200 Section - Multimodal tailored long term rehabilitation pathway for severe Spasticity in a young spinal cord injury (SCI) patient

a 28-year-old male developed spastic paraparesis (AIS-D T5 level), following spinal cord hypoperfusion in February 2019. He exhibited trunk and lower-limb spasticity with significant functional impairment (walking with a walker = WISCI-II 13, velocity 0,119 m/s). Despite medical recommendations, in the acute phase he declined implantation of an intrathecal baclofen pump

Case Description:

dynamic s-EMG pattern of lower limbs during walking was studied for treatment planning. He underwent lower limb high doses botulinum toxin injections combined with serial casting and attended a complex multimodal rehabilitation treatment (overground exoskeleton walking training, lower limb functional eletrical stimulation). These treatments were repeated every 4-6 months but only transient functional gains were observed (gait velocity 0,25 m/s with a walker 2 years after injury) and spasticity (mAS score) recurred. Then minimally invasive super-selective functional surgery (tibial nerve laser neurotomy of the motor branches to the gastrocnemius and soleus muscles and percutaneous laser myotendinous triceps lengthening) was performed in May 2024 on the right side and in February 2025 on the left side, with bilateral percutaneous flexor digitorum tenotomy. These procedures reduced involuntary contraction and improved limb alignment and walking performance with two crutches (velocity 0,355 m/s, WISCI II 16) after 6 years

Discussions:

Spasticity is a complex phenomenon in long term follow up of incomplete SCI.  mAS provides useful grading of muscle tone but do not full capture the functional burden. Dynamic emg is useful to guide treatment decisions. An effective management requires a multimodal approach integrating drugs (oral, focal chemodenervation), gait training with/without technological support and laser minimally invasive surgery

Conclusions:

Lower limb Spasticity after incomplete SCI requires a personalized adaptable multimodal treatment plan during a long term follow up. Patient preferences, clinical and instrumental dynamic emg evaluations of the evolving gait dysfunction help define goals and conservative or mininvasive procedures to optimize long term outcomes