Introduction
Spasticity is a common consequence of stroke, and brain and spinal cord trauma, causing
disability and reducing the quality of life[1 ] It is a frequent clinical sign in people with neurological diseases, affecting mobility
and leading to serious complications such as joint pain, muscular contractions, and
tightness.[2 ] Many upper and lower motor neuron disorders, such as cerebral palsy (CP), traumatic
brain injury (TBI), stroke, multiple sclerosis (MS), and spinal cord injury (SCI),
are associated with spasticity. CP is the leading cause of motor dysfunction in children.[3 ]
[4 ] In patients with SCI, spasticity is especially prevalent, affecting ∼65% of individuals.[5 ] Many studies describe neuro-orthopedic surgeries for correcting joint and limb deformities
caused by spasticity.[6 ]
The objective of this study is to analyze the indications, limitations, and effectiveness
of various surgical treatments for drug-resistant spasticity following stroke, TBI,
SCI, or CP to formulate best practices and improve patient outcomes.
Methods
This systematic review follows the Preferred Reporting Items for Systematic Reviews
and Meta-analyses (PRISMA) guidelines, searching the literature from 1993 to 2024,
including randomized controlled trials (RCTs); case reports; case series; observational,
retrospective, clinical trials; and systematic reviews. Surgical approaches for patients
with drug-resistant spasticity were evaluated for their effectiveness in improving
function, pain management, care, and quality of life. The interventions involve various
surgical treatments, including selective dorsal rhizotomy (SDR), dorsal root entry
zone lesioning (DREZotomy), selective peripheral neurotomy (SPN), and intrathecal
baclofen therapy (ITB).
PICO Framework for Surgical Approach in Spasticity
Question
Which surgical approach is effective for patients with spasticity?
Patient
Patients with spasticity due to conditions such as stroke, cerebral palsy, multiple
sclerosis, traumatic brain injury, or spinal cord injury
Intervention
Surgical approaches, selective dorsal rhizotomy (SDR), DREZ lesioning, SPN, and ITB
Comparator
Nonsurgical interventions (botulinum toxin injections, physiotherapy)
Outcomes
Reduction in spasticity, improved functional ability, pain relief, enhanced quality
of life
Eligibility Criteria
Titles and abstracts were screened for eligibility by two independent reviewers (L.K.B.
and J.B.). The inclusion criteria were as follows: observational or experimental studies,
including RCTs, case reports, case series, clinical trials, and systematic reviews,
that evaluated surgical treatments for post-stroke spasticity of patients of any age.
Exclusion criteria included articles not meeting the eligibility criteria based on
their title and abstract.
Information Sources and Search Strategy
The PubMed, Scopus, and Google Scholar databases were searched for studies published
between 1993 and 2024. The studies were selected following the PRISMA guidelines and
the specified eligibility criteria. Relevant keywords for searching articles on surgical
approaches for spasticity included terms related to the condition, such as “spasticity,”
“muscle spasticity,” “post-stroke spasticity,” “cerebral palsy,” “traumatic brain
injury,” “spinal cord injury,” and “multiple sclerosis.”
Keywords describing surgical interventions included “surgery,” “neurosurgical procedures,”
“orthopedic surgery,” “rhizotomy,” “dorsal rhizotomy,” “dorsal root entry zone lesioning,”
“selective dorsal rhizotomy (SDR),” “selective peripheral neurotomy, “intrathecal
baclofen pump (ITB),” “Radiofrequency Method” and “ITB therapy.” Outcome-related terms
included “spasticity reduction,” “functional improvement,” “motor control,” “gait
improvement,” “quality of life,” “pain management,” and “rehabilitation outcomes.”
To ensure the inclusion of relevant reviews, terms such as “systematic review” and
“evidence synthesis” were also incorporated. These keywords were combined strategically
using Boolean operators like “AND” and “OR” to retrieve comprehensive and relevant
literature.
Search Strategy Equation
(upper and lower limb) AND (post-stroke spasticity, cerebral palsy, traumatic brain
injury, spinal cord injury, multiple sclerosis) AND (surgical, neurotomy, rhizotomy,
ITB therapy).
