Abstract
Background: Upper-limb spasticity resulting from stroke, traumatic brain injury (TBI), or cerebral palsy (CP) causes deformity and functional impairment. Hyperselective neurectomy (HSN) reduces spasticity by partial resection of terminal motor fascicles while preserving voluntary control. Performing HSN under wide-awake local anesthesia with no tourniquet (WALANT) enables real-time physiologic assessment of tone and movement. This study evaluates clinical outcomes of upper-limb HSN performed entirely under WALANT. Methods: Thirty consecutive patients with focal upper-limb spasticity (Modified Ashworth Scale [MAS] ≥3) and preserved volition underwent WALANT-guided HSN between January 2019 and December 2024. Etiologies included traumatic brain injury, stroke, and cerebral palsy. Approximately two-thirds of motor fascicles supplying overactive muscles were resected at their intramuscular entry points under magnification, with incremental intraoperative assessment of tone and voluntary movement. Outcomes at 24 ± 3 months included MAS, Tardieu angle, Medical Research Council (MRC) strength, range of motion (ROM), and House functional use scores. Results: The mean age was 35 years (53% TBI, 23% stroke, 23% CP). Spasticity decreased by approximately two MAS grades, and the Tardieu R2–R1 angle narrowed significantly. Mean active gains included 50° in elbow extension, 33° in forearm supination, and 35° in wrist extension. Antagonist strength improved from MRC 2.8 ± 0.5–4.1 ± 0.4, while voluntary strength was preserved. House functional scores improved from 2.1 ± 0.9–4.5 ± 0.8 (p < 0.001). All procedures were completed as outpatient day surgeries without conversion to general anesthesia. Transient paresthesia occurred in 3 patients (10%). Conclusions: WALANT-guided hyperselective neurectomy provides durable reduction of upper-limb spasticity with meaningful functional improvement and a favorable safety profile. Real-time intraoperative titration allows physiologically guided denervation and supports WALANT as a reliable, patient-centered approach for selected patients with focal upper-limb spasticity. Level of Evidence IV: (Retrospective cohort study)