Neurosurgery for Spasticity A Practical Guide for Treating

Children and Adults

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Marc Sindou
George Georgoulis
Patrick Mertens

Neurosurgery
for Spasticity
A Practical Guide for Treating
Children and Adults
Marc Sindou, M.D., D.Sc.
Department of Neurosurgery
University of Lyon 1
Hôpital Neurologique Pierre Wertheimer, GHE
Lyon
France

George Georgoulis, M.D.

Department of Neurosurgery
University of Lyon 1
Hôpital Neurologique Pierre Wertheimer, GHE
Lyon
France

Patrick Mertens, M.D., Ph.D.

Department of Neurosurgery
University of Lyon 1
Hôpital Neurologique Pierre Wertheimer, GHE
Lyon
France

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Preface

Spasticity is a common sequelar condition frequently encountered after a variety of

pathologies that affect the upper motor neuron system. Spasticity can be useful by
compensating for lost motor strength, but may also become harmful leading to fur-
ther functional losses and irreducible contractures.
When spasticity fails to be controlled by relaxant medications and physical ther-
apy and special rehabilitation programs, functional neurosurgery can be a recourse.
By aiming at diminishing the excess of tone and re-equilibrating the tonic balances,
neurosurgical procedures, that often need to be supplemented with orthopedic oper-
ations, may help improve function and limit irreversible deformities.
The book is devoted to the neurosurgical management of spasticity. The matter
is based on an overall surgical experience of more than a thousand patients, both
adults and children. The book reports in a synthetic way the lessons from own clini-
cal observations and main literature data. The authors have attempted to organize
the whole in a didactic and practical manner.
Overall, emphasis is placed on the importance of a multidisciplinary approach,
including neurologists, pediatricians and rehabilitation specialists. Close collabora-
tion with other surgical disciplines, namely, orthopedic surgery, neuro-urology,
among many other specialties, are also outlined.
We hope that the book will be a useful aid for all physicians and professionals
directly or indirectly involved in caring these severely affected and disabled patients.

Lyon, France Marc Sindou

George Georgoulis
Patrick Mertens

v
Acknowledgements

First of all, we want to express our deep indebtedness to those patients who have to
endure their harmful disease, to their family and their caregivers, for their courage
to face so often severe handicaps.
We wish then to manifest our gratitude to the neurosurgical team whom we are
daily working with, namely doctors Gustavo Polo, Emile Simon, Afif Afif, Andrei
Brinzeu, and also the physical therapists, the nurses, the secretaries and all the staff
members, so intensively devoted to the task of treating these disabled patients.
Acknowledgements go to our partners who collaborate to the Adult Rehabilitation
program, professors Dominique Boisson and Jacques Liauté, and those who are in
charge of the Pediatric population: doctors Carole Bérard and Isabelle Poirot,
together with their medical network.
We are also indebted to distinguished universitary colleagues for their fruitful
cooperation and advices, in particular professors Milan Dimitrijevic, Rick Abbott,
Philippe Decq, Takaomi Taira, and eminent others, and also to our many pupils over
the world.
Special acknowledgement is to Mrs Silvia Schilgerius for her guidance in the
Edition work, as well as for the Editing and Production departments at Springer.
We do hope the book will be useful.

Lyon, France Marc Sindou, M.D., D.Sc.

vii
Contents

1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Part I General Information

2 History of Neurosurgical Treatment for Spasticity . . . . . . . . . . . . . . . 7

2.1 Pioneering Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Surgery on Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 Surgery on Spinal Roots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.4 Surgery on the Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5 Surgery in the Dorsal Root Entry Zone . . . . . . . . . . . . . . . . . . . . . 14
2.6 Stereotactic Lesioning Techniques . . . . . . . . . . . . . . . . . . . . . . . . 14
2.7 Intrathecal Infusion of Baclofen . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3 Anatomical and Physiological Bases of Motricity Applied
to the Study of Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1 Organization of Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1.1 Alpha Motoneurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1.2 Primary Afferents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.1.3 System of Spinal Interneurons. . . . . . . . . . . . . . . . . . . . . . 22
3.1.4 Ascending Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2 Supraspinal Descending Pathways . . . . . . . . . . . . . . . . . . . . . . . . 24
3.2.1 Corticospinal System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.2.2 Descending Lateral System . . . . . . . . . . . . . . . . . . . . . . . . 24
3.3 Importance of the Reticular Formation . . . . . . . . . . . . . . . . . . . . . 24
3.3.1 RF Afferents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.3.2 Specific Efferent RF Pathways . . . . . . . . . . . . . . . . . . . . . 25

