Journal of Hand Surgery European - 2026-03-28 - Journal Article; Review
Achieving balance in upper limb spasticity management.
Lam W, Leclercq C, Luria S, Rhee P
Topics
Key Takeaway
Hyperselective neurectomy and tendon lengthening each address upper limb spasticity tone management through distinct mechanisms, but no high-level evidence currently establishes superiority of one over the other in functional or non-functional hands.
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Summary
This narrative review examines four unresolved decision-making domains in upper limb spasticity surgery: lengthening versus hyperselective neurectomy for tone, wrist stability versus mobility goals, grasp and release restoration via finger flexor/extensor procedures, and dystonia management. The authors synthesize available evidence across bony, tendon, and nerve procedures while emphasizing individualized multidisciplinary assessment and the functional versus non-functional hand distinction as the primary treatment framework. No pooled outcome data or meta-analytic statistics are reported; conclusions are consensus- and expert opinion-based.
Key Limitation
The review lacks a systematic search methodology and quantitative synthesis, so its conclusions on comparative efficacy between procedures rest entirely on expert opinion and heterogeneous case series.
Original Abstract
INTRODUCTION
Upper limb spasticity can result from a variety of insults to the central nervous system. Disruption of the closely regulated spinal reflex arc, owing to loss of brain inhibition, results in an imbalance between antagonist and agonist muscle groups, leading to a loss of fluid coordination of motion across joints.Management strategies:A detailed, individualized assessment of each patient is mandatory in a multidisciplinary setting. Although there are objective parameters which guide treatment, variation and customization of strategies are needed for each patient, including defining a functional vs. a non-functional hand, and whether mobility or stability is the primary goal for surgery.Challenging areas in spasticity management:Surgical options include bony, tendon and nerve procedures. These aim to reduce tone, release contractures or reanimate paralysed muscles. This article examines four challenging areas in decision making for choosing these options: lengthening vs. hyperselective neurectomy for tone management, stability vs. mobility in wrist spasticity, grasp and release recovery through finger flexion and extension, and dystonia. Evidence-based treatments are discussed where available, along with key unresolved issues and future research directions.
CONCLUSION
Restoring balance in the spastic upper limb, especially when voluntary control is lost, remains one of the most complex challenges in hand surgery. A thorough understanding of biomechanical principles and neurological pathways is necessary for the hand surgeon. Furthermore, working within a multidisciplinary team is essential to utilize a comprehensive array of assessment tools, ensuring accurate diagnosis and individualized patient care.