Surgical management of spasticity

Abstract

The management of patients with cerebral palsy and other causes of spasticity is a challenge to an entire rehabilitation team and to caregivers. In South Africa,  neurosurgeons have had limited involvement in this field owing to a perceived lack of options, leaving the care of these patients largely in the hands of paediatric  neurologists and orthopaedic surgeons. A committed team-based approach, where a neurosurgeon is part of the decision-making process, can however significantly improve functional outcomes in patients with spasticity. Key to the evaluation and therapeutic decision-making is the focus on function – not only the range of  movement or the presence of spasticity. Some techniques can completely remove spasticity and contractures, but these mostly leave a patient with more functional impairment than they had before the surgery. With the careful combination of botulinum toxin injections and oral baclofen, these patients, who may benefit from further orthopaedic and neurosurgical procedures, can be identified and helped in reducing the function-limiting spasticity. With the emphasis on function as an individualising factor, significant improvements may follow minor interventions, e.g. performing a surgical procedure to allow reduced hip adductor spasticity, thereby allowing improved hygiene and less pain in a child in whom it was previously not possible to abduct the hips enough to change a nappy. Functional improvement does not necessarily equate to walking. We describe the process of evaluating patients with spasticity and outline the surgical decision-making process that helps towards an individualised therapeutic strategy in managing this challenging group of  patients.