Brown-Sequard Syndrome Treatment & Management
- Author: Carol Vandenakker-Albanese, MD; Chief Editor: Stephen Kishner, MD, MHA more...
Special care must be taken in preparing a life-care plan for a patient with Brown-Séquard syndrome. The incompleteness of the syndrome in conjunction with a good prognosis for recovery makes determination of needs over a lifetime difficult. If evaluated too early, needs may be grossly overestimated. If evaluation is performed at the time of maximal function, the expected difficulties and changes associated with aging with disability must not be forgotten.
Any SCI, regardless of degree of completeness, results in significant alterations in function of the respiratory, cardiovascular, digestive, urinary, musculoskeletal, and integumentary systems. Decreased pulmonary function, altered cardiovascular dynamics, neurogenic bowel and bladder dysfunctions, hypercalcemia, osteoporosis, heterotopic ossification, and insensate skin may not be avoidable, but secondary medical complications often are preventable with expert care. The following secondary complications need to be addressed with aggressive preventive measures and early treatment:
Development of pulmonary infections and respiratory insufficiency
Uncontrolled autonomic dysreflexia
Urinary tract infections
Avoidance of medical complications reduces morbidity and mortality; it also speeds the rehabilitation process.
Medication use is dependent on the secondary effects of SCI. Medication may be indicated for spasticity, pain, or a number of other possible complications. In general, persons with Brown-Séquard syndrome regain significant function, and many medications are not needed long term.
Nasogastric tube insertion
Nasogastric (NG) tube insertion and subsequent low-wall suction may help to prevent aspiration. Additionally, these patients are prone to developing ileus in the acute stage.
Cervical spine immobilization
Cervical spine immobilization, or lower dorsal vertebra immobilization, is required with trauma or suspicion of an unstable spine. Hard-collar immobilization or Gardner Wells tongs may be required if cervical fracture/injury is identified.
Transfer to a level I trauma center or to a facility with expertise in the care of spinal cord injuries is appropriate; however, transfer should not impede the overall evaluation of these patients, including assessment for additional injuries.
A number of community outreach programs have been developed to educate young people about the risks of traumatic injury associated with certain behaviors. Results of such injury, such as SCI, are described in detail, and preventive measures are outlined. These programs have been found to have a positive impact on the rate of injury.
The key to successful prehospital care of patients with Brown-Séquard syndrome is to suspect a cervical or other spinal injury. A low threshold for cervical spine/backboard immobilization is appropriate. One issue with prehospital evaluation of cervical spine injury is the potential for assumption of a complete spinal cord lesion rather than an incomplete lesion. Prehospital providers must be educated regarding the findings of incomplete cord syndromes and how to make a brief assessment of complete versus incomplete cord lesion.
Emergency Department Care
Care in the emergency department (ED) consists of a thorough evaluation, including a neurologic examination for level of injury. Careful cervical spine/dorsal spine immobilization is necessary, with elimination of neck movement.
The nature of sensory loss makes investigation of other injuries more difficult. This mandates a thorough and complete physical examination, with imaging studies used to supplement the exam.
Administer steroids in a timely manner: Initiate steroids promptly on the basis of the initial ED evaluation.
Physical therapy intervention starts in the acute care phase of treatment. Therapy goals include the following:
Maintaining strength in neurologically intact muscles
Maintaining range of motion in joints
Preventing skin breakdown by proper positioning and weight shifting
Improving respiratory function by positioning and breathing exercises
Achieving early mobilization to increase tolerance of the upright position
Providing emotional and educational support for the patient and his/her family
As a person with SCI advances through acute rehabilitation, physical therapy addresses mobility issues. Functional movement starts with bed mobility, followed by transfers, wheelchair mobility, and, in many cases of Brown-Séquard syndrome, ambulation. Appropriate equipment must be prescribed, and the proper use of the equipment should be taught to the patient and caregivers.
Prior to discharge, the patient's home is evaluated for accessibility and modifications, as well as for the need for adaptive equipment. The need for orthotics is assessed and recommended. After fitting, training with the orthotic device is vital to functional use.
Because neurologic recovery often continues following discharge from acute inpatient rehabilitation, physical therapy should continue in the outpatient setting. Frequent reassessments are indicated to set new functional goals and to modify treatment as needed. Patients and caregivers should be instructed in home exercise programs that are designed to maintain the patients’ strength, flexibility, and balance.
To enable patients with Brown-Séquard syndrome to regain as much independence as possible in activities of daily living, occupational therapy is essential. Upper extremity function is assessed carefully and then is used to learn new techniques, with or without the use of adaptive equipment, for the performance of oral-facial hygiene, feeding, and dressing. Head control, upper extremity strength, and trunk balance are developed to enable the patient to accomplish these tasks.
Transfers and wheelchair mobility are addressed in conjunction with the physical therapist. Driving assessment, adaptations, and training are performed when appropriate.
Patients with Brown-Séquard syndrome typically show neurologic improvement over the course of the first year after onset and may advance through several stages of independence in performing activities of daily living. Occupational therapy should be continued for as long as the patient shows improvement in functional status.
A person's leisure and recreational needs often increase after a significant change in physical function. Although patients with Brown-Séquard syndrome may regain more function than do most patients with SCI, consideration of recreational needs is still important. Premorbid interests are assessed and incorporated into the development of adaptive sports, leisure activities, and a recreational program.
The recreational therapist re-introduces a person with a disability into the community to develop the confidence needed for re-integration into society. The therapist also serves as a source of information and as a liaison to community programs for the disabled.
