Cryoneurolysis for Spasticity in a Pediatric Patient With Cold Urticaria Managed With Targeted Skin Warming: A Case Report

Abstract

Spasticity affects a significant portion of individuals with cerebral palsy, often progressing to contractures and neuro-orthopedic deformities if left untreated. Cryoneurolysis is an emerging, mini-invasive ultrasound-guided technique that induces secondary axonotmesis of peripheral nerves through the formation of an ice ball, shown to result in months of improved range of motion. However, cold urticaria is listed as a contraindication for this procedure because of the risk of localized or systemic anaphylaxis. We present a case of a 10-year-old girl with ataxic cerebral palsy who successfully underwent multisite cryoneurolysis. She had test-confirmed cold urticaria, requiring an epinephrine autoinjector to be kept on hand. By employing skin warming techniques and guided nerve branch targeting to attempt to keep the dermis above her critical temperature threshold, the procedure was completed without adverse events, achieving significant improvements in tone and gait. This case suggests that cryoneurolysis can be performed safely and is an effective spasticity treatment for patients with cold urticaria when appropriate thermal prophylactic measures are taken.