12. Management of spasticity in cerebral palsy: Case Studies

 Athetoid Cerebral Palsy

Spastic Quadriplegic Cerebral Palsy

Pre- and Post-BTX:



Pre- and Post-BTX: This is a 12-year-old girl with spastic quadriplegic cerebral palsy secondary to prematurity. She has significant spasticity involving her lower extremities. The patient had multiple lower extremity orthopedic procedures approximately six months prior to botulinum toxin injections. They included detrotational osteotomies, gastrocnemius recession, hamstring lengthening and rectus femoris transfers.

Approximately six months after completion of the surgeries, her contractures recurred and a trial of intrathecal baclofen was recommended. The family refused ITB and further surgeries; therefore, botulinum toxin therapy was initiated. It should be noted here that if this patient were between 4-6 years of age, she might have been considered a good candidate for selective dorsal rhizotomy.
However, at this stage, and because of her family’s decision not to have further surgery, botulinum toxin injections were initiated. This patient had regular botulinum toxin injections with continual positive results. She does not wish to pursue further aggressive options at this time since she continues to respond well to the botulinum toxin.

Familial spastic paraparesis


Familial Spastic Paraparesis: At first glance, one might assume this patient has spastic diplegic cerebral palsy. However, this boy has a strong family history of spastic paraparesis. He has significant spasticity that was leading to the development of multiple contractures and torsional deformities. The patient had received botulinum toxin injections into his hamstrings and gastrocnemius muscle bilaterally with some effect; however, he still had problems with spasticity. As a result, it was felt that he was an appropriate candidate for a trial of intrathecal baclofen (ITB). He subsequently responded well to ITB. An intrathecal baclofen pump was then placed. The patient also had derotational osteotomies to correct his torsional deformities. The family and the patient felt that he was much more efficient in his ambulation with intrathecal baclofen. Although the patient’s gait did not change dramatically, his comfort in walking and his general confidence in performing gross motor skills activity improved.

Hypotonic gait

Evaluation of the Upper Extremities: This case demonstrates an examination of active and passive range of motion.

Dyskinetic Cerebral Palsy

Intrathecal Baclofen Pump

ITB Pump: This section contains two case studies. The first is a child with diplegic cerebral palsy and is self-explanatory.

The second case is that of a seven-year-old boy with spastic diplegic cerebral palsy secondary to prematurity. He had received multiple botulinum toxin injections and had undergone a trial of oral baclofen. The patient experienced improvement with these treatments but continued to have significant spasticity. Over time, he became unresponsive to botulinum toxin injections. He subsequently had implantation of an ITB pump. Although the changes in his gait were modest, the family and the patient were pleased with the results because he could move much more efficiently and his gait speed was improved. This patient may also benefit from orthopedic procedures to correct torsional deformities and to improve contractures.

Localization techniques

Localization Techniques: This case demonstrates localization techniques for the upper and lower extremities.
Lower Extremities
Medial Hamstrings
Posterior Tibialis
Upper Extremities
Lower Arm 

Phenol Preparation

Phenol Preparation: This section demonstrates preparation of the phenol solution.

Reconstitution of BOTOX

Reconstitution of BOTOX®: This section demonstrates how to reconstitute a vial of BOTOX® for injection.

BOTOX Serial Casting

Rhizotomy: This four-year-old boy has spastic diplegic cerebral palsy secondary to prematurity. He has had multiple botulinum toxin injections at 6-month intervals from the age of 18 months. The patient responded well to the botulinum toxin, but over time the therapy began to have less effect. He was then felt to be an appropriate candidate for selective dorsal rhizotomy and underwent the procedure. One year following the rhizotomy the patient had significant improvement in his ambulation with more efficient gait patterns.

His parents commented that it was easier for him to run and to walk up and down steps. His overall endurance for communal activities was much improved, and he was able to play with peers more easily. He was felt to be a candidate for orthopedic procedures prior to the rhizotomy, but one year post-rhizotomy, his contractures were not severe enough to warrant more aggressive interventions.

He has not required additional surgeries for the three years following his rhizotomy. This child, however, may have gastocnemius recession, particularly on the left side, as he gets closer to his adolescent growth spurt. The patient will continue to be followed periodically, and a decision regarding further surgery will be when he is older.  

Surgical Treatment of Ambulatory CP: Although surgery was selected to improve the child’s gait, other treatments could have been utilized on a primary or adjunctive basis.  Interventions aimed at decreasing his spasticity (e.g., botulinum toxin injections coupled with serial casting, intrathecal baclofen or rhizotomy) could all have been used to decrease this child’s spasticity and the complications thereof. Although the child was young, orthopedic surgery was chosen because of significantly increased femoral anteversion and multiple fixed contractures demonstrated in his physical exam and gait study. 

EMG Hand Study