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

Paul Winston, Patricia Branco Mills, Rajiv Reebye, Daniel Vincent, Paul Winston, Patricia Branco Mills, Rajiv Reebye, Daniel Vincent

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.

Keywords: AROM, active range of motion; BoNT, botulinum toxin; Cryosurgery; DNB, diagnostic nerve block; Denervation; Hemiplegia; MAS, Modified Ashworth Scale; MSCN, musculocutaneous nerve; Muscle spasticity; Nerve block; PROM, passive range of motion; ROM, range of motion; Rehabilitation; US, ultrasound; e-stim, electrical stimulation.

© 2019 The Authors.

Figures

Fig 1
Fig 1
Left, high to low. US of musculocutaneous nerve, branch to brachialis in a nonspastic limb. Top arrow indicates the musculocutaneous nerve trunk, the lower arrow indicates the nerve branch to the brachialis muscle. Right case 2, appearance after BoNT chemodenervation. Right, the tip of the needle contacting the tibial nerve. The arrow points to the tibial nerve branches to the medial (left) and lateral (right) gastrocnemius muscles.
Fig 2
Fig 2
Case 1. Top row: left V3 before cryoneurotomy. Right 2 weeks after cryoneurotomy. Middle row: V1 before cryoneurotomy, and right 2 weeks after. Bottom row: active range of motion. Left, 2 weeks after cryoneurotomy, middle 3 months, right at 1 year. NOTE: Active range of motion was 72° prior to cryoneurotomy.
Fig 3
Fig 3
Case 2. Upper row demonstrates active range of motion. Left: before cryoneurotomy, middle: 1 month post-cryoneurotomy to MSCN, right: 2 months postcryoneurotomy to MSCN and radial nerve. Bottom row: passive as slow as possible range of motion is shown by V1. Left: before cryoneurotomy and right: after cryoneurotomy to MSCN and radial nerves.

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