Result
A comprehensive literature search across three databases—PubMed, Scopus, and Google
Scholar—identified 465 records. After removing 268 duplicates, 197 reports were screened
by title and abstract. A total of 155 reports were excluded as irrelevant, and 42
reports were assessed for eligibility and included in the systematic review. The included
studies consisted of RCTs, case reports, case series, and systematic reviews, which
were used to assess and determine the quality of the research, as shown in [Fig. 1 ].
Fig. 1 A PRISMA-style flow diagram illustrating the study selection process for this systematic
review.
The four neurosurgical techniques—SDR, dorsal root entry zone (DREZ) lesioning, ITB
therapy, and SPN—are specialized interventions designed to address spasticity and
neuropathic pain.
SDR is a neurosurgical procedure to reduce spasticity by selectively cutting sensory
nerve rootlets in the spinal cord. Performed via laminectomy with electrophysiological
monitoring, it targets 50% of dorsal rootlets while preserving ventral rootlets. SDR
is suited for children with spastic diplegia from CP who have adequate lower limb
strength and ambulation potential. Contraindications include mixed or dystonic CP,
severe weakness, cognitive impairments, and scoliosis that may hinder surgery. Intraoperative
neuromonitoring is essential during this surgery. SDR has emerged as an effective
intervention for managing functional impairments and reducing spasticity in the lower
extremities with CP.[7 ]
[8 ] This surgical procedure is primarily employed to treat conditions such as CP, where
the targeted severing of sensory nerve fibers in the spinal cord results in sustained
relief from spasticity and improved mobility.[9 ]
[10 ] SDR is particularly effective in improving ambulatory function in patients with
lower limb spasticity, especially those with causes other than multiple sclerosis.[11 ]
[12 ] On evaluating the impact of SDR combined with physical and occupational therapy
on motor function in children with spastic diplegia, with follow-up at 6 and 12 months,
the SDR showed good improvement in gross motor function measure (GMFM) scores (12.1%)
compared with the control group (4.4%). Both groups received physical therapy and
occupational therapy.[13 ] SDR combined with physical training significantly improves motor function, balance,
and walking capacity and reduces energy cost in children with spastic diplegia. A
study of 42 children (5–8 years) showed superior results for SDR compared with the
control group after 6-month and 1-year follow-up (p < 0.001). Both groups improved, but SDR group was more effective.[14 ] ITB and SDR in non-ambulatory CP (GMFCS level IV/V) children showed reduced spasticity
and improved GMF. However, complication rates were higher after ITB, due to device-related
complications, compared with SDR.[15 ] Post-SDR CP patients included 30 studies, identifying 21 types of complications.
The most common were structural complications, such as scoliosis and hyperlordosis,
along with neurological complications like constipation and sensory changes.[16 ]
DREZ lesioning (DREZotomy) is a surgical procedure that uses microsurgery or thermocoagulation to treat intractable
pain and spasticity by selectively targeting sensory nerve fibers at the spinal cord
DREZ. It is typically indicated for conditions such as brachial plexus avulsion or
SCI. Contraindications include poor general health, difficulty localizing pain sources,
or severe spinal deformities that obstruct surgical access. Intraoperative neuromonitoring
is not mandatory in this surgery. Patients with spinal cord injuries benefit from
DREZ lesioning, which reduces spasticity and neuropathic pain, improving daily function.
