Spasticity — Timoteo Almeida, MD, PhD

Spasticity

Involuntary muscle tightness and spasms that can follow brain or spinal cord conditions. When oral medications and therapy aren't enough, implantable pump therapy and selective surgical options can meaningfully improve comfort and function.

💪

Involuntary tightness & spasms

Follows conditions affecting the brain or spinal cord — spinal cord injury, MS, cerebral palsy, stroke, and others.

💧

Intrathecal baclofen pump

Delivers medication directly into spinal fluid, often achieving better tone control with less systemic sedation.

⚠

Reliable follow-up is critical

ITB requires scheduled refills — withdrawal or overdose from missed appointments can be life-threatening.

Understanding your condition

What is spasticity?

Spasticity can limit movement, cause pain, disrupt sleep, and complicate caregiving. It results from abnormal signaling between the brain or spinal cord and muscles, causing involuntary tightness, stiffness, and spasms.

Treatment is typically layered: stretching and therapy, oral medications, focal injections (like botulinum toxin), and — when severe — pump-based therapy or surgical options that address the underlying neural pathways.

Spinal cord injury

Multiple sclerosis

Cerebral palsy

Stroke

Traumatic brain injury

Am I a candidate?

Who may benefit from an intrathecal baclofen pump?

You may be a candidate if:

A screening trial is typically performed before permanent implantation to confirm benefit.

✓

Spasticity is severe, persistent, and function-limiting despite therapy and oral medications.
✓

You and/or your caregivers can commit to scheduled pump refills and follow-up visits — this is essential for safety.
✓

A screening trial suggests baclofen delivered intrathecally improves tone and comfort.

Your options

Treatment Options

The ITB pump is the primary advanced option for severe spasticity. In carefully selected patients, surgical rhizotomy procedures may also be considered.

💧 Primary option

Intrathecal Baclofen Pump (ITB)

A programmable pump implanted under the skin delivers baclofen directly into spinal fluid through a catheter, achieving targeted tone control with less systemic sedation.

Mechanism Baclofen reaches the spinal cord more directly than oral medication, allowing lower effective doses and less drowsiness or cognitive side effects.

Programming Dosing starts low and is adjusted gradually over multiple visits. The pump is fully programmable — rates can be changed to match your needs.

Refills The pump reservoir needs periodic refilling (typically every few months) via a simple office procedure with a needle through the skin.

Critical safety note Missed refills can lead to withdrawal — a medical emergency. Reliable follow-up is essential for safe, long-term pump therapy.

Adjustable Reversible Programmable dosing Screening trial first

Other Neurosurgical Options (Selected Patients)

For patients where long-term tone reduction is the goal and other treatments are insufficient.

✂ Surgical

Selective Dorsal Rhizotomy (SDR)

Selective cutting of sensory nerve rootlets

How it works Selectively cuts a portion of sensory nerve rootlets (most commonly in the lower spine) that contribute to exaggerated stretch reflexes.

Best suited for Primarily cerebral palsy–related lower-limb spasticity. May be considered in select adolescents/adults depending on spasticity pattern, baseline strength, and goals.

Important Requires structured rehabilitation afterward. Candidacy depends on baseline strength, motor control, and whether spasticity (vs. dystonia or weakness) is the main driver.

Durable Permanent Rehab required

☢ Radiosurgery

Radiosurgical Rhizotomy

Non-incisional stereotactic targeting of sensory roots

How it works Stereotactic radiosurgery targets specific sensory roots to reduce problematic spasticity — no incision or open surgery required.

Best suited for Highly selected cases — often when patients are not ideal candidates for open surgery or prefer a non-incisional approach after careful counseling.

Important Effects are gradual (weeks to months) and not adjustable once delivered. Patient selection and expectation-setting are key.

No incision Gradual onset Permanent

How these compare

ITB Pump

Adjustable dosing, reversible, excellent for diffuse and severe spasticity — but requires reliable refills and ongoing follow-up. The dose can be titrated up or down as your needs change.

SDR / Radiosurgical Rhizotomy

Potentially durable tone reduction in selected patterns (often lower-extremity predominant), but the effects are typically permanent and not titratable. Best when the goal is long-term reduction in a specific spasticity pattern.

Your journey

What to Expect

The ITB pump pathway starts with evaluation and a screening test dose, then moves to implantation and long-term management.

Before

Spasticity evaluation focused on your goals — which may include easier transfers, comfort, hygiene, or mobility. Medication review, pump education, and often a screening test dose to gauge your response to intrathecal baclofen.

During surgery

Pump and catheter placement under anesthesia. Programming begins at a low dose and is adjusted gradually over the following weeks to find your optimal level.

After

Planned dose titration and a routine refill schedule. Troubleshooting visits if spasticity suddenly worsens (possible catheter issue or low reservoir) or if sedation increases (possible dose adjustment needed).

Weighing your decision

Benefits and Risks

Potential Benefits

✦ Reduced spasms and stiffness
✦ Improved comfort and sleep
✦ Easier caregiving — transfers, hygiene, positioning
✦ Improved mobility function in some patients, depending on goals and condition

Possible Risks

△ Common: Surgical site pain, catheter/pump mechanical issues, dosing side effects (sleepiness, weakness)
△ Uncommon: Infection, catheter complications requiring urgent care

Critical Safety: Withdrawal & Overdose

Withdrawal risk

Can occur from missed refills, pump malfunction, or catheter problems. Symptoms include rapidly worsening stiffness/spasms, high fever, confusion, and severe itching/tingling. Rare cases can progress to rhabdomyolysis, organ failure, and death.

Overdose risk

Can cause excessive sleepiness, slowed breathing, and respiratory depression. This is why dosing is adjusted gradually and monitored carefully — and why reliable follow-up is essential for long-term safety.

Common questions

Patient FAQs

Will the pump limit my activities?

Many patients return to most daily activities. You'll have specific post-operative restrictions early on, and periodic refill visits long-term, but most patients adapt well to life with the pump.

What if I miss a refill?

Missing refills can trigger baclofen withdrawal — this is a medical emergency. It's essential to keep your refill appointments on schedule and to contact your team immediately if you notice warning signs.

Can the dose be adjusted?

Yes — the pump is fully programmable and dosing is individualized. Your team can increase, decrease, or change the delivery pattern over time to optimize your tone control and minimize side effects.

When to Seek Urgent Care

Go to the ER immediately for suspected withdrawal or overdose: rapidly worsening stiffness or spasms, high fever, confusion, severe itching or tingling with worsening spasticity, extreme sleepiness, slowed breathing, or seizures.