A 52-year-old man from Delhi presents to the emergency department with acute onset weakness of the right lower limb and loss of pain and temperature sensation on the left lower limb below the level of T10. Examination reveals hyperreflexia and Babinski sign on the right. MRI spine shows a lesion in the right half of the spinal cord at T10 level. What is the most appropriate next step in management?

Explanation

## Clinical Presentation Analysis This patient demonstrates **Brown-Séquard syndrome** — a classic incomplete spinal cord injury pattern caused by hemisection of the spinal cord. ### Anatomical Correlation **Key Point:** Brown-Séquard syndrome results from damage to one half of the spinal cord and produces a characteristic dissociated sensory loss pattern. | Finding | Anatomical Basis | Side Affected | |---------|-----------------|---------------| | **Motor weakness (paralysis)** | Corticospinal tract (pyramidal tract) damage | **Ipsilateral** (same side as lesion) | | **Loss of proprioception & vibration** | Dorsal column (fasciculus gracilis/cuneatus) damage | **Ipsilateral** (same side as lesion) | | **Loss of pain & temperature** | Spinothalamic tract (lateral) damage | **Contralateral** (opposite side to lesion) | | **Hyperreflexia & Babinski sign** | Upper motor neuron signs from corticospinal tract involvement | **Ipsilateral** | In this case: - Right-sided motor weakness + hyperreflexia → right corticospinal tract damage - Left-sided pain/temperature loss → right spinothalamic tract damage - **Conclusion:** Right-sided spinal cord lesion at T10 (Brown-Séquard) ### Management Priority **High-Yield:** Acute spinal cord injury is a **neurosurgical emergency**. The critical window for intervention is within 8 hours of injury onset. **Key Point:** High-dose methylprednisolone (30 mg/kg IV bolus, then 5.4 mg/kg/hr for 23 hours) is indicated if administered within 8 hours of acute traumatic spinal cord injury, as per NASCIS III guidelines. This provides modest neuroprotection. **Clinical Pearl:** Urgent neurosurgical consultation is essential to evaluate for: - Epidural hematoma requiring evacuation - Spinal instability requiring fixation - Cord compression from bone fragments or disc material - Potential for surgical decompression MRI has already identified the lesion; further imaging is not the priority — **intervention** is. ## Why This Is the Correct Next Step The combination of: 1. **Acute presentation** (within therapeutic window) 2. **Structural lesion on imaging** (MRI already done) 3. **Progressive neurological deficit** (hyperreflexia, Babinski) ...mandates **immediate corticosteroid administration** and **urgent neurosurgical evaluation** to assess candidacy for decompression/stabilization.