side I can bring so this is going for what is this from here dorsal column right d and these fibers will also go upward but they will gosal am I clear and now if in the transsection if this is damaged dorsal spinal cereberal tract then it means unconscious proception from ipsilateral side which was going to cellum is lost is that right now this unconscious proception which was going upward if laterally through the dorsal spinos baral track it was concerned with the movement coordination when we are making movements the coordination of different movements that coordination work is done by cereum and information is going to cerebelum here I have shown dorsal spinal cereal tra now if this is damage if this track is damaged look here then from where we lose the information if Catal information is lost or contralateral information is lost ifil lateral so on the below the level of Leon this is below the level of Leon ifil laterally we lose the sensations unconscious prop perception which we going to cereum so cereum become blind to the position of the limb or body on its lateral side below the level of Leon so it cannot coordinate the movement on the right side and in coordinated movement if they are produced on the right side we call them dyslexia what we call them disia so we can say due to the during the Hem section of the spine spal cord when there's damage to the posterior or dorsal spinal baral tract then ipsilateral disia is produced am I clear yes no question now we come to Interior what is this spinal cereal track interior spinal C barel track fibers are very naughty fiber a lot of twist they make they're not as simple they enter like dorsal column and go upward and go on the same side of Calum no these fibers let let me show you these are fibers which are going for these fibers enter after the entry they go contralateral and from here they go upward where they have gone Superior cereal pedal and from there within the Calum they cross back within the Calum they cross back now you see these fibers information started from the right side but it ascended on the left side but again again again crossed back and came to the right cereum it's a little twisty thing you can say this a double cross how double cross first cross at the level of Entry then Ascend on the opposite side then second cross within the cerebellum in the same way the sensations which are coming from the left side now you can understand for they will go for which interior spinos Bell track coming from the left they should go to the right and then through the right they go upward and what is this Superior cereal pral and then come on this side now it has a clinical implication what is the clinical implication if injury is on the right spinal cord right side of spinal cord hemisection on the right side then dorsal what is this D dorsal spino cereal track as well as vental spinal cereal track both are damaged both are damaged but dorsal was taking information from the ifil lateral and vent was taking information from the contralateral limb the damage to the dorsal track SP which track spino damage to the dorsal track will produce DX on the ipsilateral limb below the level of Leon but damage to the ventral tract will produce dxa in contralateral is that right so now we have added one more thing that in this patient where there was cervical spinal cord hemisection what will happen patient is having yes dyslexia problem patient will have dxa in the right lower limb due to damage to the posterior spinal track and may have DX on the left side due to Interior spinal cereal track am I clear so patient will have double daxia but remember one thing these patients have very severe daxia you know why the reason being conscious prop perception is lost below the level of Leon conscious prop perception is lost due to Dorsal column damage and unconscious prop reception is also lost due the due to the spinal cereal system and double loss of Sensations right or prop reception conscious and unconscious produces sphere dyslexia in theal side am I clear any question up to this are they both related with uh anterior and posterior are they both related with the dyslexia yeah actually listen spino cerebral system spino cell system is taking information from lower limb and Upper Limb to the cerebellum and this information is taken to the cerebellum to inform the cerebellum about the position of Upper Limb and lower limb and also inform the cerebellum about the tension in the muscles tension in the ligaments tendons and Joint capsules and cerebelum compute all that information right and that computation it determines what is the position of a specific part of a lymph in the space and if it is moving in which direction it is moving what is the rate of change of information which is coming from the prop receptive system and even it can calculate in the future that if movement continues for example tension keep on increasing with the same velocity in the muscle and GGI tendon organ what will be the position of the limb in few milliseconds is that right now what happens by this information cereum is able to coordinate you come over here I will do a little experiment with you stand Here Close Your Eyes now about his body