Treatment Of Spasticity Research Articles

Analysis of Path of Therapy in the Treatment of Spasticity in Adult Post-Stroke Patients

Analysis of Path of Therapy in the Treatment of Spasticity in Adult Post-Stroke Patients

Leg Activity Measure (LegA) Sensitivity to Change Following Treatment of Lower Limb Spasticity with a Single Cycle of AbobotulinumtoxinA in an Ambulatory Population

Leg Activity Measure (LegA) Sensitivity to Change Following Treatment of Lower Limb Spasticity with a Single Cycle of AbobotulinumtoxinA in an Ambulatory Population

Cervicothoracic ventral-dorsal rhizotomy for bilateral upper-extremity hypertonia in cerebral palsy: illustrative case.

Management of medically refractory limb-specific hypertonia is challenging. Neurosurgical options include deep brain stimulation, intrathecal baclofen, thalamotomy, pallidotomy, or rhizotomy. Cervical dorsal rhizotomy has been successful in the treatment of upper-extremity spasticity. Cervical ventral and cervical ventral-dorsal rhizotomy (VDR) has been used in the treatment or torticollis and traumatic hypertonia; however, the use of cervicothoracic VDR for the treatment of upper-extremity mixed hypertonia is not well described. A 9-year-old girl with severe quadriplegic mixed hypertonia secondary to cerebral palsy (CP) underwent cervicothoracic VDR. Modified Ashworth Scale scores, provision of caregiving, and examination improved. Treatment was well tolerated. Cervicothoracic VDR can afford symptomatic and quality of life improvement in patients with medically refractory limb hypertonia. Intraoperative positioning and nuances in surgical techniques are particularly important based on spinal cord position as modified by scoliosis. Here, the first successful use of cervicothoracic VDR for the treatment of medically refractory upper-limb hypertonia in a pediatric patient with CP is described.

Role of BoNT-A in patient with post COVID-19 spasticity, assessed by H-reflex

Background. COVID-19 is a pandemic disease due to viral infection. It spread throughout the world, and the association of COVID-19 with neuroendocrine system is a well-known fact especially while the connection between the endocrine and immune system neuroinflammation play a crucial role in pathophysiology. Therapeutic indication of Botulinum-neurotoxin-A (BoNT-A) is used in the treatment of focal post-stroke spasticity (PSS) and in re-habilitation which is regarded as a safe and effective type of treatment. Objective. To assess spasticity after COVID-19 infection. Methods. Thirty patients diagnosed as post-COVID-19 stroke spasticity were enrolled, their age ranged from (30-60 years). They had focal spasticity of lower extremities. BoNT-A was given in day 0 and 4 weeks later, in the gastrocnemius and soleus muscle. H-reflex was recorded from soleus muscles at 1st presentation and 4 weeks after injection of BoNT-A. Muscle power was assessed by Medical Research Council scale (MRC) and MAS. Results. The amplitude and latency of H-reflex record from soleus muscles and the H/M ratio showed a statistically significant difference between pre- and post-therapy with BoNT-A injection in cases with post COVID-19 spasticity. There was a significant increase in MRC scale but, MAS scale showed a significant reduction after injection of BoNT-A. Conclusion. Post COVID spasticity is a well-known complication after COVID-19 infection, there was clinical improvement in PSS post BoNT-A injections, which was assessed clinically by MAS and MRC scale, neurophysiological the H-reflex was correlated negatively regarding latency, while there was no correlation regarding H-reflex amplitude or Hmax/Mmax ratio and MAS.

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients.

The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment. The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient. Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity. We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.

Post-stroke care pathways and spasticity treatment: a retrospective study in Alberta.

Post-stroke care pathways and spasticity treatment: a retrospective study in Alberta.

Evaluating Community-Based Intrathecal Baclofen Therapy: Effectiveness, Safety, and Feasibility.

Background: Intrathecal baclofen (ITB) is used for the treatment of intractable spasticity. The burden of traveling for ITB screening and aftercare is problematic for nursing home residents with severe spasticity and seems to result in undertreatment of spasticity. The aim of this study is to evaluate the effectiveness, safety, and feasibility of ITB for nursing home residents treated in their home, describing the selection phase, the initial trial of ITB, and aftercare up to 3 months after implantation of an ITB pump. Methods: This retrospective database study included immobile, adult nursing home residents with severe spasticity, referred to an Ambulatory Care Clinic between 2016 and 2021. When eligible, an ITB trial was performed by ITB experts in the nursing home. If a permanent pump was implanted, dose titration and aftercare were performed on location. Results: A total of 102 patients were referred; 80 underwent an ITB trial on location, and 94% improved significantly on the Modified Ashworth Scale and clonus scale pre-ITB trial versus post-ITB trial, as well as at 3 months post-implantation. There was a low incidence of adverse events, mostly procedure- and drug-related. Conclusions: This study indicates that selection, testing, and aftercare for ITB on location is effective and safe.

