European Journal of Neurology 2002, 9 (Suppl.

1): 35–41

The surgical management of spasticity

Y. Lazorthes, J-C. Sol, B. Sallerin and J-C. Verdié
Department of Neurosurgery, CHU Rangueil-Larrey, University Paul Sabatier, Toulouse, France

Keywords:
neurosurgery, spasticity,
dorsal rhizotomy, chronic
neurostimulation,
intrathecal baclofen
Neurosurgery is only considered for severe spasticity following the failure of noninvasive
management (adequate medical and physical therapy). The patients are carefully
selected, based on rigorous multidisciplinary clinical assessment. In this we evaluate the
contribution of the spasticity to the disability and any residual voluntary motor function.
The goals for each patient are: (a) improvement of function and autonomy; (b) control of
pain; and (c) prevention of orthopaedic disorders. To achieve these objectives, the
surgical procedure must be selective and reduce the excessive hypertonia without
suppressing useful muscle tone and limb functions. The surgical procedures are: (1)
Classical neuro-ablative techniques (peripheral neurotomies, dorsal rhizotomies) and
their modern modifications using microsurgery and intra-operative neural stimulation
(dorsal root entry zone: DREZotomy). These techniques are destructive and irreversible,
with the reduced muscle tone reflecting the nerve topography. It is mainly indicated when
patients have localized spasticity without useful mobility. (2) Conservative techniques
based on a neurophysiological control mechanism. These procedures are totally
reversible. The methods involve chronic neurostimulation of the spinal cord or the
cerebellum. There are only a few patients for whom this is indicated. Conversely, chronic
intrathecal administration of baclofen, using an implantable pump, is well established in
the treatment of diffuse spasticity of spinal origin. From reports in the literature, we
critically review the respective indications in terms of function, clinical progression and
the topographic extent of the spasticity.

When we consider the indication for neurosurgery in
patients with spasticity, we have to define the goals to
be reached for the patients very clearly, i.e. increase
comfort, decrease pain, improve function and auto-
nomy and prevent orthopaedic disorders. These aim to
decrease severe and harmful spasticity and if possible
restore motor function. We must also explain to the
patient the actual risk of an iatrogenic effect. Surgery is
not without its consequences and the surgical procedure
must be highly selective in order to diminish the
excessive hypertonia without suppressing useful muscle
tone and limb function.
The first most important step, is to select the ‘good
candidate’. This selection is always done using a
multidisciplinary approach and surgery is only indica-
ted in cases of very severe spasticity, after all the
noninvasive management procedures have failed. This
means after the failure of adequate oral medication, and
physical treatment, including all the latest approaches,
and the suppression of aggravating factors, which can
be transient contra-indications, like urinary tract infec-
tion or decubitus ulcerations. So this surgical step is
Correspondence: Professor Y. Lazorthes, Department of Neurosur-
gery, CHU Rangueil-Larrey, University Paul Sabatier, Toulouse,
France (e-mail: Ylazorth@www.cict.fr).
becoming more selective and concerns only resistant
spasticity.
The selection for surgery is thus based on rigorous,
clinical assessment. The objective of this assessment is
to determine the role of spasticity and to differentiate
between disabling and useful spasticity. It is also
important to differentiate between muscle and joint
contracture and to differentiate contracture and retrac-
tion from spasticity. In adults, we can do a test under
brief anaesthesia with curare. An abnormal posture due
to spasticity alone may indicate a surgical procedure,
but abnormal posture of an osteo-articular origin is an
indication for an orthopaedic procedure.
The surgical procedures
Historically, neurosurgical procedures (Table 1) started
with neuro-ablative techniques (Foerster, 1913; Lorenz,
1887). The objective was to decrease the excitatory
inputs and the spinal motor neurone hyperexcitability.