position he does not have visual information but do you know where is your right hand it is up or down up okay now now it's up or down down okay and now it's upward okay he didn't look at it cerebellum is Computing information from muscle stress length tension in the muscles GGI tendon organs capsules and the ligaments right okay now I'll do another thing close your eyes can you with right F index finger can you touch your nose tip okay it means he when he was moving he was knowing where is his finger he moved from there he was also knowing where he is his nose now take it slowly there now on the way cereal is calculating if it is in right direction or not and now now it will reach he didn't look at visual information was not there it means Calum is receiving the what is this all information now do one thing I put your this finger in the air bring the other hand and same finger okay thumb of the this is right hand thumb touch the left thumb to the right thumb how could he do okay I'm separating it you again touch them rapidly now cellum was telling what was the position initial positions of both thumbs cellum was calculating and then when it was moving it Calum was calculating the velocity now do it very rapidly with Clos eyes now he misc corrected then he will correct Calum actually when he did Fast he went wrong then Calum suddenly detected position is not the desired then it corrected it so cerebellum does the function of coordination thank God for cerebelum when you are walking you don't take your both legs by chance by mistake off the ground is that right because cereum knows which part of the body in the space is how oriented thank you please right so let's come back so what happens when dorsal when dorsal what is this spinal cere track is damaged if lateral incoordination of the movements occur so it's see lateral dxa below the level of Leon and when ventral spary Barrel track is damaged it was taking information from contralateral side so contralateral DX or in coordination of movement below the level of the lon yes you have a question res or not okay listen you come here you will see come here he's saying that if it over shoot can it resist or not come here rapidly rapidly my friend it's okay your dress is beautiful don't worry don't worry just cover a little yes okay now listen uh do one thing just I'm doing with closed eyes you bring those your index finger rapidly tip to tip very rapidly okay very good now just a minute yes close your eyes because I don't want visual do it as fast as possible you a mistake and then corrected what happened that computation could not go so fast and actually he made a mistake but came to know oh desired position was this and it is not a desired position it corrected but if you go slowly now you go slowly you will not make a mistake no more slowly I hope your cereum is not drunk slowly very slowly yes now it is I think your is undergoing some emotional uh please have a seat okay yes will there be anyia yes will there be any yes there will be all features of Cal dysfunction will be there but remember D texia or Axia can be sensory Axia which is due to failure of sensory information going to Calum or thisx or taxia maybe due to primary Leon of the cereum that information is coming but it cannot compute that is called cerebral dysrexia is that right and uh it may be due to Let's suppose vestibular system because information come through dorsal column system to Calum and also come from spinal cerebral system right if these systems are damaged we call it sensory dysrexia if cereum itself is damaged then we call it cereal disia and if vestibular system which which also tell about the kinetic movements and also about the balance is vestibular system is damaged and cereum cannot get enough information or correct information and patient develop in coordination of movement we call it we call it vestibular dxa is that right in hemisection of spinal cord what kind of dysrexia can be seen sensory DX am I clear so these were sensory Leons I will sum up the sensory Leons first of all we'll see what happened at the level of Leon and then we see what happen below the level of Leon I'm talking about only sensory findings at the level of Leon yes dorsal column sensation lost uh pain temperature and Sensations lost spinal cereal unconscious property deception lost so actually we can say at the level of Leon all the sensations which are coming at the level of Leon are lost is that right now below the level of Leon that is the important understanding what Sensations are coming ipsilaterally dorsal colum sensation lost if laterally and spinothalamic sensation lost contralaterally dorsal column Sensations are what fine touch vibration two point discrimination sense of position or conscious prop perception and stenosis or form perception all these are classically you should remember at least three dorsal column sensation minimum you should remember fine touch vibration and position these are laterally right but if Catal limb has pain and temperature Sensations intact and crew touch intact because those sensation entered and cross over and escaped the Leon now below the level of Leon contralateral side which Sensations are lost spinothalamic