Part II Adults

4 Evaluation of Spasticity in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

4.1 Common Clinical Patterns of Abnormal Postures in Spasticity . . 32
4.1.1 Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.1.2 Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
ix
x Contents

4.2 Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.2.1 Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.2.2 Upper Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.2.3 Dynamic Gait Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.3 Clinical Diagnosis and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 43
4.3.1 Clinical Characterization of Spasticity . . . . . . . . . . . . . . . 43
4.3.2 Assessment of Range of Motion . . . . . . . . . . . . . . . . . . . . 44
4.3.3 Retractions and Contractures. . . . . . . . . . . . . . . . . . . . . . . 49
4.3.4 Electrophysiological Diagnosis . . . . . . . . . . . . . . . . . . . . . 49
4.4 Functional Disability Attributed to Spasticity . . . . . . . . . . . . . . . . 53
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5 Decision-Making for Treatment of Adults
with Disabling Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1 Intrathecal Baclofen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2 Neurolesioning Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6 Intrathecal Baclofen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.1 Physiologic and Pharmacokinetic Effects of Baclofen . . . . . . . . . 69
6.2 Implanted Programmable Pump . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6.3 Side-Effects and Complications of Baclofen. . . . . . . . . . . . . . . . . 75
6.4 Surgical Indications and Patient Selection . . . . . . . . . . . . . . . . . . 76
6.4.1 Spasticity of Spinal Origin . . . . . . . . . . . . . . . . . . . . . . . . 76
6.4.2 Spasticity of Brain Origin . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.4.3 Spasticity and/or Dystonia Due to Cerebral Palsy. . . . . . . 77
6.4.4 Alternative Methods for Patients with Brain Lesion
or Cerebral Palsy Harboring Focalized and Severe
Spasticity and/or Dystonia . . . . . . . . . . . . . . . . . . . . . . . . 78
6.5 Patient Selection and Screening . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.6 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.7 Postoperative Management and Dosing After Implantation . . . . . 83
6.8 Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.8.1 Effect on Spasticity and Dystonia . . . . . . . . . . . . . . . . . . . 84
6.8.2 Effect on Urinary Function . . . . . . . . . . . . . . . . . . . . . . . . 86
6.8.3 Effect on Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.8.4 Effects on Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.8.5 Effects on Orthopedic Deformities . . . . . . . . . . . . . . . . . . 87
6.9 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6.9.1 Device-Related Complications . . . . . . . . . . . . . . . . . . . . . 88
6.9.2 Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
6.10 Intraventricular Baclofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
7 Botulinum Toxin Injections for Spasticity . . . . . . . . . . . . . . . . . . . . . . 103
7.1 Clinical Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.2 Site and Dose Determination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Contents xi

7.3 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

7.4 Onset and Duration of Therapeutic Effects . . . . . . . . . . . . . . . . . . 106
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
8 Peripheral Neurotomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.1 Rationale for Selectivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.2 Technical Bases for Neurotomy . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8.2.1 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
8.2.2 Mapping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.2.3 Sectioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.3 Operative Techniques for Lower Limb . . . . . . . . . . . . . . . . . . . . . 113
8.3.1 Obturator Neurotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
8.3.2 Hamstring Neurotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
8.3.3 Tibial Neurotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
8.3.4 Femoral Neurotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
8.3.5 Anterior Tibial Neurotomy . . . . . . . . . . . . . . . . . . . . . . . . 122
8.4 Operative Techniques for Upper Limb . . . . . . . . . . . . . . . . . . . . . 123
8.4.1 Pectoralis Major and Teres Major Neurotomies . . . . . . . . 123
8.4.2 Musculocutaneous Neurotomy . . . . . . . . . . . . . . . . . . . . . 123
8.4.3 Median Neurotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
8.4.4 Ulnar Neurotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.4.5 Combined Neurotomies in Upper Limb . . . . . . . . . . . . . . 129
8.5 Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
8.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
8.6.1 Local Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
8.6.2 Neurological Complications . . . . . . . . . . . . . . . . . . . . . . . 134
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
9 Surgery in Dorsal Root Entry Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
9.2 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
9.2.1 Operative Procedure at Cervical Level . . . . . . . . . . . . . . . 145
9.2.2 Operative Procedure at Lumbosacral Level. . . . . . . . . . . . 147
9.3 Outcome, Side-effects, and Complications . . . . . . . . . . . . . . . . . . 150
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Part III Children

