Cryoneurolysis for Digital Neuralgia in Professional Baseball Players: A Case Series

Abstract

Background: Thumb injuries are common in baseball players and can sometimes be challenging to effectively manage. A subset of patients experience failed nonoperative management yet do not have a clear indication for surgery. Cryoneurolysis or cryoanalgesia is a form of neuromodulation for pain that has been approved by the US Food and Drug Administration; it has been used safely and effectively on a variety of peripheral nerves. The mechanism of action involves percutaneous introduction of a small probe under local anesthetic to nerve tissue using ultrasound guidance. The probe is then cooled to -88°C using nitrous oxide, which results in secondary Wallerian degeneration. Axonal and myelin regeneration occurs completely in 3 to 6 months.

Purpose: To describe a nonsurgical approach to refractory digital neuralgia using cryoneurolysis in a series of professional baseball players.

Study design: Case series; Level of evidence, 4.

Methods: Included were 3 professional baseball players, each presenting with thumb pain in his top batting hand refractory to nonoperative modalities. Visualization of the superficial radial sensory and ulnar digital nerves was obtained using ultrasound. The skin was prepared in sterile fashion. A 22-gauge, 1.5-inch (3.8-cm) needle was then advanced using ultrasound guidance, and local anesthetic was applied. Both treatment sites were marked using a skin marker. Cryoneurolysis was performed using a 5-mm tip, and 60-second treatment cycles were performed at each site. Each of the cycles resulted in a roughly 5 × 7-mm lesion visible as hypoechoic signal.

Results: All 3 players endorsed significant and prolonged relief and were able to return to an elite level of play.

Conclusion: Study findings indicated marked efficacy and safety of using cryoneurolysis of the ulnar digital nerve and the superficial radial sensory nerve in a small group of elite baseball players with refractory digital neuralgia.

Keywords: baseball; cryoneurolysis or cryoanalgesia; digital neuralgia or thumb pain.

Figure 1.

(A) Iovera System with 5-mm tip. (B) Schematic demonstrating cryoneurolysis lesion formation (images not to scale). Authorization to reprint copyrighted images obtained from Pacira BioSciences, Inc.

Figure 2.

(A) Axial and (B) sagittal short tau inversion recovery (STIR) magnetic resonance imaging scans of a left hand showing evidence of strain in the adductor pollicis (circled).