Sensation that isolateral system Sensations what are those Sensations pain temperature and crude touch is that right but on contralateral side dorsal column Sensations are intact am I clear right so in this patient Upper Limb all sensation lost if see lower limb dorsal column sensation lost contralaterally lower limb pain temperature and crude touch lost is that right now another thing uh Sensations which are lost contralaterally they are not they are one or two point segments below the level of Leon let me explain it how it happens just a minute this is the right these were the sensations which were going yes what were these Sensations dorsal column Sensations which go what IFC laterally right is it clear and here is our what is this this is our Leon is that right okay pain and temperature sensation now look at the point of entry they actually obliquely go and then go upward is that right so at every point of entry they go obliquely in the same way here the sensations which are coming they are after entry at the point of entry they become oblique one or two segments they ascend and then go upward is that right now look at here at the level of lean at this point pain temperature lost dorsal column lost but opposite side here pain and temperature which was crossing that is lost is that right but at the level of Leon exactly opposite side it will come and it will cross and maybe spared this is the point to understand at the level of Leon p and temperature and crude touch when they entered they became oblique and they might Escape the Leon and then they cross upward so due to this reason what really happens in the patient that contralateral side loses pain and temperature one or two segment below the lon because fibers which are entering at the level of Leon obliquely cross if they were going straight then they will be also damaged am I clear to everyone so if I make a diagram like this this is a beautiful man and I'm talking about sensory losses yes for example Leon is here right and here was your beautiful I'm making a very large spinal cord this was the center right at the level of Leon everything lost dorsal column sensation as well as spinothalamic sensation below the level of Leon if see laterally which Sensations are lost dorsal column right but uh pain and temperature if see laterally Escape is that right then dorsal column sensation on the opposite side are intact right but pain and temperature Sensations from the opposite side they cross and they are caught is that right and at the level of Leon everything is lost but pain and temperature loss on the opposite side because fibers do a little oblique everywhere they do little oque oblique entry after entry they become oblique so damage is one to two loss of sensation pain and temperature is one or two segment or three segment below the Leon is that right now we make this man more simple way now you will tell me what Sensations are lost below the Leon dorsal column Sensations Leon is on right side left side is okay okay then uh what sensation are lost here pain and temperature but pain and temperature is lost up to this level right but this dorsal column Sensations are lost up to the level of Leon Plus in the level of Leon also and at the level of Leon pain and temperature is also lost so what is the important point we have already discussed it so many times at the level of Le all Sensations lost complete anesthesia ipsilaterally below the level of Leon ipsilaterally dorsal column sensation lost below the level of lean contralaterally pain temperature crude touch loss but one or two segment below the Leon and due to failure of dorsal column sorry dorsal spino tract which goes ipsilaterally upward dorsal spinal Cal tract there is dxa on the right side and due to ventral here also ventral what spinal cere track is damage so there just TXI on the opposite side so this was about the sensory damages or sensory findings in a patient with classical hemisection of spinal cord right uh after a break we'll discuss about the motor finding right so now we are discussing the second part of Brony quad syndrome in previously part what we discussed that when hemex of spinal cord is done what will be the sensory pattern of sensory losses in the body in this part I will discuss what will be the pattern of motor losses after the hemisection of spinal cord a very brief introduction to upper and lower motor neurons right let's suppose here is your central nervous system and midb brain pawns Medela pawns Medela and here is your spinal cord here is your upper Lim and here is your beautiful lower limb okay and of course suppose there's a muscle in the Upper Limb on both side and their muscles in the lower limb on both sides right now lower motor neurons are those neurons which start from the spinal cord or motor nuclei of brain stem and directly in our we the add neuromuscular Junction so these are lower motor neurons neurons is that right now upper motor neurons the most important are cicos spinal Pathways which are paramal Pathways as well there are other upper motor neurons also which I will not discuss now other upper motor neurons like vestibular spinal pathway or rubos spinal pathway or reticul spinal pathway or lios