10 Spasticity in Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
11 Assessment of Spasticity in Pediatric Patients . . . . . . . . . . . . . . . . . . . 167
11.1 Physical Observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
11.2 Assessment of Range of Motion . . . . . . . . . . . . . . . . . . . . . . . . . . 170
11.3 Quantification of Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
11.4 Quantification of Dystonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
xii Contents

11.5 Evaluation of Functional Abilities. . . . . . . . . . . . . . . . . . . . . . . . . 174

11.5.1 Gross Motor Function Measure. . . . . . . . . . . . . . . . . . . . 174
11.5.2 New York University Classification System . . . . . . . . . . 175
11.5.3 Pediatric Evaluation of Disability Inventory . . . . . . . . . . 176
11.6 Video Recordings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
11.7 Dynamic Gait Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
12 Decision-Making for Treatment of Children with Disabling
Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
12.1 Preoperative Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
12.1.1 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
12.1.2 Therapeutic Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
12.2 Lower-Limb Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
12.2.1 Global Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
12.2.2 Focal Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
12.3 Upper-Limb Spasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
12.4 Children with Cerebral Palsy Presenting with Mixed
Spasticity and Dystonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
13 Dorsal Rhizotomies for Children with Cerebral Palsy . . . . . . . . . . . . 191
13.1 Technical Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
13.1.1 Whole Cauda Equina Exposure by Laminotomy
from L1/L2 to S1/S2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
13.1.2 Limited Exposures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
13.2 Protocol for Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
13.3 Topographical Mapping and Physiological Testing . . . . . . . . . . . 195
13.3.1 Topographical Mapping. . . . . . . . . . . . . . . . . . . . . . . . . . 198
13.3.2 Physiological Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
13.3.3 Combined Topographical Mapping
and Physiological Testing . . . . . . . . . . . . . . . . . . . . . . . . . .199
13.3.4 H-Reflex Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
13.4 Quantification of Dorsal-Root Sectioning . . . . . . . . . . . . . . . . . . . 202
13.5 Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
13.6 Complications and Their Prevention . . . . . . . . . . . . . . . . . . . . . . . 204
13.7 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Part IV Complementary Treatments and Brief on Decision-Making

for Neurosurgery

14 Orthopedic Surgery for Correction of Spastic Disorders . . . . . . . . . . 217

14.1 Spasticity in Lower Limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
14.2 Spasticity in Upper Limb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Contents xiii

14.3 Main Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

14.3.1 Hemiplegic Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
14.3.2 Paraplegic or Tetraplegic Adults . . . . . . . . . . . . . . . . . . . 221
14.3.3 Patients with Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . . 223
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
15 Management of Hyperactive Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . 225
15.1 Mechanisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
15.2 Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
15.3 Urodynamic Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
15.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
15.4.1 Urologic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
15.4.2 Neurological surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
16 Brief on Decision-Making for Neurosurgery of Adults
and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
16.1 Who to Operate? The Candidates Benefitting
from Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
16.2 Why to Operate? The Objectives and Limits
of Neurosurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
16.3 When to Operate? The Appointment of Surgery. . . . . . . . . . . . . . 234
16.4 How to Operate? The Choice of Procedure. . . . . . . . . . . . . . . . . . 234
16.5 Where to Operate? The Necessity of a Multidisciplinary Team. . . . . 235

