Spasticity

Surgery

The goals of the surgical treatment of spasticity may include improving access for hygiene, improving the ability to tolerate braces, reducing pain, improving function such as walking, or reducing the risk of further deformity.

Orthopedic Operations
With orthopedic surgery, muscles can be denervated, and tendons and muscles can be released, lengthened, or transferred. Spastic muscles in the shoulder, elbow, forearm, hands, and legs may all be treated with tendon or muscle lengthening. In tendon transfers, spastic muscles may be used to advantage by transferring them across the joint, relieving the deforming action of the muscle on the joint and simultaneously aiding the antagonist muscle. In some cases, a split transfer is desirable, for instance in the treatment of varus feet. In some situations, the transfer allows improved function. In others, the joint retains passive but not active function.32

In contracture release, the surgeon partially or completely severs the contracted tendon and then repositions the joint at a more normal angle. The joint is encased in a cast over a period of several weeks while the tendon regrows, often requiring the use of serial casting to achieve maximum success. Once the cast is removed, physical therapy is necessary to strengthen the muscles and improve the patient's range of motion.

Split tendons may also be employed in conjunction with osteotomy and arthrodesis to more fully correct the joint deformity. Osteotomies are most commonly used to correct hip displacements and foot deformities. Arthrodesis, a fusing together of bones that normally move independently, limits the ability of a spastic muscle to pull the joint into an abnormal position. Arthrodesis procedures are performed most often on the bones in the ankle and foot.

Selective Dorsal Rhizotomy
Although performed most often for the treatment of spasticity in children with cerebral palsy, selective dorsal rhizotomy may be used in the treatment of post-stroke spasticity to treat spasticity of the legs that interferes with movement or positioning. In this procedure, electrophysiologic guidance is employed to identify abnormal sensory nerve rootlets, which are then sectioned, leaving the motor nerves intact. The best candidate for selective dorsal rhizotomy is a person with good strength and balance, spasticity in either or both legs with minimal or no fixed contractures, no spasticity in the arms, and strong motivation and support.64