Amyotrophic Lateral Sclerosis and Pain: A Narrative Review from Pain Assessment to Therapy.

Amyotrophic lateral sclerosis (ALS) is the most frequent neurodegenerative disease of the motor system that affects upper and lower motor neurons, leading to progressive muscle weakness, spasticity, atrophy, and respiratory failure, with a life expectancy of 2-5 years after symptom onset. In addition to motor symptoms, patients with ALS have a multitude of nonmotor symptoms; in fact, it is currently considered a multisystem disease. The purpose of our narrative review is to evaluate the different types of pain, the correlation between pain and the disease's stages, the pain assessment tools in ALS patients, and the available therapies focusing above all on the benefits of cannabis use. Pain is an underestimated and undertreated symptom that, in the last few years, has received more attention from research because it has a strong impact on the quality of life of these patients. The prevalence of pain is between 15% and 85% of ALS patients, and the studies on the type and intensity of pain are controversial. The absence of pain assessment tools validated in the ALS population and the dissimilar study designs influence the knowledge of ALS pain and consequently the pharmacological therapy. Several studies suggest that ALS is associated with changes in the endocannabinoid system, and the use of cannabis could slow the disease progression due to its neuroprotective action and act on pain, spasticity, cramps, sialorrhea, and depression. Our research has shown high patients' satisfaction with the use of cannabis for the treatment of spasticity and related pain. However, especially due to the ethical problems and the lack of interest of pharmaceutical companies, further studies are needed to ensure the most appropriate care for ALS patients.

Multiple Sclerosis Multidisciplinary Care: A National Survey and Lessons for the Global Community

BackgroundAccess to, standardization and reimbursement of multidisciplinary care for people with MS (PwMS) is lacking in many countries. Therefore, this study aims to describe the current multidisciplinary care for people with MS (PwMS) in Belgium and identify benefits, needs and future perspectives MethodsA survey for PwMS questioned various aspects of MS and viewpoints on care. For MS nurses (MSN) and neurologists, employment, education, job-content, care organization and perspectives were inquired. Descriptive and univariate statistics were performed ResultsThe PwMS survey comprised 916 respondents with a mean age of 46±12.7 years and 75,4 % of the respondents being female. The majority of the participants had relapsing remitting MS (60.8 %) and the mean patient determined disease steps (PDDS) was 2.0 (IQR=3). 65.3 % and 60.4 % of the PwMS reported having access to a multidisciplinary team (MDT) or MSN. Access to an MSN was associated with more frequent disease modifying treatment (p=.015), spasticity (p=.042) and gait treatment (p=.035), but also more physiotherapy (p=.004), driver's license adjustment (p<.001) and a higher employment rate (p=.004). MDT access was associated with more frequent symptomatic bladder treatment (p=.047), higher physiotherapy rate (p<.001), higher work- (p=.002), insurance- (p<.001) and home support measures (p=.019). PwMS without an available MDT more often indicated that MS care needs improvement (p<.001). MSN's (n = 22) were mainly funded through various budgets, including hospital and neurology practice budgets. Finally, 69 % and 75 % neurologists (n = 62) working without an MSN or MDT stated a need of such support and 61 % agreed that MDT's should be organized at hospital-network level ConclusionMDT and MSN availability may enhance medical and socio-economic support for PwMS. Guidelines, alignment and reimbursement are needed.

Real-world differences in dosing and clinical utilization of OnabotulinumtoxinA and AbobotulinumtoxinA in the treatment of upper limb spasticity

