200 Section - Multimodal and integrated Long-term management of spasticity: a case of right hemiparesis following hemoragic stroke

Case Diagnosis: S.S., a 39-year-old male, presented with right hemiparesis following an intracranial hemorrhage on November 1, 2009, caused by the rupture of a frontocentral Arteriovenous Malformation (AVM). Initial management included emergency neurosurgery for hematoma evacuation and decompression. The resulting neurological deficit required a long-term, evolving treatment strategy for spasticity and motor function recovery.

Case Description: The patient underwent multimodal, personalized rehabilitation treatment over sixteen years. Before each intervention, comprehensive instrumental evaluation was performed in the gait and movement analysis laboratory to guide clinical decision-making. Initial treatment included ultrasound-guided Botulinum Neurotoxin Type A (BoNT-A) injections coupled with intensive rehabilitation including robotic treatment and functional electrical stimulation. Surgical interventions included functional orthopedic surgery on lower and upper limbs (tendon lengthening and transfers in 2013-2014). Later interventions involved innovative minimally invasive laser surgery for myotendinous lengthening of the thumb adductor (2019) and selective neurotomy of tibial nerve motor branches to manage triceps surae spasticity (2025).

Discussions: This long-term case demonstrates that neurological presentation can evolve over time, with changes in spasticity patterns and motor planning, necessitating continuous monitoring of neuroplasticity. Effective spasticity management requires an integrated, multidisciplinary approach. The sequential use of BoNT-A, functional surgery, robotics, and innovative minimally invasive laser surgery highlights the importance of selecting the "right treatment" at the "right moment" to achieve optimal functional independence.

Conclusions: This case underscores the physiatrist's pivotal role in comprehensive spasticity management. The physiatrist's expertise encompasses advanced assessment using movement analysis and biomechanical evaluation, infiltrative treatment with botulinum toxin, design of highly personalized multimodal protocols adaptable to evolving neuroplasticity, and interventional procedures including innovative ultrasound-guided mini-invasive approaches for targeted myotendinous lengthening and percutaneous neurotomies. These mini-invasive approaches have proven effective and safe, expanding the therapeutic armamentarium and positioning the physiatrist as essential in optimizing long-term functional outcomes.