spinal pathway teos spinal pathway we will not discuss them right now we'll only discuss about the cicos spinal pathway which is the one of the most important a promotor neurons now corticospinal fibers which they basically make Crossing at lower medala right and they are originating from cerebral cortex right now look at it from the cerebral cortex corticospinal fiber descend through the coronal radiator and pass through the internal capsule then then through the brain stem and lower part of the midd they make a crossing and then after the crossing they will descend if laterally and inate the lower motor neurons is that right in the same way these fibers which have done the crossing they are also moderating the behavior of lower motor neurons am I clear now when there is section of the spinal cord here let's suppose now look here very carefully these red neurons are lower motor neurons and green neurons are upper motor neurons let's suppose here was your cervical card now what will happen at the level of Leon if laty lower motor neurons are lost at the level of Leon I laterally lower motor neurons are lost and when these lower motor neurons are lost it means that if the Leon was from C5 6 7 8 T1 so it means the lower motor neurons which were going to the braal plexes or innovating the muscles of the Upper Limb they have lost their action right so the clinical manifestation of motor system assessment if you do the motor system assessment on this upper Lim there will be manifestation of lower motor neuron type of Leon what kind of Leon will be here lower motor neuron type of Leon type of Leon I will discuss that later but simply you just see lower motor neuron is lost but below the level of Leon below the level of Leon if laterally do you think lower motor neuron to the lower limber uh damage no below the level of Leon below the level of Leon lower motor neurons keep on supplying their muscles what is the real loss the real is loss is that lower motor neuron below the Leon have lost their upper motor neuron control you see this was upper motor neuron which was coming from here and it was destined to or it was going to regulate the lower motor neuron in lower Lim but while it was passing through the Leon it has been damaged this has been damaged so what is the real motor problem below the level of Leon the real problem is not the loss of L motor neuron lower motor neurons are there the real losses the loss of influence of upper motor neuron on the lower motor neuron is that right and now lower motor neurons behave abnormally just imagine upper motor neurons are like controlling fathers controlling fathers lower motor neurons are naughty Sons lower motor neurons are the naughty Sons so when the father dies when the upper motor neuron die initially lower motor neurons undergo spinal shock when father dies for few days Suns will be depressed the naughty Suns will be depressed underactive but after some time due to the loss of controlling influence of the dad because there's no control they start hyperfunctioning and maybe starting disturbing the family and the community and many other things I don't want to mention is that right same thing happened here here unfortunately here lower motor neuron died Suns died and here suns are intact in this part of the community but fatherly control is lost so after initial spinal shock in which lower motor neurons are underw workking they gradually recover and then they start hyperfunctioning and clinical special type of clinical features develop in this area right in which lower motor neurons are functioning abnormally because of the loss of upper motor neuron influence we call that this part of the body or this part of the motor system in the body is displaying what kind of Leon upper upper okay it should be green upper motor neuron type finding or Leons or we can say now again I will repeat at the level of Leon a ER and lower both are damaged but manifestation is there's no no control control on the muscle by lower motor neuron so we say the lower motor neuron syndrome is there and Upper Limb what will be there in this patient lower motor neuron syndrome because lower motor neuron coming out has been crashed and lower limb lower motor neuron are intact there is actually loss of influence of upper motor neuron so clinical manifestations which develop here they are upper motor neuron type here the sons are dead here father is dead and son after initial shock and grief they recovered and then they became hyper am I clear now so in this patient with hem section of spinal cord the motor findings in at the level of Leon will be lower motor neuron type below the level of Leon motor abnormalities will be of upper motor neuron loss type now what are classical features of lower motor neuron damages number one there is sere loss of mass loss of mass of muscle is that right there is spere loss of power right and then there's spere loss of tone so in the what happen that this patient has an upper Lim there is sphere loss of mass spere loss of power and there is sere loss ofone tone so upper Lim will become F flaccid hypotonia flaccid we also call it flaccid paralysis what do we call italis flaccid paralysis right and of course uh