Dorsal rhizotomy is the oldest standard surgical tech-
nique for treating spasticity, but it has been modified
and improved by many neurosurgeons, especially by
Gros (Gros et al., 1967). He developed the functional
and sectional posterior rhizotomy, but the modern
approach is the dorsal route entry zone-otomy (DREZ-
otomy). It was Sindou (Sindou et al., 1974) and

ª 2002 EFNS 35
36 Y. Lazorthes et al.
Table 1 Neurosurgery for spasticity: the surgical procedures
THE NEURO-ABLATIVE TECHNIQUES
Peripheral neurotomies Lorenz (1887)
Dorsal rhizotomies Foerster (1913)
(partial, sectional or functional) Gros et al. (1967)
Sindou et al. (1974)
Microsurgical DREZotomy Nashold et al. (1976)
THE CONSERVATIVE TECHNIQUES
Chronic neurostimulation Cook et al. (1973)
Cervical spinal cord Waltz et al. (1981)
Deep brain, cerebellar cortex Cooper (1973)
Intrathecal baclofen Penn et al. (1984)
Nashold (Nashold et al., 1976) who refined this proce-
dure even further.
More recently, we have seen the development of
totally conservative techniques which increase the
inhibitory mechanisms and decrease reflex hyperactiv-
ity, at the spinal-cord level. Chronic cerebellar stimu-
lation techniques were developed by Cooper (1973) for
cerebral palsy. Cervical spinal cord stimulation was
developed for spinal spasticity by Cook and Weinstein
(1973) and for cerebral palsy by Waltz et al. (1981).
Chronic neurostimulation has very few indications at
the present time. The main conservative technique is
now the intrathecal baclofen infusion with implantable
pumps, proposed by Penn and Kroin (1984).
Peripheral neurotomies
General principles
The objective of this procedure is to re-equilibrate the
tonic balance between agonist and antagonist muscles.
This technique is irreversible since there is no fibre
discrimination at the periphery. When we cut a periph-
eral nerve, we cut all the fibres, not only all the sensory
but also the motor neurones. For this reason, these
neurotomies must be done as distally as possible and
limited to the fascicles innervating the hypertonic
muscles. The neurotomy must also be quantitatively
selective, so we only partially section a nerve bundle for
a muscle, one half or four fifths of the total fibres, with
the objective of reducing the enhanced myotatic reflex.
Pre-operative assessment
Before performing a neurotomy, the preoperative
assessment must determine the origin of abnormal
posture and especially which nerve or nerve bundles are
to be cut and at what degree. There is a very interesting
predictive test, involving an anaesthetic block with a
long lasting anaesthetic like bupivacaine. This test
mimics the effect of a neurotomy and gives us the
opportunity to evaluate its potential effects, to deter-
mine the origin of articular limitation, and to assess
antagonist muscle strength. It also gives the patient an
appreciation of the final result.
The indications
The indication for peripheral neurotomy (Table 2) is
focal spasticity, localized to a muscular group inner-
vated by a single or few peripheral nerves, after failure
of botulinum toxin. The main indication for the upper
limb is in the spastic elbow, with section of the
musculocutaneous nerve, and in spastic hand with
section of the median and ulnar nerves. For the lower
limb, the main indications concern the spastic hip and
spastic foot. These are addressed by sciatic or obturator
nerve section. In situations of multifocal spasticity, it is
possible to perform combined neurotomies, or to
combine peripheral neurotomy with other ablative
procedures (DREZ) at the spinal level and with
complementary orthopaedic surgery. The orthopaedic
surgery must be done after reduction of spasticity by a
neurosurgical technique.
Surgical technique
The peripheral neurotomy technique itself is performed
under general anaesthesia without long-lasting curari-
zation. It involves microdissection with bipolar neuro-
stimulation at low intensity, in order to have a near
perfect intraoperative correlation with the nerve topog-
raphy for the muscle. This gives a precise picture of the
activity and an indication of the right nerve and the best
level of section. The extent of the nerve resection is
critical. It must be limited to a maximum to 4/5 fibres,
over a length of 5 mm, to prevent any regrowth. Great
care must be taken with the sensory fibres, because if
too many are cut in the sensory peripheral nerve, it is
Table 2 Selective neurotomies: the indications
Focal spasticity Target
Lower limb
Equino-varus foot and flexion of the toes Tibial nerve
Hip adduction Obturator nerve
Knee flexion Sciatic nerve
Upper limb
Shoulder adduction Brachial plexus coll
Elbow flexion Musculo-cutaneous
nerve
Wrist flexion–pronation with finger flexion Median and ulnar
nerve
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41

possible to induce neurogenic pain. If, there is no
fascicular organization, the section must be done as
distally as possible on the muscular branch.
