Neurosurgery to restore function in cerebral palsy: current practice and emerging therapies

Cerebral palsy (CP) affects 1.5-2.5 per 1,000 live births and manifests as diverse movement disorders including spasticity, dystonia, and mixed phenotypes that significantly impact motor function and quality of life. This review examines surgical and neuromodulatory interventions for medically refractory CP-associated movement disorders. Selective dorsal rhizotomy (SDR) offers a novel treatment option for spastic diplegia in ambulatory children (GMFCS II-III), with combined dorsal-ventral rhizotomy showing promise for mixed presentations. Peripheral neurectomies provide targeted focal spasticity management with sustained improvements in muscle tone and walking speed. Intrathecal baclofen (ITB) effectively reduces spasticity and dystonia through programmable drug delivery, though infection rates and potential scoliosis progression require monitoring. Deep brain stimulation (DBS) targeting the globus pallidus internus demonstrates efficacy for dystonia-predominant CP, with younger patients showing greater improvement. Emerging cerebellar DBS approaches show early promise for spasticity and mixed presentations. Spinal cord stimulation (SCS) may benefit select patients with spasticity or painful dystonia, though evidence remains limited. Focused ultrasound represents a novel noninvasive ablative option currently under investigation. Treatment selection requires multidisciplinary evaluation considering movement disorder phenotype, functional goals, patient age, and family factors. As understanding of CP pathophysiology advances, mechanism-based, individualized treatment algorithms will increasingly optimize functional outcomes for this heterogeneous patient population.