What is the treatment for Brown-Sequard syndrome?

Treatment of Brown-Séquard Syndrome

The treatment of Brown-Séquard syndrome should be directed at the underlying cause, with high-dose intravenous corticosteroids being the first-line therapy for inflammatory or idiopathic cases, while surgical decompression is indicated for traumatic or compressive etiologies.

Etiology and Diagnosis

Brown-Séquard syndrome (BSS) is an incomplete spinal cord injury characterized by:

• Ipsilateral motor weakness and proprioceptive loss
• Contralateral loss of pain and temperature sensation
• Occurs due to hemisection of the spinal cord

Common causes include:

• Traumatic injuries (most common) 1, 2
• Acute disc herniation 1, 3
• Inflammatory conditions (transverse myelitis) 4
• Tumors or space-occupying lesions
• Post-traumatic arachnoiditis 5
• Ischemia or infections (less common)

Diagnostic approach:

• MRI of the spine with and without contrast is essential to identify the cause and level of injury
• High-resolution imaging techniques such as CISS sequences may be helpful in cases of arachnoiditis 5
• Lumbar puncture may be indicated in inflammatory cases to evaluate for albuminocytologic dissociation

Treatment Algorithm

1. Inflammatory/Idiopathic Causes (e.g., Transverse Myelitis)

• First-line treatment: High-dose intravenous corticosteroids 4

  • Methylprednisolone 30 mg/kg loading dose followed by 5.4 mg/kg/hr for 23 hours
  • Alternative: Dexamethasone 10-100 mg IV followed by 4-24 mg every 6 hours

• Second-line options:

  • Intravenous immunoglobulin (IVIG) at 0.4 g/kg daily for 5 consecutive days 6
  • Plasma exchange (200-250 ml plasma/kg body weight in five sessions) 6

2. Traumatic/Compressive Causes (e.g., Disc Herniation, Fractures)

• Immediate surgical intervention is recommended for decompression 1, 3

  • For cervical disc herniation: anterior cervical discectomy and fusion
  • For thoracic compression: appropriate decompressive procedure based on pathology
  • Surgery should be performed as soon as possible to prevent further neurological deterioration

• Adjunctive measures:

  • Spinal immobilization to prevent further injury
  • Consider high-dose methylprednisolone protocol if within 8 hours of acute trauma

3. Supportive Care (All Cases)

• Pain management:

  • First-line: Gabapentinoids (pregabalin, gabapentin) 6
  • Second-line: Tricyclic antidepressants or carbamazepine 6

• Rehabilitation:

  • Early intensive physiotherapy and rehabilitation 2
  • Occupational therapy for activities of daily living

• Complication prevention:

  • DVT prophylaxis
  • Pressure ulcer prevention
  • Prevention of hospital-acquired infections 6
  • Management of neurogenic bladder and bowel dysfunction

Prognosis

The prognosis for BSS varies depending on:

• Underlying cause
• Severity of initial neurological deficits
• Timing of intervention

Outcomes are generally more favorable compared to complete spinal cord injuries:

• Early surgical intervention for compressive lesions is associated with better outcomes 1, 3
• Inflammatory causes treated with corticosteroids often show favorable recovery 4
• Pediatric patients may have better recovery potential 2

Important Considerations

• Timing is critical: Early diagnosis and treatment significantly improve outcomes, especially in compressive or traumatic cases
• Monitor for respiratory compromise: Especially with cervical lesions
• Watch for spinal shock: May overlap with neurogenic shock in acute presentations 2
• Consider secondary causes: Always investigate for underlying conditions that may have led to BSS

Brown-Séquard syndrome represents a neurological emergency that requires prompt diagnosis and treatment directed at the underlying cause for the best possible outcome.