DREZ lesioning is effective in treating chronic, refractory neuropathic pain by disrupting
pain transmission pathways in the spinal cord, commonly used for conditions such as
brachialgia after pan-brachial plexus injury, complex regional pain syndrome, and
postherpetic neuralgia.[17 ] It involves severing the DREZ, which severs the nociceptive pain fibers. DREZotomy
has been demonstrated to be a safe, effective, and long-lasting procedure for alleviating
pain associated with brachial plexus avulsion.[18 ]
[19 ] Cervical DREZ lesioning, traditionally used to manage severe neuropathic pain, targets
pain pathways in the spinal cord. Its established role in conditions like complex
regional pain syndrome contrasts with its emerging application for treating focal
dystonia in the upper limb.[20 ]
[21 ] Microsurgical DREZotomy is an alternative treatment for severe spastic CP in resource-constrained
settings where ITB pumps are not feasible. Conducted from 2016 to 2020, in a study
that included seven patients aged 6 to 21 years, postsurgery, all patients showed
improvement in Ashworth grades, from 3–4 to 0–1.[22 ] Spinal cord injuries, intractable cancer/postradiation pain, and brachial plexus
avulsion are among the chronic pain conditions that DREZotomy effectively treats after
providing pain relief for patients in whom medical management fails.[23 ]
[24 ]
Radiofrequency (RF) method is a medical technique where high-frequency electrical currents are used to
generate heat to target and treat specific areas of nerve tissue, in both SDR and
SPN, the RF method allows for precise, controlled lesions to be made on specific nerve
fibers, offering more targeted and effective treatment with minimal damage to healthy
tissues. RF ablation has proven effective in reducing spasticity in neurological conditions,
as demonstrated in a study involving 26 children with severe CP. This procedure targeted
spinal nerve roots at the L2–S1 levels. MAS score decreased from 3.0 ± 0.2 to 1.14 ± 0.15.[25 ] Fan et al conducted RCT on children with CP, dividing 64 participants into four
groups: conventional treatment, repeated transcranial magnetic stimulation (rTMS),
action observation training (AOT), and combined rTMS-AOT intervention. After 12 weeks,
the combined rTMS and AOT intervention showed the greatest improvement in motor function
compared with the rTMS, AOT, and conventional treatment groups. These results suggest
that the combined therapy is more effective than individual treatments or conventional
rehabilitation.[26 ] Ultrasound-guided treatments, including thermal RF and 35% ethyl alcohol neurolysis,
effectively reduce elbow spasticity by targeting the musculocutaneous nerve in focal
elbow flexor spasticity and hemiparetic stroke patients.[27 ]
[28 ]
SPN is a technique that targets second or third of the selective motor nerve branches
to lessen spasticity while maintaining motor function. When other therapies are unsuccessful,
it works well for localized spasticity brought on by diseases such as multiple sclerosis,
CP, stroke, or trauma. Generalized spasticity, severe muscle weakness, poor skin conditions
at the surgical site, and coagulopathies are among the contraindications. Many generalized
spasticity patients with local spasticity issues are also suitable candidates. Intraoperative
neuromonitoring is essential during this surgery. SPN is an effective neurosurgical
intervention for managing severe focal spasticity in children. It emphasizes preoperative
motor blocks for precise surgical planning and delineates specific indications for
both upper and lower limb spasticity. SPN's role in improving mobility, reducing deformities,
and enhancing the quality of life is good when conservative treatments fail.[29 ] SPN is a simple and safe procedure aimed at reducing spasticity in specific muscle
groups, such as those affected by stroke, TBI, and upper and lower limb spasticity,[30 ]
[31 ] and corrected equinovarus spastic foot deformities,[32 ] while preserving overall motor function. Selective motor fasciculotomy is a modification
of SPN wherein the motor fascicles in the main trunk of the nerve are separated, stimulated,
and cut to relieve the spasticity.[33 ] Each of the above-mentioned techniques has a distinct mechanism, indication, limitations,
and outcomes. Their application is determined by the specific condition, patient needs,
and treatment goals, as shown in [Table 1 ].
Table 1
Surgical approaches for spasticity management
Surgical approach
Mechanism
Indications
Neurological disorders
Limitations
Outcomes
Selective dorsal rhizotomy (SDR)
Selective cutting of dorsal nerve rootlets in the spinal cord to reduce spasticity
Cerebral palsy, spasticity due to brain injury, intractable spasticity
Cerebral palsy, traumatic brain injury, stroke, multiple sclerosis, hypoxic-ischemic
encephalopathy
Risk of weakness, sensory loss, and motor deficits. Needs neuromonitoring
Significant reduction in spasticity, improved function
Dorsal root entry zone (DREZotomy)
Lesioning of the DREZ in the spinal cord to disrupt pain and spasticity pathways
Spinal cord injury, severe pain with spasticity, post-stroke spasticity
Spinal cord injury, stroke, brain injury, multiple sclerosis, amyotrophic lateral
sclerosis
Risk of sensory loss, motor deficits, complications from spinal cord injury
Improvement in pain and spasticity, with variable motor outcomes
Selective peripheral neurotomy (SPN)
Selective neurectomy of 2nd/3rd of motor fibers going to spastic muscles
Focal spasticity
Spinal cord injury, cerebral palsy, stroke, multiple sclerosis, amyotrophic lateral
sclerosis
Requires extensive dissection. Needs neuromonitoring
Effective and durable reduction in spasticity
Intrathecal baclofen (ITB)
Delivery of baclofen directly into the spinal fluid to reduce spasticity
Spasticity from cerebral palsy, multiple sclerosis, spinal cord injury
Cerebral palsy, multiple sclerosis, spinal cord injury, stroke, traumatic brain injury,
brain tumors
Risk of infection, catheter complications, need for pump maintenance, high cost
Effective reduction in spasticity, but long-term management and side-effects can be
challenging
Upper motor neuron diseases often experience pain and functional issues due to a paretic
shoulder, where spasticity causes an upper limb flexion pattern, leading to discomfort,
restricted movement, and caregiving difficulties. Treatment options include orthotics,
medications, physical therapy, and pain management techniques.[34 ] SPN targets focal or multifocal spasticity, showing improvements in both spasticity
and shoulder function. A 2013 analysis of 141 SPN procedures revealed improved caregiver
comfort and enhanced shoulder function, with an average 2.6-point reduction on the
modified Ashworth scale (MAS) and a 20.6-degree increase in passive range of motion.
