What is the treatment for Brown-Sequard syndrome?

Treatment of Brown-Séquard Syndrome

The treatment of Brown-Séquard syndrome should focus on addressing the underlying cause, with high-dose corticosteroids as the first-line medical therapy for non-surgical cases, followed by intensive rehabilitation to maximize functional recovery.

Diagnosis and Initial Assessment

• Obtain neurology consultation for comprehensive evaluation 1
• Perform MRI of spine with and without contrast to identify the cause and level of injury 1
• Consider lumbar puncture for CSF analysis to rule out infectious or inflammatory causes 1
• Conduct electrodiagnostic studies to evaluate extent of neurological damage 1
• Assess respiratory function using the "20/30/40 rule" (vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, maximum expiratory pressure <40 cmH₂O) 1

Treatment Algorithm Based on Etiology

1. Traumatic Brown-Séquard Syndrome

• Acute spinal cord compression (disc herniation, epidural hematoma):

  • Emergency surgical decompression within 48 hours for best neurological outcomes 2, 3
  • Surgical approach depends on the location and nature of compression
  • Post-surgical high-dose methylprednisolone (30 mg/kg IV bolus followed by 5.4 mg/kg/hour for 23 hours) 4

• Penetrating trauma without significant compression:

  • High-dose corticosteroids (methylprednisolone protocol as above) 5
  • Conservative management with close monitoring 4
  • Surgical exploration only if CSF leak or foreign body is present

2. Inflammatory/Idiopathic Brown-Séquard Syndrome

• Transverse myelitis:
  • Intravenous high-dose methylprednisolone (1 g daily for 3-5 days) 6
  • Consider plasma exchange (200-250 ml plasma/kg in five sessions) if inadequate response to steroids 1
  • IVIG (0.4 g/kg daily for 5 days) as an alternative if steroids contraindicated 1

3. Immune-Mediated Brown-Séquard Syndrome

• For moderate symptoms (some interference with ADLs):

  • Hold immune checkpoint inhibitors if relevant to cause
  • Initiate prednisone 0.5-1 mg/kg/day 7
  • Add gabapentin, pregabalin, or duloxetine for neuropathic pain 7

• For severe symptoms (limiting self-care):

  • Permanently discontinue immune checkpoint inhibitors if relevant
  • Admit patient and initiate IV methylprednisolone 2-4 mg/kg/day 7
  • Consider IVIG or plasmapheresis for severe cases 7

Monitoring and Supportive Care

• Frequent neurological assessments using Medical Research Council grading scale for muscle strength 1
• Monitor respiratory function closely, especially with cervical and high thoracic lesions 1
• Assess for autonomic dysfunction (blood pressure instability, cardiac arrhythmias) 7
• Provide non-opioid management for neuropathic pain (pregabalin, gabapentin, duloxetine) 7, 1
• Address bowel and bladder dysfunction with appropriate catheterization and bowel regimen 7

Rehabilitation

• Initiate early intensive physical therapy focused on strengthening the ipsilateral weak limb 4
• Occupational therapy for activities of daily living 4
• Sensory retraining for contralateral sensory deficits 4
• Gait training with appropriate assistive devices 4

Prognosis

• Brown-Séquard syndrome generally has a favorable prognosis compared to other spinal cord injury patterns 4, 3
• Most significant recovery occurs in the first year but can continue for >5 years 7
• Motor function typically recovers better than sensory function 4
• Early intervention (within 48 hours for surgical cases) significantly improves outcomes 2, 3

Common Pitfalls and Caveats

• Misdiagnosis as stroke due to unilateral symptoms
• Delayed diagnosis of compressive lesions requiring surgical intervention
• Underestimating respiratory compromise, especially with cervical lesions
• Inadequate pain management leading to chronic neuropathic pain
• Premature cessation of rehabilitation efforts

Remember that rapid diagnosis and immediate treatment are crucial for optimal outcomes in Brown-Séquard syndrome, particularly when caused by a compressive lesion requiring surgical decompression.