1/16

Ever Wondered Why T...

Metadata

• Author: @emeltzermd on Twitter
• Full Title: 1/16
  Ever Wondered Why T...
• Category: #tweets
• URL: https://twitter.com/emeltzermd/status/1567346767951286273

Highlights

• 1/16
  Ever wondered why the incidence of a stab injury causing Brown-Séquard syndrome on exam questions is sky high but is rarely seen in real life? Read the below 🧵 to learn more about this common error made in medical education. #neurotwitter #meded #MedTwitter (View Tweet)
• 2/16
  I consider the teaching of Brown-Séquard syndrome one of the most ubiquitous examples of the errors made in the use of case-based learning. How many times have you seen true Brown-Séquard syndrome, and was it due to a stab injury? (View Tweet)
• 3/16
  The problem with case-based learning, is if the focus is always on the diagnosis rather than problem-solving, and the case is always the same, then the learner is rewarded to recognize specific key words or scenarios. It's only human. https://t.co/z0oBcDS7Hu (View Tweet)
• 4/16
  If a case is always presented the same way, any deviations from that prototype will be rejected. In other words, according to exams questions, all spinal cord stab injuries must be Brown-Séquard syndrome, and any Brown-Séquard must be caused by a spinal cord injury. Why?? (View Tweet)
• 5/16
  Several dramatically large Brown-Séquard syndrome case series from South Africa were published in the mid-20th century. These case series became widely cited for their discussions on the various complications and neurologic syndromes that can develop from stab injuries. (View Tweet)
• 6/16
  Lipschitz and Block reported 130 cases of stab wounds to the spinal cord over a 4-year period, and another Peacock et al published 450 cases a decade later. At the time of these publications, violence was endemic in rural South Africa under the imposed apartheid system. (View Tweet)
• 7/16
  Even in these case series, was Brown-Séquard syndrome common? https://t.co/PgOuebb7dW (View Tweet)
• 8/16
  No.
  Lipschitz describes that of 130 patients, only 16 patients (~12%) had classic Brown-Séquard syndrome. Most cases did have a partial spinal cord lesion, but it was not typically the classic hemicord syndrome we think about. (View Tweet)
• 9/16
  Peacock et al hypothesize that the large number of partial cord injuries is related to the anatomy of the spinous and transverse processes, which prevents the angle of the knife blade from deviating laterally. (View Tweet)
• 10/16
  Interestingly, they note that many of the patients with a partial cord injury had motor paralysis on the side CONTRALATERAL to the entry wound of the knife! https://t.co/8ddtZxFiJj (View Tweet)
• 11/16
  They hypothesize this is likely due to a contrecoup spinal cord injury with cord edema – hence the high rate of motor recovery, and that many (even most) of the hemicord injuries are not due to the stab wound itself. (View Tweet)
• 12/16
  Unfortunately, the message from those papers that has propagated in the literature doesn’t focus on the actual syndromes they describe, but that stab wounds are a common cause of Brown-Séquard syndrome. (View Tweet)
• 13/16
  Don't blame them!
  The first sentence of Lipshitz’s paper states, “Stab wounds of the spinal cord are rare in most parts of the world.” Could it be the authors citing these papers didn’t read their content before using them as a reference? https://t.co/8d0mUAOIYv (View Tweet)
• 14/16
  If you are a test-writer, next time you need to incorporate a question on Brown-Séquard syndrome, please, resist the urge to recycle this played out narrative. Be more creative and give the patient another etiology for their presentation. (View Tweet)
• 15/16
  It all comes back to defining the clinical syndrome. If you localize the lesion to the hemicord, pat yourself on the back! Now, identify the syndrome to narrow down the possible diagnoses. Other causes include transverse myelitis, malignancy, and compressive myelopathy. (View Tweet)
• 16/16
  Please note that Lipschitz’s paper is overtly racist. I include it in this discussion above for the sake of medical education, but it is clearly fatally flawed in its perspective.
  https://t.co/reONFiP6vg
  https://t.co/5YdHmwyyXt (View Tweet)

1/16

Ever Wondered Why T...