SPN effectively reduces spasticity, enhances function, and facilitates care. Key outcomes
included surgical complications, spasticity level using MAS, and range of motion.[35 ] Spastic deformities result from an imbalance between flexor and extensor forces
at the glenohumeral joint.[36 ] On evaluating the effect of combined selective peripheral neurotomy (cSPN) in 14
SCI patients with severe lower limb spasticity, partial neurotomy of key nerve branches
significantly reduced spasticity, improved abnormal gait patterns, enhanced walking
ability, and increased independence in daily activities, demonstrating the effectiveness
of cSPN in spasticity management.[37 ] Long-term effects of tibial nerve neurotomy in 51 post-stroke patients with lower
limb deformities showed reduced spasticity, improved motor control, balance, and walking,
with greater gains in more impaired patients. A slight decline in benefits occurred
at 2 years. Sensory disturbances were observed as side effects. Tibial neurotomy effectively
improves walking and balance in these patients.[38 ]
[39 ] The effects of selective neurotomy on focal lower limb spasticity were evaluated
by reviewing 25 nonrandomized studies and one RCT. The findings showed improvements
in muscle tone, pain, ankle range of motion, and walking speed without any negative
effects.[40 ] ITB has been found effective in spinal cord spasticity management due to tumors
and injuries.[41 ] Thirty-one patients with upper-limb spasticity underwent 64 SPNs on the musculocutaneous,
median, and ulnar nerves. Long-term follow-up (mean: 4.5 years) showed significant
improvements in motor function, spasticity, hand function, and daily activities (p < 0.01). Four patients with painful spasticity experienced complete pain relief.
The mean patient satisfaction score was 61.5. Complications occurred in 15% of patients,
including hematomas and temporary sensory and motor issues.[42 ]
ITB pump therapy involves implanting a programmable pump to deliver baclofen directly into the cerebrospinal
fluid, effectively managing generalized spasticity with minimal systemic effects.
It is indicated for conditions like CP, multiple sclerosis, or SCI unresponsive to
oral medications. Contraindications include infections, baclofen hypersensitivity,
anatomical barriers to catheter placement, or poor compliance with pump maintenance.
ITB therapy involves an implanted pump to deliver baclofen directly into the spinal
fluid, offering adjustable, reversible management of severe spasticity in conditions
like multiple sclerosis or SCI.[43 ]
[44 ] ITB was also effective in treating multiple sclerosis-related spasticity unresponsive
to oral medications. Patients experienced reduced spasm frequency and improved quality
of life, with most complications being surgical rather than pharmacological. The average
1-year ITB dose (191.93 μg/day) was lower than doses for central or spinal spasticity,
highlighting its effectiveness when conventional therapies fail.[45 ]
The ITB has a significant reduction in spasticity, with little improvement in motor
function.[46 ] It is an effective treatment for lower limb spasticity. In ambulatory patients with
spasticity[47 ] with conventional medical management for poststroke spasticity, ITB showed a significantly
greater reduction in Ashworth scale scores (−0.99 vs. −0.43). The adverse events were
more frequent in the ITB group (96 vs. 63%).[48 ] MS patients with leg muscular spasms participated in a randomized controlled experiment
that examined the effects of baclofen and self-applied TENS over a 4-week period.