Results
A group of 180 patients were studied over an average
follow-up period of 3.4 years (Mertens et al., unpub-
lished data). They report a reduction of spasticity in
82% of cases, with recurrence in only 8%. In 10% of
the patients, a functional improvement resulted in the
recovery of some ability to walk. The authors also
report an improvement in stability stance phase (97%),
increased ankle dorsiflexion (70%), a reduction in pain
due to spasticity (85%), and a reduction in cutaneous
lesions (78%). The main complication resulted from too
great a resection of the sensory fibres. This caused
allodynia, in around 7% of the patients. In 5% of
patients, this was transient, but was permanent in 2%
of the cases.
The microsurgical DREZotomy
Principle
Modern dorsal rhizotomy is a hyper-selective rhizot-
omy. In fact it is not a true dorsal rhizotomy, but
rather a section at the Dorsal Root Entry Zone. At
the periphery, the nerve fibres are mixed and only at
the entry of the dorsal root on the spinal column, is
there any differentiation between the small nociceptive
fibres, which are more anterior, and the posterior
fibres which are more ventral. This technique of
Dorsal Root Entry Zone-otomy (DREZotomy) con-
sists of cutting only the ventral portion at the entry
zone, including a large area up to the superficial
layers of the posterior grey matter. The extent of the
lesion is concerned not only with the junction
between dorsal root and dorsal column (the entry
zone), but also the more superficial layer of the dorsal
horn, the gelatinosa area. This technique was especi-
ally developed for treating neurogenic pain, in
particular secondary to a brachial plexus avulsion,
but it now has many indications in treating severe
spasticity. The principle is to selectively suppress the
myotatic and nociceptive afferent discharges to the
spinal cord and so to decrease mono- and poly-
synaptic reflexes.
Indications
In spasticity, the indications relate to severe and
regional spasticity, possibly associated with chronic
intractable pain, in one or both of the lower or upper
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41
The surgical management of spasticity 37
limbs. There are also some indications concerning a
hyperactive bladder.
Technique
DREZotomy must be performed under general anaes-
thesia, with initial short lasting nondepolarizing muscle
block. The patient is placed in a ventral position, in
order to allow access to the lower limb and to perform a
peri-operative examination. If the surgery concerns the
cervical area, the patient is operated on in the sitting
position. The laminectomy is standard at the lower level
from Th11 to L2 and at the cervical level from C4 to
C7. The first and most important step is to identify
exactly the dorsal radicular spinal junction. The section
is very delicate, because the lesion must be precisely at
45° in the ventromedial direction. The maximum depth
of the lesion is 3 mm. At the lumbar level, the lesion is
made from L1 to S1 and if there is also hyperactive
bladder involvement, proceeds to S3 and S4. At the
cervical level, the lesion is done between C5 and Th1. It
is essential to see the junction between the posterior
root and dorsal column perfectly. The lesion is made
with a blade, usually marked in millimetres and
completed by bipolar coagulation.
Another technique was proposed by Nashold and
Ostdahl (1979) which consisted of creating the lesion
with a microelectrode in the area of the substantia
gelatinosa.
Results
To date, the most significant results are those reported
by Mertens and Sindou (1998). More recently, they
have reviewed the outcome of patients treated between
1974 and 1999. Over this period, Sindou has performed
this rhizotomy in 151 patients for lower limb hyperto-
nicity. Of these patients, 53% had multiple sclerosis,
42% had spinal trauma, 16% had cerebral lesions and
12% were classed as miscellaneous. In 62% of the
patients, the spasticity was associated with chronic pain.
The patients were followed-up for a mean 5.6 years.
