What is Brown-Sequard syndrome?

Brown-Séquard Syndrome

Brown-Séquard syndrome is characterized by hemisection of the spinal cord resulting in ipsilateral motor weakness or paralysis and loss of proprioception, with contralateral loss of pain and temperature sensation below the level of injury. 1, 2, 3

Clinical Features

Neurological Manifestations

• Ipsilateral findings (same side as the lesion):

  • Motor weakness or paralysis
  • Loss of proprioception and vibratory sensation
  • Decreased or absent deep tendon reflexes in affected limbs

• Contralateral findings (opposite side of the lesion):

  • Loss of pain and temperature sensation (typically begins 2-3 levels below the injury) 4
  • Preserved motor function and proprioception

Common Causes

• Traumatic injuries:
  • Penetrating trauma (stab wounds, gunshot wounds) 2, 3, 4
  • Blunt trauma to the spine
• Non-traumatic causes:
  • Cervical disc herniation 5
  • Spinal cord tumors
  • Spinal vascular malformations
  • Infectious or inflammatory lesions

Pathophysiology

The syndrome results from damage to specific tracts within one half of the spinal cord:

1. Ipsilateral side damage affects:

   • Corticospinal tract → motor weakness
   • Posterior columns → loss of proprioception and vibration sense

2. Contralateral side effects occur due to:

   • Spinothalamic tract fibers that cross at the anterior commissure (typically 2-3 levels above where they enter the cord) → loss of pain and temperature sensation on the opposite side

Diagnosis

Clinical Assessment

• Detailed neurological examination to identify the characteristic pattern of deficits
• Determine the neurological level of injury based on sensory and motor findings

Imaging

• MRI of the spine: Gold standard to visualize the spinal cord lesion, identify the cause, and assess the extent of damage 2, 5
• CT scan: Useful in trauma cases, especially with suspected bony involvement or to locate foreign bodies (e.g., bullets) 3

Management

Management depends on the underlying cause:

Traumatic Brown-Séquard Syndrome

• Surgical intervention is indicated for:

  • Spinal cord compression from bone fragments, foreign bodies, or hematoma
  • Spinal instability requiring fusion 3
  • Persistent compression of neural elements

• Conservative management may be appropriate for:

  • Stable injuries without ongoing compression
  • Patients with significant comorbidities precluding surgery 2

Non-traumatic Causes

• Disc herniation: Surgical decompression (discectomy, laminectomy, or laminoplasty) 5
• Tumors: Surgical resection when possible
• Inflammatory/infectious causes: Treat the underlying condition

Rehabilitation

• Comprehensive rehabilitation program focusing on:
  • Physical therapy to improve motor function and prevent contractures
  • Occupational therapy for activities of daily living
  • Management of neuropathic pain
  • Bladder and bowel management

Prognosis

Brown-Séquard syndrome generally has the best prognosis among incomplete spinal cord injury patterns 3:

• Most patients show significant neurological recovery
• Motor function typically recovers better than sensory function
• Recovery can continue for months to years after injury
• Factors affecting prognosis include:
  • Age
  • Level and severity of injury
  • Timing of decompression (if needed)
  • Associated injuries

Common Pitfalls

• Delayed diagnosis: The classic presentation may not be immediately apparent, especially in the acute trauma setting
• Incomplete syndrome: Pure Brown-Séquard syndrome is rare; most cases present with mixed or partial features
• Overlooking non-traumatic causes: In the absence of obvious trauma, consider disc herniation, tumors, or inflammatory conditions
• Inadequate rehabilitation: Early and intensive rehabilitation is crucial for optimal functional recovery

Key Points for Clinical Practice

• Brown-Séquard syndrome represents a hemisection of the spinal cord with a characteristic pattern of neurological deficits
• Early recognition and appropriate management can significantly improve outcomes
• MRI is the imaging modality of choice for diagnosis and treatment planning
• Despite significant neurological deficits at presentation, the prognosis for functional recovery is generally favorable compared to other spinal cord injury patterns