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An eponymous reaction to a knife wound

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Q1: Where is the anatomical site of injury and which spinal tracts have been damaged?

A left sided hemisection of the spinal cord at T8 plus bilateral posterior column loss. This is due to the knife track coming obliquely from the right, across both posterior columns of the spinal cord before hemisecting the left side of the cord (see figs 1 and 2). The left sided tracts transected include the corticospinal tract, dorsal column, and spinothalamic tract.

Figure 1

T2 weighted sagittal MRI image of the thoracic cord showing a mixed signal abnormality (arrowed) slightly to the left of the cord at D10, representing the knife track within the cord.

Figure 2

T2 weighted axial MRI image of the thoracic cord showing an area of high signal posteriorly and to the right of the cord, consistent with the track of the knife through the soft tissues (arrowhead). The lesion within the cord is seen again slightly to the left of the midline (arrowed).

Q2: What is the name of this syndrome?

Brown-Séquard syndrome.

Q3: Give three other causes of this syndrome

Other causes of Brown-Séquard syndrome include multiple sclerosis, unilateral disc herniation, extrinsic cord lesions—for example, metastases, epidural haematomata, and unilateral ischaemic lesions of the cord.

Q4: What is the cause of his headache?

The headache is a classical presentation of low pressure headache due to leakage of cerebrospinal fluid from a dural tear.

Q5: How would you treat his headache if the symptoms persisted?

The recommended management for persistent low pressure headache in the context of a stab wound of this nature would be surgical exploration and repair of the dural defect with increased fluid intake. A blood patch or oral caffeine treatment could also be considered.

Discussion

The neurological injury is consistent with left sided Brown-Séquard syndrome.1 One of the points of interest in this case is the bilateral posterior column loss and the left sided Brown-Séquard syndrome, although the point of knife entry was right sided. The explanation is due to the oblique knife injury with the track of the blade crossing the posterior columns from the right and impinging in the left side of the cord (figs 1 and 2). A classical presentation for Brown-Séquard is ipsilateral loss of the corticospinal, posterior column, sympathetic, and spinothalamic tracts.1 Clinically this results in ipsilateral pyramidal deficit with ipsilateral loss of joint position, vibration, and soft touch at the level of the lesion. There is contralateral loss of pain and temperature sensation that manifests itself a few segments below the level of the lesion because the decussating fibres enter the spinothalamic tract a few segments rostrally to the level of entry of the nerve root.

Stab wounds are a common cause of Brown-Séquard syndrome2 with rarer causes including primary or secondary cord tumours, degenerative disc disease, cord ischaemia, inflammatory or infectious conditions—for example, herpetic infections or multiple sclerosis and subdural/epidural haemorrhage (reviewed in Peacock et al3).

The low pressure headache was as a result of continuing cerebrospinal fluid leakage from a dural tear. Low pressure headaches of this nature are also reported after some lumbar punctures and can also occur spontaneously. The classical features are a positional headache that is worse on sitting up; nausea and photophobia may also occur.4 Headaches of this nature may respond symptomatically to increased fluid intake and the use of caffeine compounds. Occasionally epidural blood patches may be useful in plugging the cerebrospinal fluid leak.4

In this case, the patient's low pressure headache resolved spontaneously without the need for surgical exploration of his wound.

Final Diagnosis

Brown-Séquard syndrome.

References

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