He observed decreased hypertonia in 78% of cases
(Ashworth scale, under 2), decreased painful spasm in
Table 3 DREZotomy for spasticity: clinical results. n ¼ 151 patients
with lower limb hypertonicity. Follow-up 5.6 years
Decreased hypertonia 78% Ashworth < 2
Decreased spasms 88%
Increased functional status from 15.6 to 7.6 (DSFTH)
Increased voluntary mobility 11%
Decreased pain 82%
38 Y. Lazorthes et al.
88% of the cases, and an increase in functional status
from 15.6 to 7.6 (DSFTH) resulting in an increase in
voluntary mobility in 11% of the cases. In the patients
with neurogenic pain, he observed a decrease of pain in
82% of the cases.
In patients with unilateral upper limb hypertonicity,
over the same period, the operation was performed in
52 patients. The spasticity was reduced in 76% of the
cases. They also observed a functional improvement,
with greater independance in daily life. There were
some complications which were very serious in some
instances, constituting an iatrogenic side-effect. They
observed a decrease in lemniscal sensitivity in 70% of
the cases, which is very high. This decrease in lemniscal
sensitivity was moderate in 44% of the patients and
marked in 26% of the patients.
This is one of the drawbacks of this type of
operation. There is a choice in exactly where the
incision is made. The more ventromedial the direction
of the lesion, the less aggressive it is, since a greater risk
arises if the lesion is too lateral where it may impact on
the pyramidal pathway. In this study, they observed
only a 9% decrease of voluntary mobility, resulting
from the extent of the lesion in this direction. They also
observed 8% sepsis and 1.9% (two cases) death.
In 38 patients with a hyperactive bladder, with a
similar aetiology, the same authors observed an
increase of compliance in 92% of cases, an increase in
capacity in 63% of cases if the detrusor was not fibrotic,
and a decrease of urinary leakage in 85% of patients.
The DREZotomy can be associated with both
selective neurotomies for specific indications and also
secondarily linked to other orthopaedic surgery (tenot-
omy, articular surgery).
These neuro-ablative peripheral neurotomy or
DREZotomy procedures, although they have increased
in selectivity, must only be considered when spasticity is
not controlled by other more conservative methods.
These conservative methods are not only oral pharma-
cological treatments, but also all the surgically conser-
vative methods, described below.
Spinal cord stimulation
One of the more conservative methods developed in the
1980s, for the treatment of spasticity, was spinal cord
stimulation. This was not only used in demyelinating
disease, but also for spinal cord injury and cerebral
palsy. The objective was selective stimulation of the
larger fibres in order to inhibit the activity of the
smaller nociceptive fibres and so to decrease the
nociceptive input at the level of the spinal cord.
The electrode implantation technique used was per-
cutaneous, or in conjunction with open surgery. The
level of stimulation was dependent on the topography
of the spasticity, but was done at the thoracolumbar
or cervical level.
The electrode must be placed in the posterior
epidural space in order to stimulate the dorsal
columns.
There are many data concerning the treatment of
severe spasticity due to spinal cord injury using this
technique (Sedan and Lazorthes, 1985; Barolat and
Mykelbust, 1986) reported data from a mean 2 years
follow-up in these patients. They found a reduction of
spasticity in 80% of the patients.
Twenty years ago, we presented our findings in
multiple sclerosis patients (Lazorthes et al., 1981). At
that time we tested 37% of 111 patients using chronic
percutaneous electrode stimulation, due to the limited
indication for this type of treatment. The improvement
was also very limited, 50% over a mean follow-up of
between 2 and 6 years.
When it was used in spasticity, the best results were
published by Waltz et al. (1981). However, a double
blind study reported by Gottlieb et al. (1985), conclu-
ded that there was no significant effect. So, over the last
decade, we have moved to consider spinal cord stimu-
lation as an alternative only if other conservative and
surgical treatments do not work, especially after failure
of intrathecal baclofen administration.
Chronic intrathecal baclofen infusion
with implantable pumps
The main conservative technique in use is intrathecal
baclofen administration. This technique was proposed
in 1984 by Richard Penn, a neurosurgeon from Chicago
(Penn and Kroin, 1984).
