Surgical Approach for Spasticity: A Systematic Review

Keywords

craniocerebral trauma - denervation - functional neurosurgery - muscle spasticity - rhizotomy - stroke

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.

Conclusion

Surgical treatments for spasticity need to be patient-specific. Most studies show positive results in well-selected patients. More high-quality research is required to establish the efficacy of these interventions.

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