Spasticity Surgery: SDR, Baclofen Pump and Other Options

Generally, surgery comes only after a fair trial of simpler treatments. Most patients combine several of them:

• Physiotherapy, stretching, splints and serial casting
• Oral medicines such as baclofen or tizanidine, which can cause drowsiness
• Botulinum toxin injections, which relax chosen muscles for three to four months
• Nerve blocks, which also preview the result of nerve surgery

If these help too little, or wear off too soon, surgery is worth discussing.

SDR permanently reduces leg spasticity by cutting selected sensory nerve rootlets in the lower spine. During surgery, the team stimulates each rootlet and divides only those with abnormal responses. It suits these patients best:

• Children with spastic diplegia from cerebral palsy, usually from about age 3
• GMFCS level II or III, as NICE guidance recommends
• Good underlying strength and little or no dystonia
• A family ready for months of intensive therapy

However, stiffness sometimes hides weak muscles. So strengthening therapy matters as much as the operation itself.

A small pump under the belly skin sends baclofen into the fluid around the spinal cord. Because the dose reaches the cord directly, it causes less drowsiness than tablets. It fits these situations:

• Severe spasticity in the arms and legs (GMFCS III to V)
• Spasticity mixed with dystonia
• Adults with spinal cord injury, MS, brain injury or stroke
• People who want an adjustable, reversible treatment

Also, doctors can adjust the dose at any time, or remove the pump. However, it needs refills every few months and a new pump about every seven years.

This operation treats one stiff area, such as a pointed foot or a clenched hand. Specifically, the surgeon partly cuts the motor branches to that muscle, guided by stimulation.

It suits focal spasticity that responded well to botulinum toxin but keeps returning. Also, a temporary nerve block beforehand predicts the likely result.

DREZ-otomy makes small, precise lesions where sensory roots enter the spinal cord. Surgeons reserve it for severe, painful spasticity in a limb without useful movement. The same technique also treats some nerve pain, as our pain surgery page explains.

Orthopedic surgery treats the effects of long-standing spasticity on muscles, tendons and bones. For example, surgeons lengthen or move tendons, realign bones and treat hip displacement.

It often complements nerve surgery rather than replacing it, for example tendon surgery years after SDR. Surgeons also time these operations carefully in children, because tightness can return with growth.

In adults, goals often differ from those in children. For example, fewer painful spasms or easier hygiene may matter more than walking speed.

For widespread stiffness, a baclofen pump is the most common operation. In contrast, one stiff hand, elbow or foot often suits neurotomy or tendon surgery. SDR in adults is possible but less common, and results vary.