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Introduction
1

Spasticity – as a component of the upper motor neuron syndrome – is a frequently

encountered clinical condition. Spasticity may be either useful – by compensating
decrease in motor strength – or harmful – by limiting both passive and active motion
and, in the extreme, by leading to irreducible contractures and deformities – or as in
most cases and harmful and useful in the same patient. A large population of adults
and children in developing countries and in wealthy societies as well is suffering
from this locomotor disability. Caring involves a large number and variety of actors.
When spasticity is disabling, an effective therapeutic armamentarium is cur-
rently available. If spasticity fails to be controlled by relaxant medications and
physical therapy and escapes rehabilitation programs, neurosurgical procedures
aiming to diminish the excess of tone and rebalance agonist and antagonist muscle
groups can be the remedy. They may help improve function and limit irreversible
deformities. Complementary orthopedic surgical corrections are often required
though.
Neurosurgery for spasticity is an important field of Functional Neurosurgery.
The concept of Functional Neurosurgery was developed in the 1950s, and defini-
tion given in 1956 by Pierre Wertheimer in his book [1], as follows. “Functional
Neurosurgery is that branch of Neurosurgery which aims at correcting the func-
tional disorders that cannot be normalized by direct cure of the causative lesion.
Operations are based on neurophysiological information. Procedures consist of
removing irritative foci or interrupting excitatory pathways. In the future new pro-
cedures will probably be developed to compensate for failing inhibitory systems.”
This definition is still valid due to the impact of the currently used selective lesion-
ing techniques and visionary in regard to the later developed intrathecal baclofen
(ITB) method [2].
Studies on the underlying mechanisms of spasticity, whatever the location of
the causal lesions, spinal cord or brain, have shown that neurobiological responses
of the central nervous system to damages entail the reorganization of synapses,
creation of new connectivities, and reestablishment of residual functions in partially
impaired structures. Neurorestoration, a newly developed sector of neurology, offers
further insight in the adaptive mechanisms after nervous system insults. The

M. Sindou et al., Neurosurgery for Spasticity, 1

DOI 10.1007/978-3-7091-1771-2_1, © Springer-Verlag Wien 2014
2 1 Introduction

concepts of neuroplasticity and neurorestoration should thus be integrated into the

contemporary management of spasticity in order to effectively optimize outcome.
Spasticity should not be treated just because it is present. Hypertonia may compen-
sate loss of motor power. Spasticity should only be treated when excess of tone leads
to further functional losses, impairs locomotion and motricity, or induces deformities.
Because the strategies of evaluation and assessment of the spastic disorders and the
decision-making processes with adult patients differ significantly from those with pedi-
atric patients, owing to the rapid locomotor and cognitive development of the child, we
present them in separate parts of the book. The book starts with an outline of the history
of neurosurgical spasticity treatment and a survey of the anatomical and physiological
bases of the disorder. Then the various treatment modalities are described with respect
to their impact, whether general or focal, and their effect, whether temporary or perma-
nent. The neurosurgical armamentarium includes: pharmacological therapy with ITB
and lesioning techniques with botulinum toxin injections, surgery to the peripheral
nerves, the dorsal root entry zone and the dorsal roots. At end, orthopedic surgery and
the management of the hyperactive bladder are briefly discussed.
In the following we briefly address the issues most relevant for the choice of an
appropriate treatment of spasticity.
Spasticity may be hard to differentiate from other types of hypertonia or move-
ment disorders; dystonia is a frequently associated disorder especially in patients
with cerebral palsy. Spasticity in the strict sense is defined as the hyperexcitability
of the stretch reflex related to the loss of inhibitory influences from descending
supraspinal structures.
Differentiation between the harmful component(s) of spasticity and its useful
contribution in the antigravity postures and locomotion may not be easy to achieve,
the more so as one and the same muscular group may be able to simultaneously
produce useful and harmful effects. Meticulous clinical and gait analysis, if neces-
sary with anesthetic blocks, are most helpful in the selection process.
The choice of the most appropriate and optimal technique is far from being obvi-
ous in most cases as all of the methods have inherent disadvantages and advantages.
First of all, discussing neurological surgery versus orthopedic surgery frequently
offers a dilemma, especially for children with cerebral palsy. Regarding neurosurgery,
choice must be based on the rationale of each method with respect to the mechanism(s)
of the neurological disorders of every particular patient. Surgery should be tailored to
each individual case. An essential step is to define the objective(s) of the planned
treatment: improvement in function, prevention of deformities, or alleviation of dis-
comfort and pain in the most disabled patients; in other words, what can be gained and
what will not be obtained by surgery. These crucial issues must be clearly explained
to the patients, relatives, and caregivers. Especially for children, the treatment of spas-
ticity must be considered before fixed musculotendinous contractures and joint defor-
mities appear and as part of a therapeutic program that extends over years.
For adult patients, ITB is indicated for paraplegia or tetraplegia with diffuse
spasticity, i.e., spasticity from spinal cord origin. ITB can also be used to treat spas-
ticity related to cerebral palsy. Lesioning operations are reserved for severe spasticity
in the limbs if treatment with botulinum toxin injections has become insufficient.
Peripheral neurotomies are preferred when harmful spasticity affects one (or a few)
References 3

