Exploratory Use of Proximal Cryoneurolysis and Distal Botulinum Toxin Type A for Upper-Limb Spasticity: A Case Report with Scoping Review.

[BACKGROUND] Upper-limb spasticity involving the shoulder girdle and elbow flexors often impairs functional hand use, and although Botulinum toxin type A (BoNT-A) is a first-line therapy, severe proximal synergies may persist while higher doses risk distal weakness.

[METHODS] We report a case of a 47-year-old woman with neurodegenerative tetraparesis and marked shoulder and elbow flexor spasticity treated with bilateral percutaneous cryoneurolysis of the lateral pectoral, thoracodorsal, and musculocutaneous nerves, followed by distal BoNT-A injections, and we conducted a scoping review following Arksey and O'Malley, Levac, and PRISMA-ScR methods to contextualize the current evidence.

[RESULTS] At one-month follow-up, the patient showed a reduction in MAS from 4 to 1-2, complete resolution of pain, improved passive shoulder abduction and elevation, preserved distal dexterity, and high satisfaction with no adverse events. The scoping review identified consistent MAS and range-of-motion improvements across multiple case reports and small series involving similar proximal nerve targets.

[CONCLUSIONS] The combined proximal cryoneurolysis-distal BoNT-A approach appears to be a feasible dual-modulation strategy for complex upper-limb spasticity when the preservation of hand function is essential, and the emerging literature supports its further investigation.