Traumatic Brown-Séquard syndrome.

Sir,

Stab wounds of the spinal cord are rare occurrences and are reported to represent 26% of all spinal cord injuries; motor vehicle accidents and gunshots are responsible for most of them.[1] We present a rare case of particularly violent self-inflicted stab injury with the steel weapon transfixing in an exceptionally precise and forceful way, the neck and the spine.

A 72-year-old woman with a long term history of major depression attempted suicide by stabbing herself in the anterior neck. She was brought to our Emergency Department with a knife still deeply stuck in the jugular notch. She was alert, quiet and calm and clinical examination revealed neither cardiorespiratory nor neurological deficit. On CT-scan the blade penetrated transversally the anterior neck, displaced the trachea and the oesophagus avoiding all major vascular structures, pierced the vertebral body at Th1 level and traversed the spinal canal with its tip lodged in the left lamina of the first thoracic vertebra [Figure 1]. A surgical intervention was performed in order to explore the wound and remove the blade from the vertebral soma; all great vessels and the trachea were preserved and a small lesion of the oesophagus’ serosa was treated by simple stitches. After extubation, hoarsness was observed and a left vocal cord paralysis due to a lesion of the recurrent nerve was documented by fiberoptic laryngoscopy. Moreover, a left spastic hemiparaplegia and an asymmetric sensitivity impairment with right preponderance below Th4 level occurred, a condition known as incomplete Brown-Séquard syndrome. MRI revealed myelopathy with haemorrhagic components at Th1-2 level. Despite early rehabilitation and intensive physiotherapy, no neurologic improvement was observed at 6 months.

Figure 1

This 3D CT-reconstruction shows the blade that pierces through the vertebra till the posterior arch

Stab injuries of the spine are rare, and usually inflicted from behind; most commonly they involve the cervical and upper dorsal spine and two-thirds of victims[2] show an incomplete cord injury with Brown-Séquard or Brown-Séquard-plus syndrome,[3] less frequently intradural or epidural hematoma. Concurrent injuries can affect every organ. A CT-scan is recommended in order to evaluate the relation between the blade and the anatomical structures, especially the spinal cord, to plan the surgical approach. The aim of surgical treatment is to remove the blade, to decompress the spinal cord if necessary, avoiding secondary spinal damage[1] due to edema or hematoma and to close any dural tears to prevent a cerebrospinal fluid leak.

In patients with incomplete spinal cord stab injuries, prognosis is fairly good with recovery being reported in about 50-60% of incomplete injuries,[1] unless MRI shows a hemorrhage into the cord.[4] Our patient had an unlucky evolution; the secondary lesion after blade removal caused more deficits than the primary lesion with sequelae persisting unvaried at 6 months.

This case presents a unique scenario (to our knowledge only one further case of self-inflicted Brown-Séquard syndrome related to “stab” injury is reported in literature[5]) in which the self-inflicted knife stab was forceful enough to transfix the neck, to pierce the vertebral body and traverse the spinal canal without causing neurological deficits, which eventually occurred after blade removal.