Spasticity
Birmingham Upper and Lower Limb Spasticity Service (BULLSS)
0121 812 3474
About
The Birmingham Upper and Lower Limb Spasticity Service (BULLSS) is a specialist surgical service for adults living with spasticity following stroke, cerebral palsy, traumatic brain injury, spinal cord injury and other neurological conditions. Our team includes three Consultant Spasticity Surgeons and an Advanced Practice Physiotherapist, specialising in neurology, with expertise in reconstructive surgery, peripheral nerve surgery and functional restoration.
We provide specialist assessment, including Diagnostic local anaesthetic blocks where appropriate, and a wide range of surgical treatments for upper and lower limb spasticity, including muscle and tendon procedures, Hyper-Selective Neurectomy (HSN), tendon transfers, reconstructive surgery and advanced peripheral nerve procedures. Our goal is to improve function, comfort and independence through treatment tailored to what matters most to each patient.
We welcome referrals from across the UK so that we can assess whether surgery could help. With 90% of procedures performed as day-case surgery and around two-thirds undertaken under regional anaesthesia, we aim to provide effective treatment while minimising the impact of surgery on everyday life.
✅ 3 Consultant Spasticity Surgeons
✅ Advanced Practice Physiotherapist, Specialising in Neurology
✅ Diagnostic Local Anaesthetic Blocks as Part of Our Assessment
✅ 90% Day-Case Surgery
✅ Around 2/3 of Procedures Performed Under Regional Anaesthesia
✅ UK-Wide Surgical Referrals Accepted
Specialist opinions and referrals are welcomed from across the UK so that we can assess whether surgery could help. Patients may be referred by their GP, consultant, therapist or other healthcare professional.
Meet our team
Patient Resources
Conditions we treat
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- Stroke
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- Cerebral Palsy
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- Traumatic brain injury
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- Spinal cord injury
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- Pseudospasticity: a clasped or clenched hand that resembles spasticity, sometimes presenting without any apparent cause
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- Other neurological conditions associated with spasticity
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We have particular expertise in both upper and lower limb spasticity.
Common problems we treat
- A clenched hand or tightly closed fingers
- Difficulty opening the hand
- Difficulty using the arm or hand
- Muscle tightness, stiffness or spasms
- Pain and discomfort
- Difficulty reaching, grasping or releasing objects
- Abnormal limb posture or positioning
- Difficulties with washing, dressing and personal care
- Problems wearing splints, orthotics or specialised footwear
- Walking, balance and mobility problems
How We Assess
Every assessment is individual. Alongside a full clinical examination and a discussion of your goals, we may use Diagnostic local anaesthetic blocks as part of our process. These are blocks where we temporarily freeze nerves in order to temporarily paralyse some muscles. These temporary blocks help us understand which muscles and nerves are contributing to the problem and how you are likely to respond, which helps us decide whether surgery could help and plan it carefully.
Surgical treatments offered
- Muscle and tendon lengthening procedures
- Tenotomies
- Tendon transfer surgery
- Joint rebalancing procedures
- Joint fusion procedures
- Hyper-Selective Neurectomy (HSN)
- Upper and lower limb reconstruction
- Contralateral C7 (CC7) nerve transfer in selected patients
- C7 neurectomy and other advanced peripheral nerve procedures
Procedures specific to the lower limb including (but not exclusive to):
- Gastrocnemius and Achilles tendon lengthening
- Tibialis posterior lengthening or transfer
- Hamstring lengthening
- Adductor release
- Hyper-Selective Neurectomy (HSN) of the tibial nerve
Our Advanced Practice Physiotherapist, specialising in neurology, supports assessment, surgical planning and recovery following surgery.
Common Goals Following Treatment
Treatment may help to:
- Open the hand more easily
- Improve the ability to grasp and release objects
- Reduce pain and muscle tightness
- Improve limb position and posture
- Improve arm and hand function
- Make washing, dressing and personal care easier
- Improve walking and mobility
- Increase comfort and confidence
- Maximise independence and quality of life
Minimising the Impact of Surgery
- 90% of procedures are performed as day-case surgery
- Around two-thirds of upper limb operations are performed under regional anaesthesia (Local Anaesthetic Blocks)
- Many patients return home on the same day
- Regional anaesthesia reduces the risks associated with general anaesthesia
- Earlier recovery and rehabilitation is often possible
Accessing Our Service
The Birmingham Upper and Lower Limb Spasticity service is a surgical service. We welcome referrals of any patient who may benefit from surgery, so that we can assess whether we can offer it.
We welcome referrals from:
- Consultants and hospital specialists
- Rehabilitation teams
- Therapists and other healthcare professionals
- GPs
Patients can be referred from both within and outside the region for specialist assessment and treatment.
Non-Surgical Management
Where appropriate, we also offer non-surgical management as part of a patient’s care with us. However, as a surgical service we are not set up to provide general non-surgical spasticity or rehabilitation assessment and management. Patients whose needs are likely to be non-surgical are best referred to their local specialist rehabilitation service in the first instance. If you are unsure whether surgery could help, we would be glad to receive a referral so that we can assess this.