because all the sensations entering here are lost as well as lower motor neurons are not there so there a reflexia a reflexia which reflexes in Upper Lim will be lost along with that the muscle when they do not have the control by the lower motor neuron right they become over sensitive to Esty choline and they become overall over sensitive even with little tapping they show fasiculations localized contractions and they may have f culations fasiculations are localized contractions in the muscles which have lost lower motor neuron control right so F culation and if you look at microscopic level we call it fibrillations now again at the level of Leon right what is the real damage okay let me show you at the level of Leon in the spinal cord here was lower motor neurons which were coming out interior horn maybe this root is damaged or of course this interior gray horn is damaged VOR gray horn is damaged and even ventral root may be damaged of course that will result into lower motor neuron loss to the muscles involved lower motor neuron syndrome there's s loss of mass loss of power especially in specific muscles sere tone loss reflexes are lost deep tendon reflexes are lost and fasiculations should be there all this together is called lower motor neuron syndrome is that right and lower motor neuron syndrome will be seen in Upper Limb at the level of Leon you will see lower motor neuron syndrome and below the level of Leon you will see upper motor neuron syndrome is that right any question up to this but yes sir is there tror and fation similar no there are tremors are different thing fasiculations are different thing now we come down trors are actually oscillating movements right and fasiculations are uh due to lower motor neuron loss and postseptic membrane on the muscles develop hypers sensitivity even with mechanical stimulation it will start Contracting a trors are very different there may be trors due to hyper adrenaline in the body or there may be tror due to Basil ganglia dysfunction in parkinsonism or there may be traas due to cerebral dysfunction so traas is a very different thing right okay let's come back so what I'm talking about now what about lower limb of this person motor loss in the lower limb this lateral cortical spinal pathway which was coming down has been this was lateral cortical spinal pathway which was coming from contralateral side this has been damaged here here yes is that right and this is loss of upper motor neuron influencing the muscles going to the leg is that right so what will happen to this number one there will be as compared to this there will be slight loss of mass because lower motor neurons are action they are in action and they are producing some trophic substances to maintain the mass of the muscle so in lower motor neuron there SP loss of muscle here is mild loss of mass but power is lost so paralysis is there paralysis is there but this paralysis is with hypertonia because reflexes here are over functioning Alpha motor neuron as well as gamma motor neurons both are overfiring due to loss of the moderation from the higher centers so this will produce paralysis with hypertonia Hyper Tonia tone is up and this tone uh is very special type of hypertonia in which if you there's initially to the passive movement lower limb to the passive movement initially there is few resistance and more you pull more resistance and sudden loss of resistance then again let me tell you what kind of hypertonia is in there can you come here okay uh in this Lim there was hypotonia in hyp onia what happen that you leave it relaxed hyp hypotonia hypotonia first that there's no resistance to the passive movement hypotonia in hypertonia there is extra resistance extraordinary resistance to the movement this is hypertonia extraordinary or excessive resistance to the passive movement of the limb hypertonia but in if lower motor NE if upper motor neurons are damaged lower motor neuron system develops uh abnormalities in which hypotonia is strange that when you pull it initially it is very difficult to pull excessive then suddenly it gives way this is called class knifing when you try to open a knife right some types of knife yes when you try to open the knife initially it is difficult then suddenly it open so we say this type of hypertonia in which there is initially excessive resistance to the passive movement followed by sudden loss of resistance this type of hypertonia is called clasp knifing of spasticity ority Spas City so what we say that in lower Lim syndrome there's flacid paralysis in lower in upper motor neuron syndrome here was lower motor neuron syndrome here the upper motor neuron what kind of paralysis there paralysis if muscles lose the power and they are hypotonic what is it lower motor neuron type of damage but if muscles lose the power but they are hyperonic and it means this this is upper modern neuron type of damage so here there is a loss of power with hypertonia and reflexes are increased hyper refle reflexia right hyper reflexia and then there is positive babinsky sign bin Signs Now I will not go into detail of binski sign because all these have discussed in detail in the lecture previous lecture on upper motor neuron and lower