Sequential Cryoneurolysis and Percutaneous Needle Tenotomy for Refractory Wrist Flexor Contracture: A Retrospective Case Series in Stroke and Spinal Cord Injury

Upper limb spasticity after stroke or spinal cord injury can lead to fixed wrist flexion contractures that limit hygiene, splinting, and functional positioning. Cryoneurolysis can effectively reduce wrist flexor spastic tone; however, when longstanding contracture is present, residual mechanical restriction often persists. Percutaneous needle tenotomy (PNT) offers a minimally invasive method to release structurally shortened musculotendinous units and restore passive mobility. In this retrospective case series, we describe the outcomes of wrist flexor PNT performed after prior cryoneurolysis in patients with refractory upper limb spasticity. Four adults with chronic upper limb spasticity secondary to stroke or spinal cord injury underwent wrist flexor cryoneurolysis followed by PNT for persistent contracture limiting passive range of motion (ROM). Passive wrist extension ROM and muscle tone were graded before and after intervention. Clinical rationale for transitioning from cryoneurolysis to PNT was qualitatively documented. Across all 4 cases, cryoneurolysis produced meaningful tone reduction; however, passive wrist extension remained limited due to fixed end-range contracture. After PNT, the patients demonstrated immediate and sustained gains in passive wrist extension ROM. Modified Ashworth Scale scores remained stable or demonstrated mild improvement posttenotomy, consistent with tone reduction achieved by preceding cryoneurolysis. No major adverse events were reported. Sequential use of cryoneurolysis followed by PNT may be effective for managing refractory wrist flexion contracture, where tone reduction alone is insufficient.