brown sequard syndrome resulting from compression due to an epidural hematoma is a relatively rare occurrence , more so with a spontaneous history .
she underwent an open door laminoplasty for evacuation of the hematoma . following surgery the patient responded rapidly and currently at 18 months
in the emergency room when a patient is clinically diagnosed as a case of brown sequard syndrome it is important to ask for an mri scan of the cervical spine .
hematoma in the cervical epidural space should be considered in the differential diagnosis of brown sequard syndrome especially in the elderly with history of doubtful trivial trauma .
brown sequard syndrome is an incomplete spinal cord lesion characterized by a clinical presentation reflecting hemi - section of the spinal cord .
this is referred to as ipsilateral hemiplegia and contralateral pain and temperature sensation deficits ( anaesthesia ) .
the most common cause is penetrating trauma such as a gunshot wound or stab wound to the spinal cord , however spinal tumours and blunt trauma to the spine have also been implicated as potential causes .
hematoma is also a cause of brown sequard syndrome but is very rare and usually occurs with predisposing risk factors for bleeding ( anticoagulant therapy , hypertension ) .
brown sequard syndrome as a result of cervical epidural hematoma is a rare entity with only a handful of cases reported in literature .
we describe a case of brown sequard syndrome in a 65 year old female without any underlying risk factors , presenting with sudden onset hemiparesis rapidly progressing to hemiplegia ( within a span of days ) due to a cervical epidural hematoma following a doubtful history of trivial trauma .
a previously healthy 65 year old female presented to us with the complaint of right side hemiplegia without any significant history of trauma . on subsequent inquiry
she gave a history of brisk involuntary hyperextension of the neck following which she developed sudden onset hemiparesis , progressed to hemiplegia within a span of five days .
she did not have a history of any congenital or acquired disorder of coagulation . on elaborate neurological survey
it was found that motor power of the patient s right side upper and lower limb was of grade 0/5 with anesthesia of left side below c3 .
she was evaluated with a cervicodorsal mri scan , which showed a hyper intense space occupying lesion suggesting an epidural hematoma at the c3-c4 level ( fig.1 ) .
the patient was taken up for emergency surgery . with the patient in prone position under general anaesthesia
, a posterior midline incision was taken exposing the tips of the spinous processes from c3 to c5 levels .
two bony gutters were drilled bilaterally at the border of the exposed laminae by means of an air drill . in our case ,
the left side border of the laminae was excised from its cranial to caudal end with a kerison rongeur and the spinous processes and the laminae were pushed laterally as if to open a door , thereby exposing the spinal canal ( hirabayashi s open door laminoplasty ) .
a. t2 weighted transverse section of the cervical cord showing an area of heterogeneous hyper intensity compressing the cord .
b. t1 weighted transverse section of the spine showing an isointense lesion compressing the cord . c. t2 weighted sagittal cut of the cervical spinal cord showing heterogeneous hyper intense signal of the hematoma .
postoperatively the patient was immobilized with a hard cervical collar and physiotherapy ( passive mobilization ) was started .
four months following the surgery the patient regained her motor strength to grade 3/5 with partial return of sensory functions . at twelve months follow up motor power of the affected side improved to grade 5/5 with regaining of normal sensory functions on opposite
about 40% of the cases reported in the literature till date do not have any demonstrable etiology and are therefore referred to as idiopathic spontaneous cervical epidural hematoma .
these need to be differentiated from other well known causes such as neoplasm and systemic diseases , anticoagulant therapy , hypertension or vascular malformations   and pregnancy   for planning of the management and to predict prognosis .
there is controversy regarding the source of the hematoma ; is it arterial or venous ?
the proponents of the venous origin theory maintain that the sudden increase in intra - thoracic and intra - abdominal pressure leads to the rupture of the thin walled epidural veins .
thus during activities like coughing , sneezing , straining during defecation and micturition , vomiting and coitus these thin walled epidural veins may rupture and lead to the generation of the hematoma .
however several authors have pointed out that since the epidural venous pressure is less than the intrathecal pressure , thus these ruptured veins are an unlikely source to produce a hematoma large enough to cause compression of the thecal sac and develope brown sequard syndrome .
after study of the arterial structures of the cervical epidural region it has been hypothesized that extreme movements at the cervicodorsal junction could result in tearing of the arteries .
the high arterial pressure can lead to development of hematoma large enough to cause compression of the dural sac leading to the clinical syndrome of cord compression .
the most common presentation of spontaneous cervical epidural hematoma is acute onset of neck pain , which is usually radiating in nature and the localization depends on the involvement of specific nerve roots .
the second most common symptom is weakness of the limbs below the level of compression .
the weakness gradually increases over days but complete loss of motor power has not been reported and this deficit rarely recovers spontaneously .
mri is the diagnostic tool of choice in spontaneous cervical epidural hematoma . on t2 weighted images the hematoma appears as an area of heterogeneous hyper- intensity of the cord with focal hypo - intense areas . on t1 weighted images the lesion is usually iso - intense in the acute phase ; however chronic hematomas may be hyper- intense .
the treatment of choice in spontaneous cervical epidural hematoma is emergency surgical decompression although a few cases have been reported in literature to have recovered without any surgical intervention .
the procedure of choice is a laminectomy , although a hemi - laminectomy or laminoplasty could be performed depending on the extent and localization of the hematoma .
ispontaneous cervical epidural hematoma leading to a brown sequard syndrome is a rare entity in clinical practice and it has a fatal progressive course in cases where the diagnosis is delayed .
spontaneous cervical epidural hematoma may present as hemiparesis prompting the emergency room physician to make an erroneous diagnosis of cerebrovascular accident , leading to delay in the diagnosis .
prompt diagnosis of the condition and urgent decompression is vital to prevent irreversible damage of the cord .
a thorough clinical examination is a must followed by a mri scan of the cervical spine to exclude this rare entity .
although there have been rare reports of spontaneous recovery , surgical decompression is the preferred modality of treatment . in cases presenting as hemiparesis , sensory examination of opposite side
an mri can delineate the cause and surgical decompression is warrented in cases of spontaneous epidural hematoma that causes neurodeficit .
 introduction : brown sequard syndrome resulting from compression due to an epidural hematoma is a relatively rare occurrence , more so with a spontaneous history . 
 we report one such case.case report : we present a 65yr old female presenting with hemiplegia with contralateral anesthesia . 
 magnetic resonance imaging showed a hematoma in the epidural space in the c3-c4 region . 
 she underwent an open door laminoplasty for evacuation of the hematoma . following surgery 
 the patient responded rapidly and currently at 18 months follow up she is neurologically grade 5/5 with normal sensations.conclusions:in the emergency room when a patient is clinically diagnosed as a case of brown sequard syndrome it is important to ask for an mri scan of the cervical spine . 
 hematoma in the cervical epidural space should be considered in the differential diagnosis of brown sequard syndrome especially in the elderly with history of doubtful trivial trauma . 