What is the appropriate evaluation and management approach for a patient post left frontotemporal‑parietal decompression craniotomy for subdural hematoma who now has flexor‑dominant upper‑limb spasticity and extensor‑dominant lower‑limb spasticity, as a junior physical medicine and rehabilitation resident?

Post-Craniotomy Spasticity Management in Subdural Hematoma Patient

As a junior PM&R resident, your primary approach should focus on comprehensive spasticity assessment followed by initiation of oral antispasticity medications, with tizanidine or baclofen as first-line agents, combined with early intensive physical therapy to prevent contractures and optimize functional recovery. 1

Initial Assessment and Documentation

Neurological Examination Priorities

• Quantify spasticity severity using the Modified Ashworth Scale (0-4 scale) for both upper and lower extremities, documenting the specific pattern: flexor-dominant upper limb (typically biceps, wrist/finger flexors) and extensor-dominant lower limb (typically quadriceps, ankle plantarflexors) 1
• Assess for complications of the craniotomy including signs of intracranial hypertension, infection, or hydrocephalus that could be contributing to abnormal tone 2, 3
• Evaluate functional impact by documenting how spasticity affects activities of daily living, positioning, hygiene care, and potential for rehabilitation participation 1
• Screen for noxious stimuli that exacerbate spasticity: bladder distension, bowel impaction, pressure injuries, deep vein thrombosis, heterotopic ossification, or occult fractures 1

Timing Considerations

The patient is in the acute post-craniotomy phase following subdural hematoma evacuation, where spasticity typically emerges 1-4 weeks post-injury as an upper motor neuron syndrome manifestation 3, 4

Pharmacological Management Algorithm

First-Line Oral Antispasticity Agents

Tizanidine (preferred initial agent):

• Start at 2-4 mg at bedtime to assess tolerance 1
• Titrate gradually over 2-4 weeks up to 8-12 mg three times daily (maximum 36 mg/day in divided doses) 1
• Monitor closely for hypotension and hepatotoxicity; obtain baseline liver function tests 1
• Advantages: less generalized weakness compared to baclofen, useful for focal spasticity patterns 1
• Caution: clearance reduced by >50% in renal insufficiency; use lower doses if creatinine clearance <25 mL/min 1

Baclofen (alternative first-line):

• Start 5 mg three times daily, titrate by 5 mg every 3 days 1
• Target dose typically 40-80 mg/day in divided doses (maximum 120 mg/day) 1
• More effective for lower extremity extensor spasticity but may cause more generalized weakness 1

Avoid These Common Pitfalls

• Do not start multiple antispasticity agents simultaneously - this prevents identification of which medication is effective or causing adverse effects 1
• Do not use benzodiazepines as first-line in brain injury patients due to cognitive impairment and sedation risks 1
• Do not abruptly discontinue baclofen - risk of withdrawal seizures and rebound spasticity 1

Physical Therapy Interventions

Immediate Rehabilitation Priorities

• Range of motion exercises performed 2-3 times daily to prevent contractures, focusing on shoulder abduction/external rotation, elbow extension, wrist/finger extension, hip flexion, knee flexion, and ankle dorsiflexion 1
• Positioning program with specific attention to preventing shoulder subluxation, maintaining hip/knee alignment, and preventing ankle equinus deformity 1
• Serial casting or splinting for severe spasticity if range of motion exercises alone are insufficient, particularly for wrist/finger flexors and ankle plantarflexors 1

Functional Training

• Task-specific training as cognition and motor control improve, emphasizing functional activities rather than isolated exercises 1
• Gait training with appropriate assistive devices once lower extremity control permits, addressing extensor synergy pattern 1

Advanced Interventions for Refractory Spasticity

Chemodenervation (Consider at 3+ Months Post-Injury)

Botulinum toxin injections for focal spasticity affecting specific muscle groups when oral medications provide insufficient relief:

• Upper limb: target biceps, brachialis, wrist/finger flexors based on functional goals 1
• Lower limb: target gastrocnemius/soleus for ankle equinus, hip adductors if interfering with hygiene 1
• Typical onset 3-7 days, peak effect 4-6 weeks, duration 3-4 months 1

Phenol or alcohol neurolysis for mixed motor-sensory nerves when botulinum toxin is insufficient or cost-prohibitive 1

Intrathecal Baclofen Pump

Reserve for severe generalized spasticity unresponsive to oral medications and focal interventions, typically not considered until 6-12 months post-injury when spasticity pattern has stabilized 1

Monitoring and Follow-Up

Short-Term (Weekly for First Month)

• Reassess Modified Ashworth scores to track response to interventions 1
• Monitor for adverse medication effects: sedation, weakness, hypotension, hepatotoxicity 1
• Evaluate for complications: DVT, pressure injuries, contracture development 1

Medium-Term (Monthly)

• Functional outcome measures: Functional Independence Measure (FIM) scores to document progress 1
• Adjust medication regimen based on spasticity pattern evolution and functional goals 1
• Consider advanced interventions if inadequate response to oral medications and therapy by 3 months 1

Red Flags Requiring Urgent Neurosurgical Consultation

• Sudden worsening of spasticity with altered consciousness - consider hydrocephalus, rebleeding, or seizures 2, 3
• New focal neurological deficits - evaluate for delayed complications of craniotomy 3, 4
• Signs of increased intracranial pressure - headache, vomiting, papilledema 2, 3

Special Considerations for Post-Craniotomy Patients

The surgical intervention (left frontotemporal-parietal decompression craniotomy) indicates significant initial injury severity with mass effect requiring surgical evacuation 3, 4. This population has higher risk for:

• Post-traumatic hydrocephalus (may develop weeks to months post-craniotomy and worsen spasticity) 2
• Post-traumatic seizures (prophylaxis typically discontinued after 7 days, but monitor for late seizures that can increase tone) 2
• Bone flap complications if cranioplasty is pending (timing typically 6-12 weeks post-decompression) 5