Metadata

• Author: @emeltzermd on Twitter
• Full Title: 1/16
  Ever Wondered Why T...
• Category: #tweets
• URL: https://twitter.com/emeltzermd/status/1567346767951286273

Highlights

• 1/16
  Ever wondered why the incidence of a stab injury causing Brown-Séquard syndrome on exam questions is sky high but is rarely seen in real life? Read the below 🧵 to learn more about this common error made in medical education. #neurotwitter #meded #MedTwitter (View Tweet)
• 2/16
  I consider the teaching of Brown-Séquard syndrome one of the most ubiquitous examples of the errors made in the use of case-based learning. How many times have you seen true Brown-Séquard syndrome, and was it due to a stab injury? (View Tweet)
• 3/16
  The problem with case-based learning, is if the focus is always on the diagnosis rather than problem-solving, and the case is always the same, then the learner is rewarded to recognize specific key words or scenarios. It's only human. https://t.co/z0oBcDS7Hu (View Tweet)
• 4/16
  If a case is always presented the same way, any deviations from that prototype will be rejected. In other words, according to exams questions, all spinal cord stab injuries must be Brown-Séquard syndrome, and any Brown-Séquard must be caused by a spinal cord injury. Why?? (View Tweet)
• 5/16
  Several dramatically large Brown-Séquard syndrome case series from South Africa were published in the mid-20th century. These case series became widely cited for their discussions on the various complications and neurologic syndromes that can develop from stab injuries. (View Tweet)
• 6/16
  Lipschitz and Block reported 130 cases of stab wounds to the spinal cord over a 4-year period, and another Peacock et al published 450 cases a decade later. At the time of these publications, violence was endemic in rural South Africa under the imposed apartheid system. (View Tweet)
• 7/16
  Even in these case series, was Brown-Séquard syndrome common? https://t.co/PgOuebb7dW (View Tweet)
• 8/16
  No.
  Lipschitz describes that of 130 patients, only 16 patients (~12%) had classic Brown-Séquard syndrome. Most cases did have a partial spinal cord lesion, but it was not typically the classic hemicord syndrome we think about. (View Tweet)
• 9/16
  Peacock et al hypothesize that the large number of partial cord injuries is related to the anatomy of the spinous and transverse processes, which prevents the angle of the knife blade from deviating laterally. (View Tweet)
• 10/16
  Interestingly, they note that many of the patients with a partial cord injury had motor paralysis on the side CONTRALATERAL to the entry wound of the knife! https://t.co/8ddtZxFiJj (View Tweet)
• 11/16
  They hypothesize this is likely due to a contrecoup spinal cord injury with cord edema – hence the high rate of motor recovery, and that many (even most) of the hemicord injuries are not due to the stab wound itself. (View Tweet)
• 12/16
  Unfortunately, the message from those papers that has propagated in the literature doesn’t focus on the actual syndromes they describe, but that stab wounds are a common cause of Brown-Séquard syndrome. (View Tweet)
• 13/16
  Don't blame them!
  The first sentence of Lipshitz’s paper states, “Stab wounds of the spinal cord are rare in most parts of the world.” Could it be the authors citing these papers didn’t read their content before using them as a reference? https://t.co/8d0mUAOIYv (View Tweet)
• 14/16
  If you are a test-writer, next time you need to incorporate a question on Brown-Séquard syndrome, please, resist the urge to recycle this played out narrative. Be more creative and give the patient another etiology for their presentation. (View Tweet)
• 15/16
  It all comes back to defining the clinical syndrome. If you localize the lesion to the hemicord, pat yourself on the back! Now, identify the syndrome to narrow down the possible diagnoses. Other causes include transverse myelitis, malignancy, and compressive myelopathy. (View Tweet)
• 16/16
  Please note that Lipschitz’s paper is overtly racist. I include it in this discussion above for the sake of medical education, but it is clearly fatally flawed in its perspective.
  https://t.co/reONFiP6vg
  https://t.co/5YdHmwyyXt (View Tweet)