muscular group(s). An anesthetic block used as a preliminary test may help predict
the outcome by mimicking the effect of a planned neurotomy. When harmful spastic-
ity affects the entire limb(s) in paraplegic or hemiplegic patients, surgery directed to
the dorsal roots (dorsal rhizotomies in the lumbar or sacral roots) or the dorsal root
entry zone (using lumbosacral or cervical microsurgical DREZotomy) may be the
solution. Complementary orthopedic operations are frequently needed for patients
developing irreducible contractures and/or joint deformities.
For children with cerebral palsy it is essential to consider the evolution of their
motor abilities and of their cognitive functions; moreover, the capability of the
family to participate in the therapeutic program and the quality of the educational
environment, which are of paramount importance, have to be taken into account.
For diffuse spasticity of the lower limbs, dorsal rhizotomy or ITB administration
are available; dorsal rhizotomy is preferred when definitive action is targeted to a
number of muscular groups in the lower limbs. For focal spasticity, botulinum
toxin injections permit to delay surgery until the child is old enough to undergo a
neurotomy. Anesthetic blocks or botulinum toxin injections are administered to
particular muscles in order to simulate the effect that would be obtained by the
neurotomy. These tests allow the child and her/his environment to estimate the
benefits that are expected from the neurotomy. In hemiplegic adolescents harbor-
ing severe spasticity and/or dystonia in the upper limb, a (cervical) deep microsur-
gical DREZotomy may be a remedy. For children with cerebral palsy, orthopedic
surgical corrections are frequently needed, either as the first-line treatment or as an
adjuvant to neurosurgical treatment.
Timing of surgery is also an object of debate. Its determination is relatively easy
for adult patients; but deciding the optimal time is not so obvious for children with
cerebral palsy because of their prospective growth and cognitive development.
Whatever the final decision, all steps of the program should be conceived, dis-
cussed, and applied within the frame of a multidisciplinary team, including spe-
cialists in neurology, pediatrics, and rehabilitation, and close collaboration with
other specialities, such as orthopedic surgery and neurourology, should be sought.
In this book, we gathered those pieces of knowledge most relevant to present-
day neurosurgical management of disabling spasticity and synthesized them with
the lessons we learned from clinical observations, gained in the treatment of more
than a thousand patients. A comprehensive review of personal or published data was
not intended. Details of rehabilitation programs and physical therapy are beyond the
scope of this book.
An appendix contains scales, schematic drawings, and forms that can be used in
dealing with patients.

References
1. Wertheimer P (1956) La neurochirurgie fonctionelle. Masson, Paris
2. Sindou M (2001) Presidential address to the Quadrennial Meeting of the World Society for
Stereotactic and Functional Neurosurgery: stereotactic surgery has merged into general neuro-
surgery; functional neurosurgery is increasingly “applied neurophysiology”. Stereotact Funct
Neurosurg 76:133–136
 Part I
General Information