Spinal Reduction, Stabilization, and Decompression
Surgical intervention in traumatic SCI has been controversial, focusing primarily on spinal stability.[13, 20] The need for prompt reduction of any spinal deformity is well accepted. The reduction can be achieved either posturally or operatively.
Stabilization of the reduced spine to prevent further injury to the cord is more controversial. Stability may come from direct surgical repair with bone grafting and (often) instrumentation or from natural healing or autofusion in an orthosis. Most stable spinal injuries are treated nonoperatively, while unstable injuries are treated surgically.
Surgical decompression of the spinal canal may be indicated for an incomplete syndrome in which residual compression is present. Nontraumatic etiologies of Brown-Séquard syndrome usually involve mechanical compression or herniation of the spinal cord and require surgical decompression.
Acute consultations are based on patient symptomatology and the etiology of the Brown-Séquard syndrome. Although patients with Brown-Séquard syndrome frequently regain bladder function, consultation with a urologist is required most commonly for evaluation of neurogenic bladder dysfunction. In addition, it is essential that physical medicine and rehabilitation specialists be consulted early on in the initial stages of patient care.
Other specialists who should be available for consultation over the course of the patient's rehabilitation include the following:
Infectious disease specialist
General medicine specialist
Basic medical follow-up care for SCI is recommended every 1-3 years. The suggested assessments include full history and physical (eg, weight, vital signs), vital capacity if the injury level is above T6, routine blood tests, neurologic evaluation with ASIA scoring, and cardiac risk assessment. Urologic evaluation also is recommended, but it is not necessary if a patient with Brown-Séquard syndrome has regained normal bladder function.
Brown-Séquard syndrome carries a more favorable prognosis than do most SCIs, with ongoing neurologic recovery occurring for up to 2 years following the injury. As long as a person's neurologic status is improving and his/her rehabilitation goals change, ongoing physical and occupational therapy are indicated. Following achievement of an optimal functional level, assessment by a physical therapist, occupational therapist, psychosocial counselor, and therapeutic recreation specialist is recommended every 1-3 years.
In the patient who recovers ambulatory function, regular evaluation of any orthotics or assistive devices also is necessary, to ensure safety and prevent skin breakdown.
Musker P, Musker G. Pneumocephalus and Brown-Sequard syndrome caused by a stab wound to the back. Emerg Med Australas. 2011 Apr. 23(2):217-9. [Medline].
Mac-Thiong JM, Parent S, Poitras B, Joncas J, Labelle H. Neurological Outcome and Management of Pedicle Screws Misplaced Totally Within the Spinal Canal. Spine (Phila Pa 1976). 2012 Jul 18. [Medline].
Moin H, Khalili HA. Brown Séquard syndrome due to cervical pen assault. J Clin Forensic Med. 2006 Apr. 13(3):144-5. [Medline].
Urrutia J, Fadic R. Cervical disc herniation producing acute Brown-Sequard syndrome: dynamic changes documented by intraoperative neuromonitoring. Eur Spine J. 2012 Jun. 21 Suppl 4:S418-21. [Medline]. [Full Text].
Chen PY, Lin CY, Tzaan WC, et al. Brown-Sequard syndrome caused by ossification of the ligamentum flavum. J Clin Neurosci. 2007 Sep. 14(9):887-90. [Medline].
Lipper MH, Goldstein JH, Do HM. Brown-Séquard syndrome of the cervical spinal cord after chiropractic manipulation. AJNR Am J Neuroradiol. 1998 Aug. 19(7):1349-52. [Medline].
Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine. 2007 Nov. 7(5):571-4. [Medline].
Spinal Cord Injury Information Network. Facts and Figures at a Glance. February. [Full Text].
Little JW, Halar E. Temporal course of motor recovery after Brown-Sequard spinal cord injuries. Paraplegia. 1985 Feb. 23(1):39-46. [Medline].
Pollard ME, Apple DF. Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine. 2003 Jan 1. 28(1):33-9. [Medline].
Kohno M, Takahashi H, Yamakawa K, et al. Postoperative prognosis of Brown-Séquard-type myelopathy in patients with cervical lesions. Surg Neurol. 1999 Mar. 51(3):241-6. [Medline].
Hayes KC, Hsieh JT, Wolfe DL, et al. Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients. Arch Phys Med Rehabil. 2000 May. 81(5):644-52. [Medline].
Clatterbuck RE, Belzberg AJ, Ducker TB. Intradural cervical disc herniation and Brown-Séquard's syndrome. Report of three cases and review of the literature. J Neurosurg. 2000 Apr. 92(2 Suppl):236-40. [Medline].
Jacobsohn M, Semple P, Dunn R, et al. Stab injuries to the spinal cord: a retrospective study on clinical findings and magnetic resonance imaging changes. Neurosurgery. 2007 Dec. 61(6):1262-6; discussion 1266-7. [Medline].
Parmar H, Park P, Brahma B, et al. Imaging of idiopathic spinal cord herniation. Radiographics. 2008 Mar-Apr. 28(2):511-8. [Medline].
Miranda P, Gomez P, Alday R, et al. Brown-Sequard syndrome after blunt cervical spine trauma: clinical and radiological correlations. Eur Spine J. 2007 Aug. 16(8):1165-70. [Medline].
Massicotte EM, Montanera W, Ross Fleming JF, et al. Idiopathic spinal cord herniation: report of eight cases and review of the literature. Spine. 2002 May 1. 27(9):E233-41. [Medline].
Scivoletto G, Cosentino E, Morganti B, et al. Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions. Disabil Rehabil. 2007 May 11. 1-8. [Medline].