Building a pediatric spasticity surgery program in a low-awareness setting: capacity creation, multidisciplinary...

Selective dorsal rhizotomy (SDR) and other spasticity-relieving procedures remain markedly underutilized in many regions of the world, not because of technical infeasibility but because of low awareness among referring specialties, the absence of structured referral pathways, and limited multidisciplinary integration. We describe the stepwise establishment of a pediatric spasticity surgery program in such a setting, with emphasis on capacity creation, stakeholder engagement, individualized treatment selection, and early clinical outcomes.

This program was developed at a tertiary care government-aided academic hospital in Western India, beginning in April 2024 under a fellowship-trained functional neurosurgeon. In the absence of a preexisting referral ecosystem, initial cases were identified through surgeon-led screening of existing neurosurgical follow-up patients, with all identified candidates reviewed through structured multidisciplinary assessment before surgical candidacy was confirmed. In parallel, a physiologist was trained in intraoperative neurophysiological monitoring (IONM) using published protocols to build local monitoring capability. An initial cohort of four adult patients with severe post-traumatic spasticity (three with post-spinal cord injury paraparesis/quadriparesis, one with post-traumatic brain injury paraparesis) underwent SDR, confirming technical feasibility and perioperative safety of the locally developed protocol. Between April 2025 and March 2026, nine pediatric patients (age 5-18 years) underwent spasticity surgery (SDR, n = 8; selective tibial neurectomy, n = 1). The approach comprised (1) surgeon-led case identification with structured multidisciplinary review, (2) in-house neurophysiology capacity building, and (3) progressive integration with pediatric neurology, orthopedics, and rehabilitation services with an explicit individualized treatment selection framework.

Most pediatric patients presented late, with severe spasticity (Modified Ashworth Scale [MAS] grade 3/4), often accompanied by secondary fixed musculoskeletal contractures. A significant reduction in tone was achieved in all patients (MAS 3 → 1 in four patients, MAS 4 → 1 in four patients; MAS 4 → 2 in one patient). No perioperative neurosurgical complications occurred. All patients also demonstrated improvement in ambulatory status after surgery. Three patients with fixed deformities subsequently underwent planned, staged orthopedic contracture release once tone had been reduced. Over the course of the program, progressive multidisciplinary engagement led to improved awareness, increased referrals, and more coordinated care.

The principal barrier to pediatric spasticity surgery in settings such as ours is low awareness and the absence of structured referral pathways, rather than technical limitations. Capacity building and active stakeholder engagement are critical to program development, and a staged, multidisciplinary approach integrating individualized treatment selection, neurosurgical intervention, and orthopedic management is essential for optimal outcomes. This experience offers a clinician-driven model that may provide applicable lessons for centers seeking to establish spasticity surgery programs in similar low-awareness settings.