Ultrasound-Guided Alcohol Neurolysis for Poststroke Upper Limb Spasticity to Facilitate Arteriovenous Fistula Creation in Hemodialysis: A Case Report

Abstract

Spasticity affects up to 80% of stroke survivors and is associated with significant pain, impaired function, and reduced quality of life. In patients with end-stage renal disease, severe upper limb spasticity presents additional challenges by restricting positioning for arteriovenous fistula (AVF) creation. Oral antispasmodic agents are often poorly tolerated because of impaired renal clearance and systemic side effects. Although alcohol neurolysis is an established intervention for focal spasticity, its use to facilitate AVF creation has not been previously described. We report the case of a 53-year-old woman with newly diagnosed end-stage renal disease who developed multi-territorial strokes resulting in severe generalized spasticity (Modified Ashworth Scale 3-4) with associated pain and abnormal limb posturing. Spasticity presented a major barrier to AVF creation. Oral agents, including baclofen and tizanidine, were avoided or discontinued because of safety concerns in the setting of ESRD with recurrent intradialytic hypotension. Botulinum toxin injections improved pain but failed to restore sufficient range of motion. At 7 months after her strokes, she underwent ultrasound-guided alcohol neurolysis of the right musculocutaneous and median nerves. This produced significant spasticity reduction (elbow flexors: Modified Ashworth Scale 3→1+; forearm pronators: 3→1; wrist flexors: 4→2 by 28d), pain resolution, and improved joint mobility, enabling successful right radiocephalic AVF creation under local anesthesia 13 days later without complications. To our knowledge, this is the first reported case of alcohol neurolysis facilitating AVF creation in a dialysis-dependent stroke patient with refractory spasticity. This case highlights alcohol neurolysis as a safe and effective intervention when systemic agents and botulinum toxin are unsuitable or inadequate, and underscores the importance of an individualized, multimodal, and multidisciplinary approach to spasticity management in complex patients.