According to prescribing information, potency units are not interchangeable between botulinum toxin A products. This exploratory study compared real-world dosing and utilization of onabotulinumtoxinA and abobotulinumtoxinA in adults with upper limb spasticity. In this retrospective study, 101 clinicians provided chart data via online surveys for 215 US post-stroke patients treated for upper limb spasticity with ≥3 onabotulinumtoxinA or abobotulinumtoxinA doses (phase 1: 9/18/2020–12/10/2020; phase 2: 9/30/2021–12/7/2021). Most participating clinicians were physicians (70.3%) specializing in neurology (71.3%) or physiatry (20.8%). In the onabotulinumtoxinA (n = 107) and abobotulinumtoxinA (n = 108) groups, ∼75% of patients had moderate-to-severe spasticity. A range of onabotulinumtoxinA:abobotulinumtoxinA dose ratios (1:2.2 [95% CI: 1.8, 2.6] to 1:4.1 [95% CI: 3.0, 6.0]) was observed across muscles. For the most recent dose, mean number of muscles injected was greater for onabotulinumtoxinA (4.3) versus abobotulinumtoxinA (3.1; P = 0.0003). For onabotulinumtoxinA versus abobotulinumtoxinA, the proportion of injections was 81.3% versus 63.9% (P = 0.0067) in forearm muscles and 23.4% versus 3.7% (P = 0.0001) in hand muscles. Mean injection intervals were similar (onabotulinumtoxinA: 102.0 days; abobotulinumtoxinA: 99.1 days). Differences in real-world dosing and utilization of onabotulinumtoxinA and abobotulinumtoxinA for upper limb spasticity were observed. There was no standard dose-conversion ratio, consistent with each product's prescribing information.

Safety of dry needling in stroke patients: a scoping review.

Spasticity is a common problem in stroke patients. Treatments of spasticity often have side effects or are insufficiently effective. Dry needling (DN) has been proposed as a potential additional option to consider in the multimodal treatment of post-stroke spasticity, although questions about its safety remain. The goal of this study is to assess the safety of DN in stroke patients. A systematic search in Medline, Embase, The Cochrane Library, Web of Science, CIHNAL and PEDro was conducted in June 2023. Two reviewers independently screened abstracts according to the eligibility criteria. Twenty-five articles were included in this review. Only six studies reported adverse events, all of which were considered minor. None of the included studies reported any serious adverse events. In four of the included studies anticoagulants were regarded as contra-indicative for DN. Anticoagulants were not mentioned in the other included studies. There is a paucity of literature concerning the safety of DN in stroke patients. This review is the first to investigate the safety of DN in stroke patients and based on the results there is insufficient evidence regarding the safety of DN in stroke patients. Although DN could be a promising treatment in post-stroke spasticity, further research is indicated to investigate its mechanism of action and its effect on outcome. However, before conducting large clinical trials to assess outcome parameters, the safety of DN in stroke patients must be further investigated.

Effect of Botulinum Toxin Injections in the Treatment of Spasticity of Different Etiologies: An Umbrella Review.

Spasticity is a very common neurological sequelae that significantly impacts the quality of life of patients, affecting more than 12 million people worldwide. Botulinum toxin is considered a reversible treatment for spasticity, but due to the large amount of available evidence, synthesis seems necessary. Therefore, we conducted an overview of existing systematic reviews and meta-analyses to evaluate the effect of botulinum toxin injections in the treatment of spasticity of different etiologies. A systematic search of different databases, including Pubmed, Scopus, the Cochrane Library, and Web of Science, was performed from inception to February 2024. Standardized mean differences (SMDs) and their respective 95% confidence intervals (CIs) were calculated to assess the effect of botulinum toxin compared to that of the control treatment using the Modified Ashworth Scale (MAS). All the statistical analyses were performed using STATA 15 software. 28 studies were included in the umbrella review. The effect of botulinum toxin injections on spasticity, as measured by the MAS, was significantly lower in all but three studies, although these studies also supported the intervention. The SMDs reported by the meta-analyses ranged from -0.98 to -0.01. Botulinum toxin injections were effective at treating spasticity of different etiologies, as indicated by the measurements on the MAS. This implies an improvement in muscle tone and, consequently, in the patient's mobility and quality of life.

Effectiveness of Extracorporeal Shock Wave Therapy in Treatment of Spasticity of Different Aetiologies: A Systematic Review and Meta-Analysis.

Background: Spasticity is a motor disorder characterised by exaggerated movements of the tendons and accompanied by hyperreflexia and hypertonia. Extracorporeal shock wave therapy (ESWT) is used as a treatment for spasticity, although more evidence is needed on the effectiveness of this therapy in the treatment of spasticity. Therefore, the aim of this study was to assess the effectiveness ESWT in the treatment of upper and lower limbs spasticity in both children and adults through different aetiologies. Methods: A systematic search was performed in different databases from inception to December 2023. Random-effects meta-analysis was used to estimate the efficacy of ESWT on spasticity using the Modified Ashworth Scale. Results: Sixteen studies were included in the systematic review and meta-analysis. The effect of ESWT on spasticity measured with the Modified Ashworth Scale shows a significant decrease in spasticity in the upper limbs and in the lower limbs in adults with chronic stroke and in children with cerebral palsy, is more effective immediately after application, and maintains its effect up to 12 weeks post treatment. Conclusions: These findings are important for clinical practice since they show evidence that ESWT is effective in reducing spasticity in both children and adults.

