What is the treatment for Brown-Sequard syndrome?

Treatment of Brown-Séquard Syndrome

The treatment of Brown-Séquard syndrome should include early surgical decompression and fusion for traumatic cases, followed by comprehensive rehabilitation including physical therapy, pain management, and supportive care to maximize functional recovery. 1

Initial Management

• Surgical intervention:

  • For traumatic Brown-Séquard syndrome (especially penetrating injuries), early surgical decompression and fusion is indicated after medical stabilization 1
  • Removal of foreign bodies (bullets, knife fragments) and decompression of the spinal cord should be performed promptly to prevent further neurological damage

• Medical management:

  • High-dose corticosteroids may be beneficial, particularly in inflammatory causes such as idiopathic transverse myelitis 2
  • For non-traumatic causes (inflammation, tumors), treatment should target the underlying etiology

Rehabilitation Program

• Physical rehabilitation:

  • A structured rehabilitation program with a rehabilitation specialist, physiotherapist, and occupational therapist is crucial 3
  • Exercise programs should include range-of-motion exercises, stationary cycling, walking, and strength training to improve physical fitness and independence in activities of daily living 3
  • The intensity of exercise must be closely monitored as overwork can cause fatigue 3

• Pain management:

  • Neuropathic pain is common and should be treated with:
    • First-line: Gabapentinoids (pregabalin, gabapentin) 4
    • Second-line: Tricyclic antidepressants or carbamazepine 4
  • Pain management is crucial as severe pain is reported in at least one-third of patients with similar neurological conditions 3

Monitoring and Supportive Care

• Respiratory monitoring:

  • Apply the "20/30/40 rule" for respiratory assessment:
    • Vital capacity < 20 ml/kg
    • Maximum inspiratory pressure < 30 cmH₂O
    • Maximum expiratory pressure < 40 cmH₂O 4
  • These parameters predict the need for mechanical ventilation

• Prevention of complications:

  • DVT prophylaxis
  • Pressure ulcer prevention
  • Prevention of hospital-acquired infections 4
  • Management of bowel and bladder dysfunction

• Psychological support:

  • Address anxiety, depression, and psychological distress that may occur following sudden neurological deficit 3
  • Early recognition and management of psychological distress is important as mental status can influence physical recovery 3

Prognosis

• Patients with Brown-Séquard syndrome generally have the best prognosis among all spinal cord injury patterns 1
• Recovery depends on the level and severity of injury, with cervical injuries having more variable outcomes than thoracic or lumbar injuries 1
• Significant functional improvement can be expected with appropriate treatment and rehabilitation, with some patients achieving near-complete recovery 1, 5

Special Considerations

• The management approach should be adapted based on the etiology (traumatic vs. non-traumatic)
• Higher cervical injuries require more intensive monitoring and management due to potential respiratory complications
• Regular assessment of muscle strength using the Medical Research Council grading scale helps monitor progress 4

Brown-Séquard syndrome, characterized by ipsilateral motor weakness and proprioception loss with contralateral pain and temperature sensation loss, requires prompt diagnosis and treatment to maximize functional recovery and minimize long-term disability.