Hyperselective Peripheral Neurectomy Versus Medical Therapy for Refractory Poststroke Spasticity: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES: Poststroke spasticity is a common and debilitating condition that limits functions, is associated with pain, and impairs independence. Medications are often costly, temporary or insufficient to manage this condition. We aimed to compare the efficacy and safety of hyperselective peripheral neurectomy with best medical therapy in patients of poststroke spasticity. METHODS: This trial was a prospective, randomized controlled study performed on adults with poststroke spasticity [modified Ashworth scale (MAS) score of 3-4] refractory to maximal tolerated baclofen. Patients were randomized (1:1) to undergo surgery plus rehabilitation or to continue medical therapy with rehabilitation. The primary outcome was change in MAS score at 12 months from baseline. RESULTS: Fifty patients were randomized equally into the 2 groups. At 12 months, the surgical group had significantly greater reduction in spasticity with a between-group difference of 1.36 points (95% CI 0.97-1.74; P < .001). The surgical group also had clinically meaningful ≥1-grade improvement in MAS score in 96% of patients compared with only 8% in the medical group (number needed to treat 1.14). Functional independence improved only within the surgical group, with no significant between-group difference. No differences were observed in power or sensory outcomes. Transient neuropathic pain was observed in 5 patients in the surgical group (resolved with medicines in 2-3 months). CONCLUSION: The hyperselective peripheral neurectomy is associated with substantial and sustained reduction in spasticity in carefully selected patients. TRIAL REGISTRATION NUMBER: CTRI/2023/11/060191.