This didactic will cover surgical considerations in spasticity management. I am Andrea Toomer, a physiatrist with the Coligea Neurological Clinic and the Louisiana State University Department of Neurosurgery. I am a speaker and an advisor for a number of pharmaceutical and device companies. In this didactic, we will discuss the surgical treatment options for spasticity, and we will also outline the surgical options to treat the manifestations of increased muscle tone. In this first portion, we will discuss the surgical options for treating spasticity. Intrathecal baclofen is one surgical treatment option for spasticity. Baclofen is a GABA agonist that acts at the spinal cord level to impede the release of excitatory neurotransmitters that cause spasticity. Intrathecal baclofen is delivered into the intrathecal space through a surgically implanted programmable pump. Appropriate candidates for intrathecal baclofen therapy have generalized problematic severe spasticity. These patients have had a positive response to an intrathecal baclofen screening test. These patients also have sufficient body habitus to accommodate the size of the intrathecal baclofen pump. Intrathecal baclofen therapy is delivered through a surgically implanted pump. This pump is programmable so that different doses of intrathecal baclofen can be delivered depending on patient response. The therapy is completely reversible. Intrathecal baclofen can be lowered and stopped, and the pump can be explanted at any point in time. There is some risk of malfunction or loss of integrity of the pump and catheter system, which increases the risk of baclofen withdrawal or baclofen overdose. With the intrathecal baclofen pump system, the pump needs to be replaced approximately every seven years due to battery life. This would require a repeat surgical intervention for pump replacement. Selective dorsal rhizotomy is another surgical option for the treatment of spasticity. This is a permanent neurosurgical procedure for the treatment of spasticity. The procedure involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Selective dorsal rhizotomy has evolved with the advancement of intraoperative neuromonitoring techniques. Patient selection is very important in order to obtain a positive outcome after selective dorsal rhizotomy. Appropriate candidates are children with spastic diplegic cerebral palsy. Patients who have truncal weakness, dystonia, or athetosis are not good candidates for selective dorsal rhizotomy. In these cases, the patients may have poor ability to rehabilitate after the procedure. Weakness can be exacerbated and dystonia can be unmasked by selective dorsal rhizotomy. Concerns surrounding selective dorsal rhizotomy include causing spinal instability resulting from a multilevel laminectomy. This can cause collapse into lordosis. There is also a concern that this is a permanent procedure based on how a child is functioning at a particularly young age. We know that children grow and weakness can progress as these children grow. The selective dorsal rhizotomy procedure is permanent and cannot be altered or changed as the child grows and weakness progresses. In this next section, we will discuss surgical options to treat the manifestations of spasticity. These procedures do not treat spasticity itself, but rather treat the manifestations of long-term spasticity. Manifestations of increased muscle tone can be seen in all of the joints of the body, including the spine. Joint deformities and contractures can develop due to increased muscle tone. Tendons can be subluxed or dislocated. Increased muscle tone can affect the alignment of the vertebrae resulting in scoliosis, which often manifests as pelvic obliquities and difficulty with seating. Tendon transfers can be performed to improve function. These procedures change the force line of the muscle, for example, turning a flexor into an extensor. Pictured here is a split tibialis anterior tendon transfer to correct varus deformity at the ankle. Depending on the tendons involved, tendon lengthening can be performed to correct deformity. Fusions can also be performed to correct joint deformity and give stability. Hamstring lengthening tends to have worse outcomes in older age as it does not account for changes at the trunk, the hip, and the ankle, which also contribute to the flexed knee posture. For example, finger flexor releases do not do well and can cause further deformity at the fingers, whereas toe flexors can be released with good outcomes. Spinal fusion can be performed to correct and stabilize severe scoliosis. Hip flexor and adductor tenotomies can be performed to prevent hip dislocation. Femoral osteotomy involves cutting the bone in order to realign and restore a more normal anatomy. When making surgical referrals for spasticity treatment, we should consider that early treatment will provide for better long-term outcomes. Surgical intervention will only be successful if the underlying spasticity is being addressed. Any surgical intervention should be coupled with bracing to maintain the improved positioning achieved with the surgical intervention. All of the following is true about selective dorsal rhizotomy except it is a permanent neurosurgical procedure for the treatment of spasticity. It involves selective lesioning of the sensory rootlets in an effort to reduce spasticity. Several candidates have truncal weakness and dystonia in addition to spasticity. It has evolved with the advancement in intraoperative neuromonitoring techniques. Selective dorsal rhizotomy is a permanent neurosurgical procedure for the treatment of spasticity. The surgery involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. The ideal patient is an ambulatory child with cerebral palsy of the spastic-diplegic subtype without any dystonic features or truncal weakness. Exclusion criteria for selective dorsal rhizotomy includes truncal weakness and dystonia. These characteristics all lead to inability to rehabilitate as the weakness is exacerbated and the dystonic or dynamic movement component is unmasked by selective dorsal rhizotomy. Selective dorsal rhizotomy technique has evolved with the advancement in intraoperative neuromonitoring techniques. Intrathecal baclofen treatment requires surgical implantation of a programmable pump for delivery of medication to the intrathecal space. Selective dorsal rhizotomy is a permanent surgical procedure for the treatment of select patients with spastic-diplegic cerebral palsy. Surgical interventions for the manifestation of tone may be of benefit, and surgical interventions must be coupled with bracing and treatment of underlying spasticity in order to have successful outcomes.

spasticity management

intrathecal baclofen

selective dorsal rhizotomy

joint deformities

early treatment