Cryoneurotomy as a Percutaneous Mini-invasive Therapy for the Treatment of the Spastic Limb: Case Presentation, Review of the Literature, and Proposed Approach for Use

Abstract

Objective To provide a proof-of-concept study demonstrating that the decades old procedure of cryoneurotomy, used traditionally for analgesia, is a safe adjunctive and effective treatment for limb spasticity. Design Case series. Setting Publicly funded outpatient hospital spasticity clinic and community interventional anesthesia clinic. Participants Patients (N=3) who had plateaued with standard of care spasticity treatments including botulinum toxin. Two hemiplegic stroke patients with elbow spasticity and 1 pregnant patient with multiple sclerosis and a spastic equinovarus foot for whom botulinum toxin was now contraindicated. Interventions Selective anesthetic diagnostic motor nerve blocks with ultrasound and e-stimulation with 1cc of 1% lidocaine to the motor nerve to the targeted spastic muscle were performed to either the musculocutaneous nerve to brachialis, radial nerve to the brachioradialis or the tibial nerve. If the benefits included improved active and passive range motion and or decreased clonus, a percutaneous cryoneurotomy was performed. Main Outcome Measures Active and passive range of motion were measured using the Modified Tardieu Scale. The change in resistance to passive stretch was measured using the Modified Ashworth Scale (MAS). Videos of the before and after treatment were collected. Results Both elbows’ treatments resulted in MAS improving from a 3 to a 1+. Greatly improved active range of motion was noted at 94 and 64 degrees, respectively, as well as improvements in passive range on the Modified Tardieu Scale. The tibial nerve cryoneurotomy resulted in improvements in all parameters with a much improved gait. Results were maintained up to 17 months of follow-up. Conclusion Cryoneurotomy as a treatment for spasticity is a novel safe adjuvant treatment. Our initial results suggest patients can achieve significantly increased active and passive range of motion in the upper extremity and decreased clonus, and improved gait after tibial nerve cryoneurotomy.

Case Report: Perspective of a Caregiver on Functional Outcomes Following Bilateral Lateral Pectoral Nerve Cryoneurotomy to Treat Spasticity in a Pediatric Patient With Cerebral Palsy

“…The MAS remained reduced at 9 months with much greater ease in passive ROM of the shoulder. This is consistent with findings of cryoneurotomy for flexed elbow spasticity (14) and the tibial nerve (3).…”

“…Pharmacological regimens may consist of diazepam, baclofen, or trihexyphenidyl (7)(8)(9)(10)(11)(12). Cryoneurotomy percutaneously induces selective neurolysis of a motor nerve to manage spasticity, similar to other injectable and surgical modalities, such as partial neurotomy and chemodenervation by alcohol or phenol (2,3). In cryoneurotomy, the axons and myelin of peripheral nerves are disrupted by the tip of the cryoprobe which may reach −70 • ; however, the epineurium is maintained allowing for nerve regeneration (3,4,13).…”

A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

“…For the elbow, the recommended targets for nerve blocks are the branches of the MSCN nerve to the brachialis and biceps and the radial nerve to the brachioradialis (25,31). For the wrist and fingers, median and ulnar nerve DNBs are performed.…”

“…The DNB is performed by the infiltration of small volumes (1-4 ml) of a 2% lidocaine around a nerve or nerve fascicle to select the most responsible muscles in a spastic deformity (25,34,35). To assist localization, we recommend that they are performed in combination with e-stimulation and ultrasound (30,31).…”

“…In the absence of an established clinical pathway, we have drawn on our own use of the clinical evidence, such as prednisone for the treatment of CRPS (29), the use of motor DNB for spasticity assessment, suprascapular DNB for isolated shoulder pain (13,30,31), and early intervention for spasticity (32). We propose an algorithm to assist in the assessment and management of new-onset HSP in shoulders with stiffness and a reduced ROM built from our own clinical experience in treating this condition.…”