What is the management and treatment for spinal cord syndromes such as Brown-Sequard syndrome, posterior cord syndrome, anterior cord syndrome, and central cord syndrome?

Management and Treatment of Spinal Cord Syndromes

Early surgical decompression (within 24 hours of injury) is strongly recommended for all incomplete spinal cord syndromes to improve neurological outcomes and reduce morbidity and mortality. 1

General Management Principles for All Spinal Cord Syndromes

• Immediate optimization of cardiorespiratory and hemodynamic parameters is essential to prevent secondary injury and improve outcomes 1
• Management in a specialized acute SCI unit reduces morbidity and mortality 1
• Comprehensive rehabilitation should begin from the first days of injury and continue through all phases of care 1
• Careful attention to prevention and management of complications including autonomic dysreflexia, respiratory dysfunction, thromboembolism, pressure ulcers, bowel dysfunction, and depression 1

Brown-Sequard Syndrome

Brown-Sequard syndrome is characterized by hemisection of the spinal cord resulting in:

• Ipsilateral motor weakness and proprioception loss
• Contralateral pain and temperature sensation loss
• Often caused by penetrating injuries, but can also result from disc herniation 2, 3

Management:

• Early surgical intervention is recommended for cases caused by disc herniation 2
• Microdiscectomy and anterior cervical fusion for cervical disc herniation cases 2
• Posterolateral transpedicular approach with operative microscope for thoracic intradural disc herniation 3
• Prognosis is generally favorable with early intervention, with patients showing significant motor recovery 2, 3

Anterior Cord Syndrome

Anterior cord syndrome results from damage to the anterior portion of the spinal cord, affecting:

• Motor function
• Pain and temperature sensation
• Preservation of proprioception and vibration sense

Management:

• Surgical decompression for cases with identifiable compressive lesions 4
• These patients typically have the longest length of stay in rehabilitation compared to other SCI syndromes 4
• Careful attention to rehabilitation as functional gains can be achieved despite initial severe deficits 4

Posterior Cord Syndrome

Posterior cord syndrome is the rarest of the incomplete cord syndromes, affecting:

• Proprioception and vibration sense
• Preservation of motor function and pain/temperature sensation

Management:

• Surgical decompression for cases with identifiable compressive lesions 4
• Focused rehabilitation on sensory retraining and compensatory strategies 4
• Patients show functional improvements with inpatient rehabilitation 4

Central Cord Syndrome

Central cord syndrome is the most common incomplete spinal cord syndrome, characterized by:

• Greater weakness in upper extremities than lower extremities
• Often occurs in older patients with underlying cervical spondylosis through hyperextension mechanism 5, 6
• Can also occur in younger patients with high-energy trauma 6

Management:

• Early surgical decompression is recommended, particularly for patients with radiographic evidence of spinal cord compression 5, 6
• Surgical timing should be within 24 hours of injury when possible 1
• For older patients with preexisting cervical spondylosis, anterior or posterior decompression and stabilization may be required 5, 6
• Patients with central cord syndrome typically present with the lowest admission functional level of all SCI syndromes but can achieve significant improvement with rehabilitation 4

Pitfalls and Caveats

• Delays in transfer to specialized centers often result in patients arriving outside the critical 24-hour window for optimal surgical intervention 1
• Only 20-50% of SCI patients are transferred to appropriate centers within 24 hours of injury 1
• Intradural disc herniation causing Brown-Sequard syndrome may be overlooked without careful imaging review and surgical planning 3
• Central cord syndrome in elderly patients may be misattributed solely to age rather than recognized as a treatable condition 5, 6
• Careful management of cardiovascular instability is critical, as cervical and high thoracic injuries can cause loss of sympathetic innervation leading to profound hypotension 1

Rehabilitation Considerations

• Rehabilitation should begin immediately in the acute phase and continue through all phases of recovery 1
• Patients with cervical Brown-Sequard syndrome achieve higher functional improvement by discharge compared to central cord syndrome patients 4
• Cauda equina and conus medullaris syndromes exhibit similar functional outcomes 4
• Anterior cord syndrome patients show functional gains but have the longest length of stay 4