motor neuron and their liens I will just tell you briefly right that in a patient where the Leon is at cervical cord upper limp shows the signs of lower motor neuron damage and lower limb or will show the signs of upper motor neuron damage am I clear lower limb will show Upper Limb will show lower motor neuron damage which is sphere loss of mass loss of power in specific muscles loss of tone loss of reflexes and there may be fications below the level of Leon there is paralysis there's mild there may be mild loss of mass but there is loss of power especially in specific movements and spasticity we call it paralysis with Hyper reflexia or clonus and with that binsky upgoing binsky upgoing or we say dorsy flexion of the foot on stimulating the outer part of the foot sole right or there may be we can say upgoing ski or positive bbon ski or dorsy dorsy flection of the foot on stimulation right any question up to this so these are the motor findings ifil laterally right contralaterally what happened no major motor loss power loss but you remember there is anterior spino corticos spinal track let me show you there are two types of cortico spinal TR back another diagram suppose this is a spinal [Music] cord here are lower motor neurons going out right now upper motor neurons type one I told you lateral corticos spinal tract where fibers came and then crossed on the lateral side and while on going down they stimulate the control the lower motor neuron in the same way they will come over here and while going down now this these fibers are coming down in lateral funiculus so they're called lateral cortico spinal Tri but some of these fibers continue directly without Crossing these is and they're descending into interior they're descending into interor interior funiculus and from here at the level of lower motor neuron they cross in the same way this is also interior cicos spinal track and at the this is coming in this area and then crosses to the opposite side so we can say lateral corticos spinal tracts cross at lower medala anterior SP cical spinal tract come down and where they are going to inate the or control the lower mot neuron at same spinal level the cross am I clear now imagine if a is here Fon is here now Contra corticos spinal track which was going to inate the FC lateral muscles these are lost yes right and that will lead to lower motor upper motor neuron type of Liam in in lower limb in my situ my example clear but this uh fiber what was this anterior corticos spinal they are also damaged but they were controlling qura lateral lower LM but they give a very minor control so there there may be minor loss of power in contralateral LM due to loss of interior coros spinal track am I clear so these were the motor losses again I will repeat the motor losses the most important thing I will make a test Leon is at C5 to T1 here on the right side what kind of loss will be in upper motor upper LM right side yes L lower motor neuron type and what kind of loss will be in the right leg up motor neuron is that right now imagine if there's Leon at the left side what type of problem motor problem will be on the left upper LM lower motor neuron type and what type of problem will be left leg upper motor neuron time so you understand it any question there's one more just you have a question sir what happens to the V mot to I'm going to talk about that yes is there going to be any rigidity yeah of course there will be rigidity actually rigidity mean hypertonia hypertonia is of different type there's lead pipe rigidity there's clas knife rigidity clas knife rigidity is called spasticity right for example there's a disease called parkinsonism we develop rigidity in that also but that rigidity is throughout the range of the movement such excessive resistance to the passive movement which is throughout the range of the movement is called lead pipe rigidity but class knife rigidity is that rigidity initially is excessive but then suddenly it disappears there class knifing am I clear okay now we come back so uh now autonomic fibers right especially I should mention about the Horner syndrome right I will make from the side actually here is your beautiful face you do have a tongue and other things also I hope okay now here is hypothalamus with the pitutary system actually from hypothalamus autonomic fibers come down I'm talking sympathetic outflow poly sinapic Pathways come down and as they are going down at T1 level fibers start coming out now these fibers which are T1 T2 to L L1 L1 or L2 right this is sympathetic outflow now actually these fibers which are coming out at T1 section right these fibers which exit out they go upward through the sympathetic chain and the terminate and Superior cervical ganglion from here poing Landing fibers go upward and they supply to the face skin they also supply to the ey they also supply to the dilat pupil they also Supply the superior Taral muscle is that right now what happens if Leon is if Leon is above the T1 for example here then fiber T1 fiber of sympathetic outflow they have lost the stimulation from upper level is that right now in my example I was telling that damage was at C5 6 7 8 D1 so it means in my example the Paras sympathetic