Spasticity

Spasticity is a form of muscle stiffness caused by abnormal signaling between the nervous system and the muscles. Instead of relaxing normally, affected muscles remain tense or contract involuntarily, which can make movement difficult, cause pain, interfere with sitting or positioning, and make daily care more difficult for patients who depend on others for support. Spasticity is common in conditions such as cerebral palsy, spinal cord injury, multiple sclerosis and stroke.

Spasticity does not look the same in every patient, and its effects go well beyond stiffness alone:

• Muscle tightness that resists passive movement, and abnormal postures in the arms or legs
• Pain and muscle spasms, sometimes triggered by touch, movement or a full bladder
• Difficulty with walking, transfers, sitting or positioning in a wheelchair
• Interference with sleep and with daily care such as dressing, washing or diaper changes
• Over time, a risk of fixed joint contractures if severe spasticity is not adequately managed

Most patients with spasticity are managed well with oral medication, targeted botulinum toxin injections, physical therapy, bracing and positioning equipment, and this remains true for the majority throughout the course of their condition. Neurosurgical treatment is generally considered only when spasticity is severe, widespread, and no longer adequately controlled by these measures; and when it is significantly limiting movement, comfort, positioning or ease of care.

Two neurosurgical options are used for carefully selected patients, and they suit different patterns of spasticity:

• Selective Dorsal Rhizotomy (SDR): a procedure that permanently reduces abnormal sensory signals contributing to spasticity, most often used in children with spastic diplegic cerebral palsy affecting the legs, where spasticity itself is the main factor limiting movement.
• Intrathecal Baclofen Pump Therapy: an implanted, adjustable pump that delivers a muscle-relaxant medication directly into the spinal fluid, generally considered for more severe, generalized or regional spasticity affecting the legs and sometimes the trunk and arms.

Neither treatment is appropriate for every patient with spasticity, and careful, individualized patient selection is central to both. Evaluation typically involves close coordination between neurosurgery, rehabilitation medicine and physical therapy, and often, for children, close involvement of the family in planning post-treatment rehabilitation.

• Detailed assessment of the pattern, severity and functional impact of spasticity
• Neurological examination distinguishing spasticity from weakness, dystonia, ataxia or fixed contractures
• Gait analysis and standardized function scoring, where walking is a relevant goal
• Physiotherapy assessment of current function and rehabilitation potential
• Imaging of the spine where surgery is being considered

Treatment goals vary between patients and are set individually rather than assumed. For some patients, particularly those with good underlying strength and motor control, the goal may be a more efficient walking pattern and greater independence. For others, the goal may be reduced pain, easier positioning and transfers, and easier caregiving. Neither SDR nor intrathecal baclofen therapy is presented as restoring normal movement.

Both treatments are described in full, including their specific risks, on their own pages. In general terms: SDR produces a permanent reduction in spasticity and carries the risks of major spinal surgery; intrathecal baclofen therapy is adjustable and reversible but requires an implanted pump, regular medical follow-up, and carries specific risks related to the medication itself. Which option, if either, is appropriate depends on the pattern of spasticity, its underlying cause, and the patient’s overall goals.