Upper limb spasticity is a frequent and disabling consequence of cervical spinal cord injury. In tetraplegic patients, spasticity may either support residual function or severely compromise surgical reconstruction, hygiene, comfort, and independence. Over the past decade, advances in neurophysiology, diagnostic tools, and surgical techniques have substantially modified the management of spastic upper limbs in tetraplegia. This review synthesizes recent advances with a particular focus on surgical decision-making, selective neurotomy, and combined tendon procedures, and highlights their impact on clinical practice.