Spasticity was significantly reduced in both groups; however, TENS improved MAS scores
more than baclofen.[49 ] In 40 patients with severe spasticity treated with ITB pumps over a 4-year follow-up,
the average Ashworth score improved to 1.8 ± 0.6, with 85% of patients satisfied and
willing to repeat the procedure. Functional independence remained stable, while 37%
experienced complications, primarily involving the catheter or pump, and 12% had severe
side-effects during refills.[50 ]
SDR has shown significant benefits, with 85 to 90% of patients reporting reduced spasticity
and improvements in motor function, although 15 to 20% experienced complications.
DREZotomy was found to be highly effective in managing chronic pain and spasticity,
with 73 to 87% of patients showing pain relief. RF-based methods like percutaneous
thermal rhizotomy and rTMS combined with AOT are minimally invasive options that offer
substantial improvements in spasticity and motor function. SPN has been effective
in reducing spasticity and improving mobility in 86.5% of patients, with minimal complications.
ITB therapy also has proven effective in reducing spasticity.
Each intervention for managing spasticity and neuropathic pain is suited to specific
patient needs. SDR is most effective for children with spastic diplegia from CP, significantly
improving lower limb function and reducing spasticity, especially when combined with
physical therapy. DREZotomy is ideal for refractory neuropathic pain and spasticity
in conditions like brachial plexus avulsion or SCI, offering targeted pain relief.
ITB therapy benefits patients with generalized spasticity due to CP, multiple sclerosis,
or SCI, providing adjustable and reversible management, though it has higher complication
rates. SPN is a safe and effective option for focal spasticity, particularly in post-stroke
or CP patients, improving mobility and reducing deformities. The choice of surgical
techniques depends on spasticity distribution, underlying conditions, and specific
treatment goals.
Each surgical approach to managing spasticity requires rigorous evaluation and well-designed
studies to establish its long-term efficacy and safety. Advances in these surgical
fields will enhance patient care and contribute to better clinical outcomes and functional
independence. [Table 2 ] gives a summary of the various studies included in this review.
Table 2
Summary of the various studies included in this review article
Surgical approaches
References
Level of evidence
Types of study
No. of cases
Follow-up
Performed intervention
Result
SDR
Dudley et al[8 ]
Level 4
Case series
102 pre-op, 97, 62, 57, 14
1, 5, 10, and 15 y
SDR with/without adjunct orthopedic procedures or Botox injections
Long-term improvements in muscle tone, gross motor function, and ADLs, better outcomes
in GMFCS I–III, diplegia, lower hip adductor spasticity
SDR
Kakodkar et al[11 ]
Level 4
Case series
141
Short to mid term
SDR performed on adult patients with spasticity
Improved ambulation and reduced spasticity
SDR
Lu et al[12 ]
Level 1
Systematic review
636 patients
Not specified
Systemic, epidural, and intrathecal analgesia
Variations in regimens reported; opioid-based regimens common with evolving multimodal
approaches
SDR
Wright et al[13 ]
Level 1
RCT
24 (12 RG, 12 CG)
12 mo
SDR with PT and OT vs. PT and OT alone
RG showed greater GMFM improvement (+12.1% vs. +4.4% in CG, p < 0.02); reduced tone, increased
SDR
Abd-Elmonem et al[14 ]
Level 1
RCT
42 (5–8 y)
1 y (post I and II)
SDR + PT with progressive functional strength training and SOM
Improvement in GMF, balance, walking capacity, SMC, and ECW compared to controls (p < 0.001)
SDR and ITB
