Hypertonia occurs commonly in individuals with cerebral palsy and can impair comfort, functional progress, skin integrity and caretaking. In these cases, management of hypertonia is essential to improve function and quality of life. Non-surgical management of hypertonia can be achieved through non-pharmacologic, pharmacologic and procedural interventions, and in many cases a combination of these strategies is employed to optimize function and quality of life in those with cerebral palsy.Non-pharmacologic management includes the use of orthoses, physical and occupational therapies and the inclusion of evidence-based therapeutic techniques. Pharmacologic management is the use of enteral medication to minimize generalized hypertonia. Procedural management involves targeted injection of muscle groups or of nerves or their motor points and is typically used for focal hypertonia.In summary, hypertonia management involves a multidisciplinary approach and is tailored individually based on the severity, pattern and distribution of hypertonia, functional level, goals and social context. Commonly, multiple treatment modalities are used to achieve the best outcome for the individual.
Neuromuscular scoliosis (NMS) is a progressive spinal deformity commonly seen in children with cerebral palsy (CP), particularly in those with severe functional impairment. Operative treatment is indicated for progressive deformity, functional decline, and impaired quality of life, with curve magnitude and pelvic obliquity remaining important decision-making factors. Careful preoperative multidisciplinary assessment is essential given the high burden of pulmonary, nutritional, and medical comorbidities in this population. The risk of major complications after surgery is as high as 39%, which underlines the importance of multidisciplinary management and good preoperative optimization. Although complication rates remain high, recent literature demonstrates durable radiographic correction and meaningful improvements in health-related quality of life. Continued advances in surgical techniques and perioperative optimization remain essential to further improve outcomes in this high-risk patient population.
Hypertonia in cerebral palsy, including spasticity and dystonia, contributes to progressive musculoskeletal deformity, impaired mobility, pain, and challenges with care. When conservative measures fail, surgical tone management offers targeted interventions to reduce pathologic tone and improve function, comfort, and quality of life.This article provides a practical, technique-focused review of the principal neurosurgical strategies for tone management, including intrathecal baclofen pump placement, selective dorsal rhizotomy, ventral–dorsal rhizotomy, and deep brain stimulation with consideration of both lower and upper extremity involvement. Emphasis is placed on context driven and phenotype-driven patient selection, differentiation of dynamic tone abnormalities from fixed deformities, and integration of surgical decision-making within a multidisciplinary care framework. Key operative steps, technical nuances, and procedure-specific pitfalls are highlighted.A tailored, multidisciplinary approach is essential to optimize outcomes. As surgical techniques continue to evolve, including minimally invasive and precision-based approaches, treatment paradigms are increasingly shifting toward individualized, goal-directed strategies for tone management in cerebral palsy.
Upper extremity involvement in cerebral palsy results from complex muscle imbalance, spasticity, weakness, and progressive contracture, producing characteristic deformities that may impair function, hygiene, appearance, and independence. Although nonoperative management remains the mainstay of treatment, carefully selected patients may benefit from surgical intervention based on individualized, realistic goals and comprehensive assessment of the entire upper extremity. Surgical planning should account for the dynamic interaction among the shoulder, elbow, forearm, wrist, fingers, and thumb, with single-event multilevel surgery frequently used to restore muscle balance and optimize limb positioning and function.This review describes the operative principles and techniques used to manage upper extremity deformity in cerebral palsy. Soft-tissue procedures, including musculotendinous lengthening, releases, and tendon transfers, remain central to surgical reconstruction, while hyperselective neurectomy provides an evolving option for selected patients with dynamic spasticity and preserved voluntary motor control. Osteotomy and arthrodesis may be appropriate for severe fixed deformities when soft-tissue reconstruction is insufficient. Specific operative strategies for deformities of the shoulder, elbow, forearm and wrist, and thumb-in-palm are reviewed, emphasizing appropriate patient selection, technical principles, postoperative rehabilitation, and the importance of matching the surgical approach to each patient's functional abilities and goals.
