Spontaneous hemorrhage in the spinal canal leading to Brown-Séquard syndrome: a case report and review of the literature.

backgroundSpontaneous hemorrhage in the spinal canal is a rare but life-threatening neurosurgical emergency which has a complex mechanism and presents with diverse clinical manifestations, often resulting in Brown-Séquard syndrome, characterized by typical damage to one side of spinal cord function. CASE PRESENTATION: A 56-year-old Han Chinese female presented with a 10-year history of generalized limb numbness and acute-onset left-sided weakness for 1 h. "Physical examination: the patient exhibited Grade 2 muscle strength in the left extremities and Grade 4 strength in the right extremities, accompanied by reduced anal sphincter tone. Neurological examination revealed bilateral hand numbness, marked sensory loss below the sternal angle on the right side of the trunk, and numbness affecting the right perineum and lower limb. Reflex evaluation revealed diminished left upper limb reflexes, although right upper limb reflexes were preserved and no pathologic reflexes were noted in any limbs. Cervical magnetic resonance imaging (MRI) revealed a C4-6 extradural mass involving the vertebral body and disc spaces, suspicious for a neoplastic lesion with associated mild cord edema. Preliminary diagnosis: (1) Cervical spinal canal mass: tumor, hematoma, or other etiology; (2) Brown-Séquard syndrome; (3) Cervical spinal stenosis; (4) Stage 2 hypertension (moderate-risk).The patient underwent surgery under general anesthesia for cervical spinal canal lesion resection, including C4-6 laminectomy, decompression, and spinal nerve release. Intraoperatively, a fibrous blood clot was identified compressing the spinal cord on the dural surface. Postoperative pathology confirmed a blood clot. On postoperative day 1, the left-sided limb strength improved to Grade 4; the right-sided strength to Grade 5, while numbness in the right trunk remained unchanged. On postoperative day 16, the patient reported significant improvement in left limb strength and symptom relief (e.g., reduced limb numbness and walking instability), Physical examination: Muscle strength was Grade 5 in all four limbs. Anal sphincter tone was reduced. Right-sided sensory numbness was noted in the trunk below the right costal arch and right lower limb. Bilateral knee reflexes were preserved. Pathological reflexes were absent in all limbs. At 1-year follow-up, all limbs had normalized strength, except for residual numbness in the right buttock and lower limb. Follow-up cervical MRI demonstrated resolved spinal cord edema and reduced intramedullary ischemic signals.

conclusionSpontaneous spinal canal hemorrhage leading to Brown-Séquard syndrome typically manifests acutely and carries a high disability rate. Although surgery remains the mainstay treatment, some cases may achieve favorable outcomes with conservative management.