Davidson et al[15 ]
Level 1
Systematic review
27 studies
12–36 mo
SDR sectioning of selective sensory nerve rootlets and ITB implantation for CP
SDR and ITB reduce spasticity (Ashworth scale) and improve GMF (GMFM); ITB has higher
complication rates due to device-related risks
SDR
Mishra et al[16 ]
Level 2
Systematic review
30 studies
Long-term (varied)
Sectioning of selective sensory nerve rootlets to reduce spasticity
➢Scoliosis and sensory changes
Cervical spinal cord DREZ lesioning (radiofrequency thermocoagulation)
Khalifeh et al[17 ]
Level 5
Case report
1 patient
3 mo postoperatively
DREZ lesioning with radiofrequency thermocoagulation targeting pain fibers
Complete pain relief postsurgery, sustained at 3-mo follow-up
Cervical DREZotomy for BPA pain
Ko et al[18 ]
Level 3
Case series
27 patients
62.5 mo
Cervical DREZotomy for BPA pain relief
Initial success rate was 73%, but it declined to 66% after a median follow-up time
of 62.5 mo
MDZ
Doddamani et al[19 ]
Level 4
Case series
56 patients
32 mo
Microscissor DREZotomy for post-BPA brachialgia
87% patients experienced pain relief (>25%)
Cervical MDT
Sindou et al[20 ]
Level 4
Case series
3 patients
Not mentioned
Deep cervical microsurgical DREZotomy for focal dystonia
Hypertonia reduction, suppression of dystonic postures, improved residual motor function
Right radiofrequency dentatotomy
Villegas-López et al[21 ]
Level 5
Case report
1 patient
8 mo postoperatively
Right radiofrequency dentatotomy for spasticity with intraoperative electrophysiological
monitoring
Significant decrease in spasticity at 1 mo (Ashworth 1), further decrease to Ashworth
0 after 8 mo, but increase in spasms
MDT
Goyal et al[22 ]
Level 4
Case series
7 patient
Last follow-up
MDT performed at L3–S1, L3–S4, and C5–T1 levels based on patient's spasticity pattern
Significant improvement in Ashworth grade (from 3.14 to 0.29). Improvement in care
tasks (physiotherapy, hygiene, etc.)
DREZ lesioning (DREZotomy)
Mongardi et al[23 ]
Level 2
Systematic review
1,242 patients
Medium to long term
DREZotomy for chronic pain in conditions like brachial plexus avulsion, spinal cord
injury, etc.
Good outcomes in brachial plexus avulsion and spinal cord injury. Lower success in
phantom limb pain and post-herpetic neuralgia
DREZ lesioning (microsurgical vs. radiofrequency assisted)
Shekouhi et al[24 ]
Level 1
Systematic review
917 patients
Variable across studies
Comparison between microsurgical DREZotomy (MDT) and radiofrequency-assisted DREZ
lesioning (RF) for pain management in BPA
MDT results in better VAS score improvements and lower rates of motor deficits compared
to RF-assisted DREZ lesioning
Percutaneous thermal radiofrequency rhizotomy
Shapkin et al[25 ]
Level 4
Case series
26 pediatric patients
Long term
Thermal RF rhizotomy at L2–S1 levels at 70°C for 90 s
Significant reduction in spasticity (MAS score: from 3.0 ± 0.2 to 1.14 ± 0.15
rTMS, AOT, combined intervention
Fan et al[26 ]
Level 1
RCT
64 children with SCP
12 wk
Conventional, rTMS, AOT, combined rTMS + AOT
Combined rTMS + AOT showed the highest improvement in gross motor function, compared
to conventional, rTMS, and AOT
Thermal radiofrequency for musculocutaneous nerve
Otero-Villaverde et al[27 ]
Level 4
Case series
12 patients
6 mo
Ultrasound-guided thermal radiofrequency at 80°C for 90 s to musculocutaneous nerve
Improvements in spasticity
Ultrasound-guided alcohol neurolysis
Lee et al[28 ]
Level 4
Case series
10 patients
2 mo
Ultrasound-guided alcohol neurolysis at 35% concentration to musculocutaneous nerve
Musculocutaneous nerve to relieve elbow spasticity in hemiparetic stroke patients
SPN
Sindou et al[29 ]
Level 4
Case series
20 patients approx.