Principle
As Professor Abbruzzese has commented, in these
proceedings (Abbruzzese 2002), the use of intrathecal
baclofen as a treatment for spasticity control is not
only a medical approach, but also a surgical tech-
nique. It is now considered to be the main technique
for functional neurosurgery of severe spasticity. One
year after it was described by Richard Penn, we had
the opportunity to start using this procedure our-
selves, and published our first results in 1985 in
patients with cerebral palsy (Lazorthes, 1985). Since
then, we have developed the use of intrathecal
baclofen far more than other invasive surgery like
DREZotomy. The objective is to administer the
baclofen to its site of action, the area of the spinal
cord with the molecular receptors for a GABAb
agonist, on the superficial layer of the dorsal horn, in
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41

order to decrease the hyperactive reflexes at the pre-
and postsynaptic level.
Technique
It is administered via an implantable pump, which can
be programmable or nonprogrammable. This presents
opportunities for giving a continuous administration,
or a bolus, or a complex administration. In addition to
the difference in programming in these pumps, there is
also a difference in the quantity of baclofen in reserve.
There is a larger reserve in the continuous, nonpro-
grammable pump. The subarachnoid catheter is
implanted between Th6 and Th9 level.
Patient selection
Concerning the management of adult spasticity, the
indication is severe and diffuse spasticity after failure of
oral treatment. In order to confirm the indication, a
percutaneous trial must be done using an access port or
a percutaneous catheter. In our group, we prefer an
access port rather than doing many lumbar punctures,
since lumbar puncture induces a nociceptive input,
which may increase the spasticity. So we implant an
intrathecal access port, initially, and wait one or two
weeks before doing the percutaneous trial (progressive
doses of baclofen: 25, 50, 75, 100 mg vs. placebo). After
a positive trial, we implant a programmable pump
(SynchromedÒ Medtronic). The second and more
difficult step is to titrate the individual dose and to
organize a follow-up.
Results
There are a lot of data concerning the use of intrathecal
baclofen: Dralle et al. (1985); Müller et al. (1987);
Lazorthes (1988); Müller et al. (1988); Ochs et al.
(1989); Penn et al. (1989); Lazorthes et al. (1990).
However, when we examine the findings of the different
groups, it is important to remember that the initial
doses are in micrograms (lg), whereas by the oral route
they are in milligrams (mg). The initial doses are 1000
time lower by the intrathecal route than by the oral
route. This is easily understood when the absorption of
the drug from the digestive tract, its passage through
the liver and its ability to cross the blood–brain barrier
are taken into account. The initial intrathecal doses are
very low, but with chronic administration a small
degree of tolerance develops. In many aspects this is not
so much a true tolerance as a progressive increase in the
required dosage. Although there are a large number of
studies, many are based on individual case experience
and very few are controlled studies.
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41
The surgical management of spasticity 39
The only controlled study published is from Richard
Penn (1992). From 66 patients screened, he performed
an implantation in 62; half of the patients had spinal
cord injury and the other half had multiple sclerosis
with severe spasticity. The mean follow-up was
30 months. The clinical response was positive in 84%
of the patients, with a reduction in the Ashworth Score
and decreased painful spasms.
There was a multicentre study in 1993 Coffey et al.
(1993) including for trial patients and selecting 75% for
chronic baclofen administration. They only reported
evaluations of spasticity score, with few observations on
changes in the quality of life. In a paper by Ordia
(Ordia et al., 1996), 59 patients were involved in a
double-blind, randomized placebo controlled trial, with
only nine patients, (this is one of only two blinded
studies). The clinical responses were very significant,
with decrease in the Ashworth score, decrease in the
frequency of painful spasms, and improvements in the
activities of daily life. The patients became more
independent, with easier transfer and an increase in
bladder capacity. This was a very interesting, but small
study.
In 1998, we reported our experience from 60
patients with cerebral palsy (Lazorthes et al. (1998)).
We tried to analyse the quality of life in terms of the
change in the clinical stage. Some patients were able
to change from a wheelchair to walking. A similar
pattern was seen in 17 patients with spinal spasticity,
secondary to spinal cord injury. In multiple sclerosis
there have also been some patients with a change of
category.
The most important issue relating to the clinical
use of intrathecal baclofen is patient selection. The
surgical technique is relatively easy, but many diffi-
culties arise in organizing the patient follow-up. For
each individual we have to be able to refill the pump,
when the patient needs it. This is generally every
1–2 months, depending on the concentration of the
baclofen inside the pump. There are two concentra-
tions in general use, 500 or 2000 lg/ml. The patient
has an alarm and is alerted 1 week before needing to
return to the centre. The prescriptions are individual;
the daily effective dose and delivery rate can be
modulated using the two different concentrations of
baclofen. There is a very large variability between
different individuals.
