Selective peripheral neurotomy for multifocal spasticity: Two-dimensional operative video.

Background: Spasticity is a disabling condition, usually present as a manifestation of upper motor neuron syndrome. It can be diffuse, focal, or multifocal, and the treatment should be individualized considering the factors as type, cause, progression over time, as well as joints and muscles functionality. Case Description: We present the case of a 35-year-old female patient developing a left-sided multifocal spasticity following the bleeding of an arteriovenous malformation 5 years ago. Unfortunately, the patient presented progressive symptoms over the years which were refractory to different medical treatments. Considering no muscle contractures, no definitive joint deformities, the existence of antagonist muscles functionality, as well as a multifocal scenario, we performed a selective peripheral neurotomy to the most affected nerves. Under the guidance of intraoperative neurophysiological monitoring and employing microsurgical techniques, we approached nerve branches of the musculocutaneous and median nerve in the upper limb, and the tibial nerve in the lower limb. During the procedure, it was already possible to see changes in the electroneuromyography and reduction of muscle tone. The patient presented improvement of symptoms in the 1st days following the procedure, with a significant decrease in abnormal flexor tone of the affected muscles. Conclusion: Careful preoperative neurological examination is essential to plan the most accurate surgical strategy, and rehabilitation adherence is mandatory for a favorable long-term outcome. Patient consented to the procedure and publication of this operative video.