What is the treatment for Brown-Sequard syndrome?

Treatment of Brown-Séquard Syndrome

Brown-Séquard syndrome should be managed conservatively in most cases, with surgery reserved only for patients requiring decompression (retained foreign body, bony/ligamentous instability, or progressive neurological deterioration), as this incomplete spinal cord injury pattern has the best prognosis of all spinal cord injury types and neurological recovery depends primarily on whether the injury is contusive versus direct transection. 1, 2

Initial Assessment and Stabilization

Immediate Evaluation

• Confirm the diagnosis clinically: Look for ipsilateral motor weakness and loss of proprioception/vibratory sensation with contralateral loss of pain and temperature sensation 1, 2, 3
• Obtain urgent MRI of the spine to identify the lesion location, assess for cord compression, and determine if there is penetrating trauma with retained foreign body, disc herniation, or structural instability 2, 4, 5
• Assess for Brown-Séquard-plus syndrome: Check for additional neurologic findings involving eyes, bowel, or bladder function 3
• Monitor for spinal shock and neurogenic shock, which can overlap at presentation and require hemodynamic support 3

Treatment Algorithm

Conservative Management (Preferred for Most Cases)

• High-dose corticosteroids may be considered in the acute setting, though evidence is extrapolated from general spinal cord injury literature 3
• Immediate intensive physiotherapy and rehabilitation should be initiated as soon as medically stable 3
• Serial neurological examinations to monitor for improvement or deterioration 1

The rationale for conservative management is that neurological improvement depends on whether spinal tracts were injured by contusion (which recovers) rather than direct transection (which does not), and most patients show good to complete recovery with medical management alone 1, 3

Surgical Indications (Limited and Specific)

Surgery should be performed only when:

• Retained foreign body (bullet, knife blade) requires removal AND there is associated bony/ligamentous instability requiring stabilization 1, 2
• Significant cord compression from disc herniation or bone fragments with progressive neurological deterioration 2, 4, 5
• Intradural pathology (such as intradural disc herniation) is suspected based on clinical presentation and imaging 5

Surgical approach when indicated:

• For cervical injuries with compression: anterior cervical decompression and fusion after medical stabilization 2, 4
• For thoracic intradural lesions: posterolateral transpedicular approach with operative microscope, opening the dura mater to avoid missing intradural pathology 5
• Timing: early decompression and fusion after medical stabilization has shown favorable outcomes 2

Critical Pitfalls to Avoid

• Do not rush to surgery in penetrating trauma without clear indications—conservative management should be preferred as neurologic improvement correlates with injury mechanism (contusion vs. transection), not surgical intervention 1
• Do not miss intradural disc herniation in non-traumatic cases—Brown-Séquard syndrome with thoracic disc herniation on MRI should raise suspicion for intradural location, requiring dural opening during surgery 5
• Do not assume all penetrating injuries need surgery—only those with retained foreign bodies causing instability or progressive compression require operative intervention 1, 2

Prognosis and Follow-up

• Brown-Séquard syndrome has the best prognosis of all spinal cord injury patterns, with potential for good to complete neurological recovery 2, 3
• Recovery timeline: Neurological improvement typically begins immediately to within weeks post-injury, with continued improvement over months 2, 3
• Rehabilitation is essential: Intensive physiotherapy should continue throughout the recovery period to maximize functional outcomes 3