1–3 y
SPN on various nerves affecting spastic muscles, including obturator nerve, hamstring,
tibial, and femoral nerves
Effective in reducing spasticity and improving motor function in children with focal
spasticity. Positive outcomes in most cases
Peripheral neurotomy for spasticity
Decq et al[30 ]
Level 4
Case series
277 patients 392 neurotomies
Not mentioned
Peripheral neurotomy on posterior tibial nerve collateral branches for spastic foo
Improvement ankle and improved angular variations during stance
Hyperselective peripheral neurotomy
Bajaj et al[31 ]
Level 4
Case series
21 patients
6 mo
Selective resection of ∼70% of terminal nerve branches of spastic muscles using neuromonitoring;
tendon release in cases with contractures
MAS score reduced to ≤2 in all patients; significant pain reduction (VAS ↓); no major
motor deficits; minor complications like transient neuropathic pain in some cases
Hyperselective tibial neurotomy for SEF
Bajaj et al[32 ]
Level 5
Case report
1 patient
6 mo
Hyperselective tibial neurotomy
Correction of deformities, abolition of clonus, improvement in spasticity (Modified
Ashworth score decreased from 4 to 1)
Selective motor fasciculotomy (musculocutaneous, median, ulnar nerves)
Puligopu et al[33 ]
Level 4
Case series
20 patients
Not specified
Selective motor fasciculotomy on musculocutaneous, median, and ulnar nerves for upper
limb spasticity
Significant reduction in spasticity, improvement in selective voluntary control, hand
functions (grasp), and self-care (Wee FIM) without complications or recurrence of
spasticity
Surgical management of shoulder and elbow in spasticity
Landi et al[34 ]
Level 4
Case series
138 (50 shoulder/elbow surgeries
Varies
Shoulder/elbow deformity surgery (e.g., tendon release, muscle rebalancing)
Improvement in shoulder stability, range of motion, and reduction in hypertonus/spasticity
in most patients, with a mean FIM score improvement
SPN
Sitthinamsuwan et al[35 ]
Level 4
Case series
33 patients and 141 SPN
Short to medium term
SPN for severe intractable focal and multifocal spastic hypertonia
SPN reduced spasticity (MAS: 3.0 to 0.7, p < 0.001) and improved PROM (78.3° to 102.3°, p < 0.001). Ten ambulatory patients showed gait improvement, and nine bed-bound patients
had better sitting and mobility
Combined SPN (cSPN)
Liu et al[37 ]
Level 4
Case series
14 patients
Not specified
cSPN for severe lower limb spasticity in SCI patients
Significant reduction in spasm, improved gait, and enhanced motor function
Tibial nerve neurotomy
Rousseaux et al[38 ]
Level 4
Case series
51 patients
3 mo to 2 y
Partial resection of tibial nerve motor branches in patients with lower limb deformity
Reduced spasticity, improved motor control, balance, gait; sensory disorders in some
cases
Selective tibial neurotomy for spastic equinovarus foot
Deltombe et al[39 ]
Level 4
Case series
30 patients
2 y
Selective neurotomy at motor nerve branches of the tibial nerve for spastic equinovarus
foot
Reduced spasticity, improved gait speed, lasting effect with no muscle weakness
Selective neurotomy for focal lower limb spasticity
Ploegmakers et al[40 ]
Level 2
Systematic review
Total: 26 studies
Non-RCT (25)
RCT (1)
Variable
Selective neurotomy for lower limb spasticity
Improved muscle tone, pain, ankle motion, and walking speed; more evidence needed
through controlled trials
ITB for spinal cord injury with neurofibromatosis
O'Brien et al[41 ]
Level 5
Case report
1
6 wk
Intrathecal baclofen pump implantation after trial
Improved spasticity (MAS 1-2/4), independence in transfers and ADLs, minimal support
needed post-rehabilitation
SPN for upper limb spasticity
Maarrawi et al[42 ]
Level 4
Case series
31 patients
4.5 y
Selective peripheral neurotomy on musculocutaneous, median, and ulnar nerves
Improved spasticity, hand function, daily activities. 61.5% satisfaction. Low complication
rate (15%)
ITB therapy
Schiess et al[43 ]
Level 4
Case series
1,743 patients
Long-term
Baclofen delivered intrathecally via pump
Reduction in severe spasticity, improved quality of life
ITB for spinal origin spasticity
Ochs et al[44 ]
Level 4
Case series
Long-term
ITB therapy for spinal cord injury, spinal cord disease, and MS-related spasticity
Reduced spasticity, better functional outcomes
ITB
Cozzi et al[45 ]
Level 1
Systematic review
17 studies
12 mo
ITB pump implantation for MSRS
Significant reduction in spasm frequency, improved quality of life, and few complications
ITB
Masrour et al[46 ]
Level 1
Systematic review
501 implantations
12 mo
ITB therapy for spasticity in cerebral palsy patients
