Typically caused by injury to areas in the brain or spinal cord that control muscles and reflexes, spasticity is most commonly driven by traumatic brain injury, stroke and other events in adulthood. In children, cerebral palsy is the most common underlying cause of spasticity. Without proper management, children may experience muscle and joint tightness, involuntary spasms and other symptoms, along with troublesome complications, such as chronic constipation. Through Nicklaus Children’s Hospital's (Nicklaus Children's) Cerebral Palsy and Spasticity Program, children born with spasticity receive comprehensive care that addresses the various facets of spasticity and improves quality of life.

“Our program is unique because we don’t just focus on spasticity; we deal with every facet of living with spasticity,” says Migvis Monduy, MD, pediatric neurologist and Medical Director of the Neuromuscular and Movement Disorders Programs at Nicklaus Children's Hospital. “We look at the big picture and try to address all of an individual patient’s needs.”

Surgical Standards of Care

Such a comprehensive approach requires a multidisciplinary team consisting of neurologists, physiatrists, orthopedic surgeons and more. Together, these specialists aim to identify appropriate treatment for each patient, including surgical options.

According to Dr. Monduy, surgical intervention for pediatric spasticity has remained the same in recent years. The two most frequent surgical solutions applied in pediatric spasticity cases are:

• Intrathecal baclofen pump implantation. A baclofen pump administers a steady flow of muscle relaxant medication within the intrathecal space, helping to normalize abnormal electrical signals commonly associated with spastic muscles. This approach is particularly helpful in children with dystonia and spasticity.
• Selective dorsal rhizotomy. A neurosurgeon divides dorsal nerve roots, promoting improved nerve activity within the spinal cord and thereby decreasing spasticity and leg pain, improving balance while sitting and helping specific children with cerebral palsy walk with greater ease.

An additional method for patients who have dystonia instead of spasticity  is deep brain stimulation (DBS). In select children with dystonia, specific genetic mutations and uninjured target areas of the brain, DBS has proven an effective means of relieving dystonia when medication fails. Such use of DBS is available for children with generalized and secondary dystonia.  

Improvement is generally realized quickly with these surgical solutions when used in the appropriate patient population. For severe cases, such as those with quadriplegia, neurectomy provides a permanent solution to excess spasticity, which helps prevent future deformity.

Nonsurgical Intervention and Ruling Out Surgery

Care for pediatric spasticity does not always start in the operating room. Rather, the team at Nicklaus Children’s usually exhausts other methods first, resorting to surgery when more conservative measures fail to bring release and relief.

“The surgical program is reserved for more severe cases,” Dr. Monduy says. “When we’ve done our best with medical management and the patient hasn’t tolerated treatment well, possibly due to medication side effects, we think outside the box to determine what else we can do.”

Nonsurgical approaches include:

• Botulinum toxin injections
• Casting or bracing
• Occupational or physical therapy

When these treatments are unsuccessful, surgery is still not automatically prescribed. Prior to surgery, patients must meet specific criteria to gain candidacy.

“We don’t just do surgery because we can,” Dr. Monduy says. “Our multidisciplinary team holds discussions related to each patient and their individual needs, working to remain objective and do what’s right for  each child and their family.”

Criteria used to rule out certain children for specific interventions include:

• Location of spasticity concerns. While selective dorsal rhizotomy positively affects spasticity, it does not improve dystonia symptoms. As a result, the ideal candidate for the procedure is between 4 and 7 years old and lives with spastic dysplasia mostly affecting the lower extremities. When spasticity affects the upper extremities, a baclofen pump is a better choice.
• Social concerns. As Dr. Monduy says, “The baclofen pump is a big commitment for a child’s family.” To be eligible to receive a pump, therefore, the child’s family must be reliable and capable of visiting Nicklaus Children’s for medication refill. Otherwise, baclofen may be suddenly unavailable after the body has grown accustomed to its presence, causing devastating and potentially fatal consequences.

Tracking Progress, Reaching Goals

Clinicians with the Cerebral Palsy and Spasticity Program at Nicklaus Children’s track patient outcomes from baseline to post-treatment. A gait analysis laboratory takes objective measurements of improvement, and patients and their loved ones are surveyed to determine improvements in range of motion, function and quality of life.

Specialists also work to move patients toward their goals, with progress toward success beginning with early consultations between patients and providers. Within the care team, specialists collaborate and cooperate, voicing their opinions to promote the well-being of patients. By working hand in hand, this multidisciplinary team creates a treatment plan that addresses spasticity and its complications in an appropriate order, helping families understand the plan and purpose along the way. This reduces or even eliminates confusion.

“If families had to see specialists separately, they would learn all the steps their child needs to take to find relief,” Dr. Monduy says. “They would not, however, know which step to take first. That’s yet another benefit of our unique, multidisciplinary approach.”

Regardless of the treatment plan, the patient’s short- and long-term gain remains at the forefront, as specialists and subspecialists aim to maximize benefit to the patient in all endeavors.

“If we help a child who requires an assistive device walk independently, that’s impactful,” Dr. Monduy says. “Even if the child needs braces, we can decrease pain and reduce the need for a more significant future surgery with proper intervention today.”

To refer a patient or learn more about the Nicklaus Children’s Cerebral Palsy and Spasticity Program, email our physician liaison.