This article reviews nerve-based surgical approaches for treating upper-limb spasticity, focusing on their anatomic targets and functional outcomes. Central procedures, like selective dorsal rhizotomy and contralateral C7 transfer, reduce tone at the root level but lack muscle specificity. In contrast, peripheral techniques—including hyperselective neurectomy, neurotomy, and nerve transfers—enable targeted modulation of spastic muscles while preserving strength or restoring volition. These interventions provide durable, functionally meaningful results and can be combined with other therapies as part of a precise, patient-based treatment plan.