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.