Further resources and support
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Cerebral Palsy information http://www.cerebralpalsy.org.uk/
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Stroke association https://www.stroke.org.uk/
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Headway – The brain injury association https://www.headway.org.uk/
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Multiple Sclerosis Society https://www.mssociety.org.uk/
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Parkinson’s disease society https://www.parkinsons.org.uk/
Less pain, more independence, life changing care
Every person’s experience of spasticity is different.
Whether your goal is to improve hand function, reduce pain, make personal care easier, improve mobility or increase independence, we will work with you to determine whether surgery could help, discuss non-surgical options alongside it where appropriate, and develop a treatment plan focused on the outcomes that matter most to you.
Our focus is helping you achieve meaningful improvements in function, comfort, independence and quality of life.
Clinician Resources
Up and coming courses
The department runs a range of training courses for undergraduates and postgraduates. You can find out more about available courses and how to book here: Royal Orthopaedic Hospital | MSK Academy - Courses intro
On-demand learning
We have developed a resource of on-demand videos and presentations for clinicians ranging from patient examination guidance to diagnosing, treating and managing advice. This resource can be found at Royal Orthopaedic Hospital | MSK Academy - On Demand Learning
Research and Clinical Trials
The Royal Orthopaedic Hospital is committed to advancing medical research and discovering new treatments to improve patient outcomes, and has a strong interest in all aspects of upper and lower limb spasticity and research.
For more information on our research activities visit Royal Orthopaedic Hospital - Research
Clinical Trials
We are recruiting patients for research studies. Please ask your doctor in our clinic if you would like to be involved in the trials or contact us on our email
Publications
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Mikalef & Powell (2017) The role of neurectomy in the management of spasticity of the upper limb
Neurectomy is one of the treatments available to the surgeon treating patients with spasticity of the upper limb. Its popularity has increased in recent years. Accurate knowledge of the anatomical variations of the terminal branches to the muscles is required in order to achieve a successful outcome. Although the anatomy has been thoroughly studied, there are still controversies regarding the percentage of the nerve to be resected for a successful result, and also regarding the terminology that has been used in the literature to describe the procedure. The literature for neurectomies for the upper limb is reviewed and an agreement regarding terminology is proposed.
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Leclerq et al (2021) Hyperselective neurectomy for the treatment of upper limb spasticity in adults and children: a prospective study
Hyperselective neurectomy (HSN) procedures in the spastic upper limb aim to reduce tone by excising some branches of the involved peripheral motor nerves, at the point of entry of each motor ramus into the target muscle. In this prospective study, 42 patients with upper limb spasticity were treated by HSN for the muscles of elbow flexion, forearm pronation and wrist flexion and evaluated for their short-term results (average 6 months) and long-term outcomes (average 31 months). Results at both time points showed an effective reduction of the spastic tone, with no decrease of muscle strength in the operated spastic muscles. Comparison of results between the two time points showed durability of the improvement, which remained statistically significant despite a slight relapse in spasticity. The results of HSN compare favourably with the other techniques of partial neurectomy; however, the technique requires a detailed knowledge of upper limb motor anatomy
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Chung et al (2025) Hyperselective neurectomy for the treatment of upper limb spasticity: a long-term follow-up
Hyperselective neurectomy is increasingly recognized as one of the major treatment strategies for spasticity of the upper limb. However, concern remains about postoperative recurrence of the spasticity. In a previous prospective study of 42 patients, we reported significant improvement in spasticity with minor recurrence but overall tone reduction at an average of 31 months post-surgery. In this follow-up study we reassessed a subpopulation of patients from the same cohort to evaluate the long-term efficacy of hyperselective neurectomy. At an average of 53 months post-surgery, the results of 39 patients showed a similar trend to the previous study with significant improvement in the modified Ashworth and Tardieu scale within a year, and this improvement remained stable at the final follow-up. There was also significant improvement in spontaneous posture (mean 75–40° elbow flexion), with no decline in the range of motion and strength of the operated muscles. Antagonist muscle groups and functional scores demonstrated a general trend towards improvement (House score from 2.2 to 3.4). This study highlights the sustained effectiveness of hyperselective neurectomy on upper limb spasticity more than 4 years after the procedure.
Contact us
For Clinicians
Do you have a patient you would like to refer to us? Referrals need to consider the following criteria:
- Adults over the age of 18
- We receive referrals from any area of the UK from GP and Specialist Consultants
- Adults with any neurological impairment including but not limited to Cerebral palsy, stroke, traumatic brain injury, MS and Parkinson’s disease
- Referrals will be screened by our specialist team and if accepted, the patient and their family/ care team will be invited to attend a Multi-disclipinary Team assessment
Links to our referral forms and further referral contact information can be found here: Royal Orthopaedic Hospital - Referral
Please note, all referrals from Primary Care should be sent via ERS
Come work with us!
If you would like to arrange a clinical visit to the Trust, or would like to find out more about job opportunities, please contact the team:
Get in touch
Spasticity Service
The Royal Orthopaedic Hospital
Bristol Road South
Birmingham
B31 2AP
0121 685 4000 ext. 3474