The effect of selective dorsal rhizotomy on the improvement of the quality of life of children with stage GMFCS IV and V cerebral palsy: Pain, nursing, positioning, and dressing.

The objective of this study is to evaluate the benefit of selective dorsal rhizotomy on the quality of life of patients with severe spasticity with significant impairment of gross motor functions (GMFCS stages IV and V) according to 4 items: pain, nursing care, positioning, and dressing. We conducted a monocentric retrospective cohort study including patients who underwent selective dorsal rhizotomy between March 2008 and May 2022 at the University Hospital of Marseille. Seventy percent of patients showed an improvement in quality of life criteria: dressing, nursing, positioning, and pain at the last follow-up. A small proportion of patients still showed a worsening between the first 2 follow-ups and the last follow-up. Postoperatively, 27.3% of patients were free of joint spasticity treatment, and we have shown that there was a significant decrease in the number of children who received botulinum toxin postoperatively. However, there was no significant reduction in the number of drug treatments or orthopaedic procedures following RDS. For the CPCHILD© scores, an overall gain is reported for GMFCS IV and V patients in postoperative care. The gain of points is more important for GMFCS IV patients. Improvement was mainly observed in 2 domains, "comfort and emotions" and "hygiene and dressing". For the "quality of life" item, only 3 parents out of the 8 noted a positive change. Our study shows an improvement in nursing care, positioning, and dressing which are associated with a reduction in pain in children with a major polyhandicap GMFCS IV and V who have benefited from a selective dorsal rhizotomy.

Assessment of spasticity-related pain in cerebral palsy and the efficacy of its treatment with incobotulinumtoxin A (literature review)

Pain in cerebral palsy (CP) occurs in 30–60% of cases. Pain associated with spasticity (PAS) is one of the most common causes of pain syndrome in cerebral palsy, which is often associated with impairment of the child’s daily life. Recently, more studies have been published on the use of botulinum toxin type A preparations to control PAS. The review article presents the results of a special pooled analysis of data on the analgesic effect of the drug Xeomin (incobotulinumtoxin A) in the treatment of PAS based on data from three phase III multicentre prospective comparative studies in children and adolescents with spastic forms of cerebral palsy. To evaluate PAS and the effect of incobotulinumtoxin A on it, a special questionnaire (Questionnaire on Pain caused by Spasticity, QPS) was used in these studies. The QPS reflects the child's pain associated with spasticity, which can be observed at rest and during various activities of the child.It was found that the children included in these studies reported the presence of PAS in more than 80% of cases with lower limb spasticity and in almost 70% of cases with upper limb spasticity. Parents or caregivers of these children observed an even higher prevalence of PAS. The use of incobotulinumtoxin A showed not only a pronounced antispastic effect, but also a significant reduction in the frequency and intensity of PAS in children and adolescents with cerebral palsy during normal daily activities, and during strenuous activities such as physical exercise and rehabilitation treatment. With repeated injection cycles of incobotulinumtoxin A, PAS continued to decrease, ensuring a reduction in pain even when physical activity became more difficult. Nowadays, injections with incobotulinumtoxin A can be considered as a routine therapeutic approach for the treatment of spasticity and increased muscle tone, but it is certainly an innovative method for effective pain reduction in cerebral palsy patients with lower and upper limb spasticity accompanied by PAS.

Comparison of tendon and muscle belly vibratory stimulation in the treatment of post-stroke upper extremity spasticity: a retrospective observational pilot study

Previous studies have reported the effects of vibratory stimulation (VS) therapy in reducing upper extremity spasticity after stroke. However, the effective location of the VS in patients with stroke remains unclear. This study aimed to determine the VS location that is most effective in reducing post-stroke finger and wrist flexor spasticity. We enrolled 27 consecutive patients with stroke and upper extremity spasticity in this retrospective observational study. The participants received stretching, tendon vibration, and muscle belly vibration for 5 min over a period of 3 days. To evaluate spasticity, we assessed the Modified Ashworth Scale score before and immediately after each treatment and immediately after voluntary finger flexion. Participants who received tendon vibration showed greater improvement in flexor tone in the fingers than participants who received stretching and muscle belly vibration (P < 0.05 and < 0.001, respectively). Participants who underwent VS showed no significant improvement in the wrist flexor tone compared to those who underwent stretching. Our results suggest that the tendon may be the most effective location for treating spasticity of the finger flexor muscles and that VS may not significantly improve spasticity of the wrist flexors more than stretching.