The use of intrathecal baclofen in treating spasticity
of a spinal origin, is only indicated for intractable and
severe spasticity. In this field, there are only a few
controlled studies and no meta-analysis, but 15 years of
experience is documented in the literature. We can tell
that this technique is safe, clinically effective, and also
cost-effective.
40 Y. Lazorthes et al.
Intrathecal baclofen vs DREZotomy
In comparing intrathecal baclofen (ITB) with DREZ-
otomy (Table 4), it is important to remember that
rhizotomy is an ablative and irreversible technique. On
the other hand, intrathecal baclofen is totally conser-
vative and reversible. The modulation of tone following
DREZotomy is absolute and relates to the nerve
topography. The effect seen following ITB is a function
of the baclofen dose and the spread from the caudal
area, where it is injected, to the cranial area. This is also
one of the limitations of ITB treatment, since if too
much baclofen is given at the cervical level, it can have
side-effects at a supraspinal level.
DREZotomy is indicated when the spasticity is
extensive, but limited to the region of the lower or
upper limbs. Baclofen is indicated when the spasticity is
diffuse, in the limbs and axial. Rhizotomy is reserved
for situations when regional disabling spasticity exists,
without any useful spasticity, but baclofen is used in the
first instance, in diffuse spasticity with useful mobility,
because the dose can be finely modulated in order to
preserve useful spasticity.
Conclusion
In the surgical management of severe spasticity, there
are no rigid protocols, no panacea. The indication for
functional neurosurgery depends on the topographic
extent of the spasticity (local, regional or diffuse) but
also the clinical stage and on the possible persistent
functional motor activity. The strategy and objectives
of treatment are not the same with bedridden, wheel-
chair bound or walking patients. In some instances, as
seen with intrathecal baclofen treatment, the outcome
results in a change in the clinically functional level for
that patient. The indication also depends on associated
fixed deformities and/or contracture limitation, which
contra-indicates intrathecal baclofen. On these occa-
sions, the strategy is to perform orthopaedic surgery
after a reduction of spasticity using other methods.
We also have to differentiate the topographic extent
Table 4 Neurosurgery for spasticity. Comparison of intrathecal (ITH)
baclofen infusion and DREZotomy
DREZotomy ITH baclofen infusion
Ablative, irreversible Conservative, reversible
TONUS MODULATION
Topographic (metameric) Quantitative (caudal to cranial)
INDICATIONS/MOBILITY
Regional spasticity Diffuse spasticity (limbs + axial)
(lower or upper limbs)
No useful mobility Useful mobility
between hemiplegia, paraplegia or tetraplegia. The
specific indications for surgery are also a function of
one’s own surgical experience and the ease of follow-up.
References
Abbruzzese G (2002). The medical management of spasticity.
Eur J Neurol 9(Suppl. 1):30–34.
Barolat-Romana G, Mykelbust JB (1986). Immediate Effects
of Spial Cord Stimulation on Spinal Spasticity. Proceedings
of 7th European SSFN 1986 Birmingham UK, Abstract.
Coffey RJ, Cahill D, Steers W, Park TS et al. (1993).
Intrathecal baclofen for intactable spasticity of spinal
origin: results of a long term multicentre study. J Neuro-
surgery 78:226–232.
Cook AW, Weinstein SP (1973). Chronic dorsal column
stimulation in multiple sclerosis. New York State J Medicine
73:2868–2872.
Cooper IS (1973). Effect of chronic stimulation of anterior
cerebellum on neurological diseases (Letter). Lancet 1:206.
Dralle D, Muller H, Zierski J et al. (1985). Intrathecal
baclofen for spasticity (Letter). Lancet 2:1003.
Foerster O (1913). On the indications and results of the
excision of posterior spinal nerve root in men. Surg Gynecol
Obstet 16:463–474.
Gottlieb GL, Mykelbust BM, Stefoski D, Groth K et al.