40.25% reduction in spasticity, minor motor function improvement (9.62%), some complications
like seizures and infections
ITB
Lee et al[47 ]
Level 1
Systematic review
534 patients
Not specified
ITB therapy in ambulatory patients with spasticity
No loss of ambulatory function, improvements in gait speed and spasticity
ITB
Creamer et al[48 ]
Level 1
RCT
60 patients
6 mo
➢ITB vs. conventional medical management
ITB significantly reduced spasticity compared to CMM, with more adverse events in
ITB group
Baclofen vs. TENS for spasticity in MS
Shaygannejad et al[49 ]
Level 1
RCT
52 patients
4 wk
Baclofen vs. TENS
Both baclofen and TENS significantly reduced spasticity, with TENS showing greater
efficacy (p < 0.05) and few side effects compared to baclofen
ITB
Plassat et al[50 ]
Level 4
Case series
40 patients
4 y
ITB pump implantation
Effective long-term spasticity reduction, patient satisfaction (7.4/10), 37% complication
rate (catheter issues, pump malfunctions), 12% severe side effects requiring ICU
PRISMA-based modified scoping review
Suputtitada et al[51 ]
Grade A
Systematic review
14 studies
2000–2023
Stretching exercises, TENS, extracorporeal shock wave therapy, peripheral magnetic
stimulation, noninvasive brain stimulation, ITB, whole body vibration, localized muscle
vibration
Effective for improving functional recovery and quality of life in post-stroke spasticity
SMF of MCN
Purohit et al[52 ]
Level 4
Case series
52 patients
17 mo
SMF of MCN for spastic elbows in cerebral palsy
62.66% elbows achieved total relief of spasticity, improved motor function, no recurrence
or side effects
Abbreviations: ADL, activity of daily living; AOT, action observation training; BPA,
brachial plexus avulsion; CP, cerebral palsy; DREZ, dorsal root entry zone; ECW, energy
cost of walking; GMFM, gross motor function measure; ITB, intrathecal baclofen; MAS,
modified Ashworth score; MCN, musculocutaneous nerve; MDZ, microscissor DREZotomy;
MDT, microsurgical DREZotomy; MSRS, multiple sclerosis-related spasticity; OT, occupational
therapy; PROM, passive range of motion; PT, physiotherapy; RCT, randomized controlled
trial; rTMS, repeated transcranial magnetic stimulation; SDR, selective dorsal rhizotomy;
SMC, selective motor control; SMF, Selective musculocutaneous fasciculotomy; SPN,
selective peripheral neurotomy; TENS, Transcutaneous Electrical Nerve Stimulation-;
TMS, transcranial magnetic stimulation.
Discussion
A systematic review of surgical treatments for spasticity, including SDR, DREZotomy,
SPN, and ITB, shows promising results in improving function, reducing pain, and enhancing
quality of life for patients with neurological conditions such as stroke, TBI, multiple
sclerosis, and CP. SPN, particularly targeting the musculocutaneous, median, ulnar,
and tibial nerves, has also demonstrated benefits in reducing spasticity and improving
upper and lower limb function, with long-term follow-up revealing significant improvements.[30 ]
[38 ]
[39 ]
[50 ] A 2013 retrospective study on SPN suggested that more data on long-term outcomes
are needed.[35 ] ITB has demonstrated significant efficacy in treating spasticity associated with
multiple sclerosis and SCI.[41 ] Despite positive outcomes, surgical interventions are associated with risks such
as infection, nerve damage, and bleeding, emphasizing the need for expert surgical
skills and careful patient selection.[32 ] Preserving sensory and motor fascicles is crucial to avoid complications such as
sensory loss and muscle weakness. Success depends on careful patient selection, precise
techniques, and intraoperative monitoring. Postsurgery rehabilitation is essential,
and the complexity of the operation, which may require microscope-assisted dissection,
can extend its duration. Surgical interventions hold promising potential for better
outcomes and quality of life with ongoing innovations.
Future surgical interventions in neurosurgery should focus on integrating advanced
neuroimaging techniques and neurophysiological monitoring to ensure precise and patient-specific
treatments. This approach will aid in accurately identifying surgical targets and
reducing unnecessary tissue damage. Additionally, adopting minimally invasive techniques
like robotic-assisted surgeries and laser-guided interventions can enhance surgical
outcomes by lowering recovery times and minimizing complications. Emphasis must also
be placed on multidisciplinary care by incorporating optimized postsurgical physical
and occupational therapy. Longitudinal studies are essential to evaluate the long-term
impact of these strategies on patient recovery and overall quality of life.