Cost-effectiveness of abobotulinumtoxinA plus best supportive care compared with best supportive care alone for early treatment of adult lower limb spasticity following an acute event.

Spasticity is an incurable chronic condition, and patients with spasticity frequently experience symptoms such as muscle stiffness, restricted mobility, fatigue, spasms, and pain. The study objective was to assess the cost-effectiveness of abobotulinumtoxinA plus best supportive care compared with best supportive care alone for the early treatment of adult lower limb spasticity following an acute event (e.g. stroke or traumatic brain injury), from an Australian payer perspective. Using clinical data from published pivotal trials, an economic model based on a Markov model was developed to capture changes in treatment costs, healthcare resource use costs, functional outcomes, and health-related quality of life over a lifetime horizon. Scenario analyses and a probabilistic sensitivity analysis were conducted to explore the uncertainty in the model parameters and assumptions used in the base case. AbobotulinumtoxinA plus best supportive care was cost-effective versus best supportive care, yielding an incremental cost-effectiveness ratio of $35,721 per quality-adjusted life year gained. Sensitivity analyses confirm the robustness of the base case, with most results remaining below the commonly acceptable cost-effectiveness willingness-to-pay threshold of $75,000 per quality-adjusted life year for cost-effectiveness in Australia. Inputs and assumptions that produced the top four highest incremental cost-effectiveness ratios include the application of different health resource utilisation source, short time horizon, unweighted regression analyses to determine regression probabilities, and no stopping rule. AbobotulinumtoxinA plus best supportive care has a 74% probability of being cost-effective compared with best supportive care alone at the willingness to pay threshold. AbobotulinumtoxinA plus best supportive care treatment is cost-effective in Australia for the management of adult lower limb spasticity in patients treated within 2 years of an acute event.

Multidisciplinary collaborative consensus statement on the barriers and solutions to care access, patient and caregiver support, and clinical capacity and capability for patients with spasticity.

There is evidence that patients with spasticity are not receiving adequate care. Identifying the unmet needs of patients with spasticity is essential to develop services and treatment strategies to better support this population This is an effort to identify challenges related to treatment of spasticity and provide the springboard for the implementation of identified solutions. To identify the main barriers to spasticity care and identify potential solutions. Delphi process. Expert panel. A total of 35 participants with diverse experience and knowledge related to spasticity care were invited and 29 attended an in-person 2022 Spasticity Summit hosted by the American Academy of Physical Medicine and Rehabilitation. The expert panel participated in a presummit survey to identify the main potential barriers to spasticity care. During the in-person meeting the panel initially worked in small groups and then as whole to reach consensus through the Delphi process. The panel also completed a postsummit survey. Several barriers to spasticity care and potentials solutions were identified. Consensus was reached for the top three barriers and potential solutions (>50% and >75%, respectively). Top barriers included the need for a document listing all the challenges related to access of care for spasticity, increased caregiver and community awareness of spasticity, and education of clinicians regarding patient needs. Top solutions to barriers included increasing the number of providers who treat spasticity, enhancing patient and caregiver education, and developing and publishing a consensus guidance statement. Consensus was achieved on the top three barriers to spasticity care and potential solutions. The purpose of this analysis is to pave the way for further development of solutions to improve the care of patients with spasticity.

Novel Synthetic Industrial Approach for Efficient Synthesis of Baclofen through C–C Bond Formation

AbstractBaclofen is an active pharmaceutical ingredient used for the treatment of muscle spasticity. We describe our efforts to develop a novel synthetic approach through C–C bond formation and a cost-effective route to baclofen. The synthesis involved a two-step approach through C–C bond formation using the extensively and commercially available starting material 4-chlorobenzyl cyanide with chloroacetic acid as a reagent in an aprotic solvent, followed by reduction of the nitrile functional group. The synthetic route to baclofen has been demonstrated to be commercially viable, cost-effective, and environmentally friendly. Execution of the developed process led to the isolation of (+)-baclofen in an overall yield of 60% at a multikilogram scale with &gt;99.5% HPLC purity. This article also discusses the cost-effectiveness of the process, the impurity profiling, and the product quality.

Lateral Pectoral Nerve Identification through Ultrasound-Guided Methylene Blue Injection during Selective Peripheral Neurectomy for Shoulder Spasticity: Proposal for a New Procedure.

Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients' post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions.