doi:10.1016/j.jocn.2008.10.013 Brown-Sequard syndrome associated with Horner’s syndrome following a penetrating drill bit injury to the cervical spine Jeremy H. Russell * , Samuel J. Joseph, Broughton J. Snell, Rondhir Jithoo Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia article info Article history: Received 11 January 2008 Accepted 24 February 2008 Keywords: Brown-Sequard syndrome Cervical spinal cord injury Horner’s syndrome MRI Penetrating injury Power drill abstract We report a 41-year-old male who presented with a partial Brown-Sequard syndrome and Horner’s syn- drome following a penetrating drill bit injury to his mid cervical spine. As the injury was not a complete hemisection of the spinal cord, the patient presented with ipsilateral motor deficit and hyperesthesia and diminished contralateral fine touch sensation; however, proprioception, vibration and temperature were all initially intact. A cervical CT and MRI scan showed a damaged spinal cord at the C5/6 level with pos- terior cord compression secondary to haematoma. A decompressive laminectomy and evacuation of the haematoma was performed. Over the following 5 days the patient’s right-sided motor deficit improved daily; however, he developed a contralateral deficit to pain and temperature upon wakening from the operation which did not resolve. The right-sided Horner’s syndrome also persisted. Crown Copyright Ó 2008 Published by Elsevier Ltd. All rights reserved. 1. Introduction Brown-Sequard syndrome (BSS) has a wide variety of aetiolo- gies, with penetrating trauma to the spinal cord being the most common. 1 The literature describes many cases of penetrating in- jury causing this syndrome; however, this is the first reported work-place incidence involving a power drill. 2. Case report A 41-year-old male builder had a power drill fall on to him from the top of a 3-m high ladder while his head was tucked into his chest. The drill bit penetrated the dorsal aspect of his mid cervical spine just right of midline before dislodging itself (Fig. 1). The patient experienced sudden onset right-sided weakness and left-sided paraesthesia. There was no loss of consciousness. The patient was taken to a level 1 trauma centre. Neurological examination revealed right-sided motor weakness with 1/5 and 0/5 power in the upper and lower limbs respectively, hypotonia, absent reflexes and an extensor plantar response. There was no motor deficit on the left. Hyperaesthesia was present on the right, diminished fine touch sensation on the left; however, temperature An attempt should be made to identify the source of the embo- lism, although a recognizable cause was reported in only 37% of Matjasko’s series of 189 VAE. 2 Unlike the posterior fossa approach, bilateral jugular vein compression may have little value in identi- fying the source of VAE in cervical surgery, even as high as C2. 12 Besides the practical difficulty of squeezing the neck of a cervical laminectomy patient, the different routes draining venous blood in this watershed region should be considered. We were unable to identify the site of venous air entrainment in our patient, and we could not prevent the second episode of VAE when we tried to resume the procedure despite packing the surgical field with sal- ine-soaked gauze and cottonoids. The second attempt was not only unsuccessful, it probably worsened the clinical course. We do not advise resuming an operation after massive VAE of unknown origin but suggest rescheduling the operation and performing the proce- dure on the prone patient. Although it is hard to weigh up the advantages and disadvan- tages of the sitting position during the posterior cervical approach, this position is still of great value to neurosurgeons. References 1. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery 1984;14:649–58. 2. Matjasko J, Petrozza P, Cohen M, et al. Anesthesia and surgery in the seated position: analysis of 554 cases. Neurosurgery 1985;17:695–702. 3. Leslie K, Hui R, Kaye AH. Venous air embolism and the sitting position: a case series. J Clin Neurosci 2006;13:419–22. 4. Black S, Ockert DB, Oliver Jr WC, et al. Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions. Anesthesiology 1988;69:49–56. 5. Sibin MS, Babinski M, Maroon JC, et al. Anesthetic management of posterior fossa surgery in the sitting position. Acta Anaesthesiol Scand 1976;20:117–28. 6. Young ML, Smith DS, Murtagh F, et al. Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position. Neurosurgery 1986;18:157–61. 7. Orebaugh SL. Venous air embolism: clinical and experimental considerations. Crit Care Medicine 1992;20:1169–77. 8. Papadopoulos G, Kuhly P, Brock M, et al. Venous and paradoxical air embolism in the sitting position. A prospective study with transoesophageal echocardiography. Acta Neurochir 1994;126:140–3. 9. Gale T, Leslie K. Anaesthesia for neurosurgery in the sitting position. J Clin Neurosci 2004;11:693–6. 10. Bithal PK, Pandia MP, Dash HH, et al. Comparative incidence of venous air embolism and associated hypotension in adults and children operated for neurosurgery in the sitting position. Eur J Anaesthesiol 2004;21:517–22. 11. Giebler R, Kollenberg B, Pohlen G, et al. Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery. Br J Anaesth 1998;80:30–5. 12. Losasso TJ, Muzzi DA, Cucchiara RF. Jugular venous compression helps to identify the source of venous air embolism during craniectomy in patients in the sitting position. Anesthesiology 1992;76:156–7. 13. Albin MS, Carrol RG, Maroon JC. Clinical considerations concerning detection of venous air embolism. Neurosurgery 1978;3:380–4. 14. Voorhies RM, Fraser RA. Cerebral air embolism occuring at angiography and diagnosed by computerized tomography. Case report. J Neurosurg 1984;60:177–8. * Corresponding author. Present address: 5 Durham St, Richmond, Victoria 3121, Australia. Tel.: +61 419 837414. E-mail address: jezza@bigpond.net.au (J.H. Russell). Case Reports / Journal of Clinical Neuroscience 16 (2009) 975–977 975