downflow sympathetic fibers which are coming down right they have been interrupted due or crushed due to spinal cord hemisection so T1 fibers outflow sympathetic outflow on right side is dysfunctional and that will lead to impairment of sympathetic supply to the face and oculi clinically it will manifest as loss of sympathetic Supply to half of the head and neck right suppose right half I lateral that will produce a clinical situation called horer syndrome already we have a big lecture on horal syndrome which is recorded but I will just mention briefly sympathetic fiber normally act as people P dilator pupilo dilator so loss of sympathetic fibers will lead to pupilo constriction due to loss of pupilo dilator and pupil become miotic so they meosis secondly sympathetic fiber help the levator PP sporus to keep the upper lid elevated and when sympathetic fibers are lost upper lip upper lid eyelid become slightly drooped so we say there's partial toses along with that these sympathetic fibers also Supply the sweat glands on the half of the face so sweating will be lost there no sweating that is called anhydrosis and with that vessels in this area they may dilate and produce rubber or red redness of face in this area all this situation together is called horer syndrome so what is horer syndrome horer syndrome is a condition when half of the face or sympathetic OS sympathetic pathway or sympathetic fibers going to the half of the pH those sympathetic fibers have been dysfunctional right and that will lead clinical to what situation that will lead to meosis with partial tosis and hydrosis and maybe vation on the face right but if Leon is below the T1 then of course hormonal syndrome will not be seen right so now we come in the end again recap what are the causes of hor Hornos no what are the causes of brown SE quart syndrome ham section of spinal cord remember the Clean Cut hemisection is clinically not seen commonly but partial hemisection is seen commonly so patient may have less commonly a classical complete Brony quad syndrome but more commonly patient have partial Brown SE quart syndrome now in brown SE quart syndrome what could be the causes I told you most common is trauma Stab Wound bullet injury Dart cakes then there may be expanding tumors there may be dis prolapse or there may be cervical spond liis loses or there may be multiple sclerosis or there may be militis right yes or septic ambuli is that right now we come to again recap yes we'll put uh two spinal cord levels and see what happens with the H section let's suppose hem section is here this part of spanel cord is lost now dorsal column Sensations which are going up they are lost here what will produce dorsal column sensation lost from if laterally below the level of Leon and also at the level of the Leon then spinothalamic Sensations they were actually yes what was happening they're going contralateral and they are also lost so pain and temperature lost on contralateral side is that right but because at here little bit angulation occur due to that reason it is between one or two segments down then what happen at the level of Leon complete anesthesia below the level of Leon if laterally dorsal column sensation loss contralaterally pain and temperature crud touch lost is that right any question up to this and in this area because lower motor neurons are itself damaged so L lower motor neuron type syndrome and here lower motor neurons are functioning but upper motor neurons which are coming here they are lost so upper motor neuron type syndrome is there and then spinal cere barel damage that will lead to dxas any question no question okay now I will ask and you will tell me we have a spinal cord here we make half section now tell me at the level of Leon at the level of Leon which Sensations are lost all Sensations lost right below the level of Leon ifil laterally dorsal colum Sensations below the level of Leon contralaterally paint temperature very good pain temperature crude touch one or two segments below is that right and due to damage to the posterior spinal cereal tract there is dxa inal ifal area below the level of Leon and due to damage to ventral spinal cereal tract there disia to the contralateral area below the Leon and motor dysfunction at the level of Leon all the motor fibers which are going down they are damaged so what kind of Damages lower motor neuron damage and below the level of Leon lower motor neuron functional upper motor neurons are damaged while they were passing through the Leon so what kind of syndrome is there upper motor neuron type of syndrome is there class dismas

Channel: Dr. Najeeb Lectures

Views: 242,606

Keywords: neuro medicine, hemiparaplegic syndrome, brown sequard syndrome, brown sequard syndrome usmle, brown sequard syndrome explained, internal medicine, brown sequard syndrome physiology, spinal cord injury, brown sequard syndrome anatomy, brown sequard, sequard, hemisection of spinal cord, hemisection of spinal cord physiology, brown sequard syndrome features, brown sequard syndrome dr najeeb, brown syndrome, brown sequard syndrome lecture, usmle, dr najeeb, brown sequard explained

Id: nTvPn3UzpFk

Length: 83min 27sec (5007 seconds)

Published: Sat May 09 2015