(1985). Evaluation of cervical stimulation for chronic
treatment of spasticity. Neurology 35:699–704.
Gros C, Ouaknine G, Vlahovitch B, Frèrebeau P (1967). La
radicotomie sélective postérieure dans le traitement neuro-
chirurgical de l’hypertonie pyramidale. Neurochirurgie
13:505–518.
Lazorthes Y (1985). Neuropharmacologie en application
intrathécale. Neurochirurgie 31:95–101.
Lazorthes Y (1988).Chronic intrathecal administration of
baclofen in treatment of severe spasticity. In: Muller, H,
Zierski, J, Penn, RD, eds. Local Spinal Therapy of Spastic-
ity. Springer-Verlag Berlin, pp. 215–222.
Lazorthes Y, Sallerin B, Verdié JC, Casaux J et al. (1998).
Traitement de la spasticité par administration intrathécale
chronique de baclofène. Neurochirurgie 44:201–208.
Lazorthes Y, Sallerin-Caute B, Verdie JC, Bastide R et al.
(1990). Chronic intrathecal baclofen administration for
control of severe spasticity. J Neurosurgery 72:393–402.
Lazorthes Y, Siegfried J, Broggi G (1981).Electrical spinal
cord stimulation for spastic motor disorders in demyelinat-
ing disesaes: a cooperative study. In: Hosobuchi, Y, Corbin,
I, eds. Indications for Spinal Cord Stimulation. Excerpta
Medica Princetown, pp. 48–57.
Lorenz F (1887). Uber chirurgische Behandlung der ange-
borenen spastischen Gliedstarre. Wien Klin Rdschr 21:25–27.
Mertens P, Sindou M (1998). La drézotomie microchiururgi-
cale dans le traitement de la spasticité invalidante des
membres inférieurs. Neurochirurgie 44:209–218.
Müller H, Zierski J et al. (1988). Intrathecal baclofen-induced
sedation. In: Müller, H, Zierski, J, Penn, RD, eds. Local-
Spinal Therapy of Spasticity. Springer-Verlag Berlin,
pp. 253–254.
Müller H, Zierski J, Dralle D et al. (1987). The effect of
baclofen on electrical muscle activity in spasticity. J Neurol
234:348–352.
Nashold BS, Ostdahl PH (1979). Dorsal root entry zone
lesions for pain relief. J Neurosurgery 51:59–69.
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41

Nashold BS, Urban B, Zorub DS (1976). Phantom relief by
focal destruction of substantia gelatinosa of Rolando. In:
Bonica, JJ, Albe-Fessard, D, eds. Advances in Pain Research
And. Therapy. Raven Press New York, pp. 959–963.
Ochs G, Struppler A, Meyerson BA, Linderoth B et al. (1989).
Intrathecal baclofen for long-term treatment of spasticity: a
multi-centre study. J Neurol, Neurosurgery Psychiatry
52:933–939.
Ordia JI, Fischer E, Adamski E, Spatz EL (1996). Chronic
intrathecal delivery of baclofen by a programmable pump
for the treatment of severe spasticity. J Neurosurgery
85:452–457.
Penn RD (1992). Intrathecal baclofen for spasticity of spinal
origin: seven years of experience. J Neurosurgery 77:236–240.
ª 2002 EFNS European Journal of Neurology 9 (Suppl. 1), 35–41
The surgical management of spasticity 41
Penn RD, Kroin JS (1984). Intrathecal baclofen alleviates
spinal cord spasticity (Letter). Lancet 1:1078.
Penn RD, Savoy SM, Corcos D (1989). Intrathecal baclofen
for severe spinal spasticty. N Engl J Med 230:1517–1521.
Sedan R, Lazorthes Y (1985). La neurostimulation électrique
thérapeutique. Neurochirurgie 31:1–118.
Sindou M, Fischer G, Goutelle A et al. (1974). La radicellot-
omie postérieure sélective dans le traitement des spasticités.
Revista Neurologia 130:201–216.
Waltz JM, Reynolds LO, Riklan M (1981). Multi-lead spinal
cord stimulation for control of motor disorders. Appl
Neurophysiol 44:244–257.