Cryoneurolysis

Last updated
Cryoneurolysis
Specialty neurology
UsesTreating nerve injury

Cryoneurolysis, also referred to as cryoanalgesia, is a medical procedure that temporarily blocks nerve conduction along peripheral nerve pathways. The procedure, which inserts a small probe to freeze the target nerve, can facilitate complete regeneration of the structure and function of the affected nerve. Cryoneurolysis has been used to treat a variety of painful conditions.

Contents

Medical uses

Cryoneuralysis has been used to relieve pain after thoracotomy, mastectomy, and knee or shoulder arthroplasty. [1] [2] Combined with ultrasound imaging, the procedure can be administered using a hand-held device in an office, and appears to provide an expedient, safe, and nonpharmacological option for treating various chronic pain conditions. [1]

Mechanisms of action

Nerve anatomy

Each nerve is composed of a bundle of axons. Each axon is surrounded by the endoneurium connective tissue layer. These axons are bundled into fascicles surrounded by the perineurium connective tissue layer. Multiple fascicles are then surrounded by the epineurium, which is the outermost connective tissue layer of the nerve. The axons of myelinated nerves have a myelin sheath made up of Schwann cells that coat the axon. [3]

Classification and mechanism

Nerve injury classification table of temperatures required for injury and pain relief Nerve injury classification table of temperatures required for injury.png
Nerve injury classification table of temperatures required for injury and pain relief

Classification of nerve damage was well-defined by Sir Herbert Seddon and Sunderland in a system that remains in use. [7] The adjacent table details the forms (neurapraxia, axonotmesis and neurotmesis) and degrees of nerve injury that occur as a result of exposure to various temperatures, with the intent to interrupt nerve traffic and relieve pain.

Cryoneurolysis treatments that use nitrous oxide (boiling point of −88.5 °C) as the coolant fall in the range of an axonotmesis injury, or 2nd degree injury, according to the Sunderland classification system. [1] Treatments of the nerve in this temperature range are reversible, usually within a few months. [1] [2] Nerves treated in this temperature range experience a disruption of the axon, with Wallerian degeneration occurring distal to the site of injury. [1] [2] The axon and myelin sheath are affected, but all of the connective tissues (endoneurium, perineurium, and epineurium) remain intact. [1] [8] Following Wallerian degeneration, the axon regenerates along the original nerve path at a rate of approximately 1–2 mm per day. [1] [2] [9]

Cryoneurolysis differs from cryoablation in that cryoablation treatments use liquid nitrogen (boiling point of −195.8 °C) as the coolant, and therefore, fall into the range of a neurotmesis injury, or 3rd degree injury according to the Sunderland classification. Treatments of the nerve in this temperature range are irreversible. Nerves treated in this temperature range experience a disruption of both the axon and the endoneurium connective tissue layer. [10] [11]

The efficacy of cryoneuralysis procedures for pain relief depend on the proximity of the probe to the targeted nerve, surface area of tissue covered by the probe, the rate and duration of cold treatment, and the temperature applied. [2]

History

The use of cold for pain relief and as an anti-inflammatory has been known since the time of Hippocrates (460–377 BC). [12] Since then there have been numerous accounts of ice used for pain relief including from the Ancient Egyptians and Avicenna of Persia (982–1070 AD). [13] In 1812 Napoleon's Surgeon General noted that half-frozen soldiers from the Moscow battle were able to tolerate amputations with reduced pain [14] and in 1851, ice and salt mixtures were promoted by Arnott for the treatment of nerve pain. Campbell White, in 1899, was the first to use refrigerants medically, and Allington, in 1950, was the first to use liquid nitrogen for medical treatments. [12] In 1961, Cooper et al. created an early cryoprobe that reached −190 °C using liquid nitrogen. [12] Shortly thereafter, in 1967, an ophthalmic surgeon named Amoils used carbon dioxide and nitrous oxide to create a cryoprobe that reached −70 °C. [12]

Devices

Cryoprobe

Cryoneurolysis is performed with a cryoprobe, which is composed of a hollow cannula that contains a smaller inner lumen. The pressurized coolant (nitrous oxide, carbon dioxide or liquid nitrogen) travels down the lumen and expands at the end of the lumen into the tip of the hollow cannula. No coolant exits the cryoprobe. The expansion of the pressurized liquid causes the surrounding area to cool (known as the Joule–Thomson effect) and the phase change of the liquid to gas also causes the surrounding area to cool. This causes a visible iceball to form and the tissue surrounding the end of the cryoprobe to freeze. The gas form of the coolant then travels up the length of the cryoprobe and is safely expelled. The tissue surrounding the end of the cryoprobe can reach as low as −88.5 °C with nitrous oxide as the coolant, and as low as −195.8 °C with liquid nitrogen. Temperatures below −100 °C are damaging to nerves.[ citation needed ]

Cryoanalgesia .jpg

Cryo-S Painless cryoanalgesia device is the next generation of apparatus used by many experts in the field since 1992. The working medium for Cryo-S Painless is carbon dioxide: CO2 (−78 °C) or nitrous oxide: N2O (−89 °C), very efficient and easy to use gases. Cryo-S Painless is controlled by a microprocessor and all the parameters are displayed and monitored on a LCD screen. Mode selection probe, cleaning and freezing can be performed automatically using footswitch or touch screen which allows to keep the site of a procedure under sterile conditions. Electronic communication (chip system) between the connected probe and device allows recognition of optimal operating parameters and auto-configures to cryoprobe characteristics. Pressure and gas flow are set automatically, any manual adjustment is not necessary. Cryoprobe temperature, cylinder pressure, gas flow inside of cryoprobe and procedure time are displayed during freezing. Built-in voice communication Built-in neurostimulation (sensory, motor).[ citation needed ]

Other devices

The Endocare PerCryo Percutaneous Cryoablation device utilizes argon as a coolant and can be used with four different single cryoprobe configurations with a diameter of either 1.7 mm (~16 gauge) or 2.4 mm (~13 gauge) in diameter . [15]

The Myoscience Iovera is a handheld device that uses nitrous oxide as a coolant and can be used with a three-probe configuration with a probe diameter of 0.4 mm (~27 gauge). [16]

Related Research Articles

<span class="mw-page-title-main">Nerve</span> Enclosed, cable-like bundle of axons in the peripheral nervous system

A nerve is an enclosed, cable-like bundle of nerve fibers in the peripheral nervous system.

<span class="mw-page-title-main">Nervous tissue</span> Main component of the nervous system

Nervous tissue, also called neural tissue, is the main tissue component of the nervous system. The nervous system regulates and controls body functions and activity. It consists of two parts: the central nervous system (CNS) comprising the brain and spinal cord, and the peripheral nervous system (PNS) comprising the branching peripheral nerves. It is composed of neurons, also known as nerve cells, which receive and transmit impulses, and neuroglia, also known as glial cells or glia, which assist the propagation of the nerve impulse as well as provide nutrients to the neurons.

<span class="mw-page-title-main">Motor nerve</span> Nerve located in the central nervous system

A motor nerve, or efferent nerve, is a nerve that contains exclusively efferent nerve fibers and transmits motor signals from the central nervous system (CNS) to the muscles of the body. This is different from the motor neuron, which includes a cell body and branching of dendrites, while the nerve is made up of a bundle of axons. Motor nerves act as efferent nerves which carry information out from the CNS to muscles, as opposed to afferent nerves, which transfer signals from sensory receptors in the periphery to the CNS. Efferent nerves can also connect to glands or other organs/issues instead of muscles. The vast majority of nerves contain both sensory and motor fibers and are therefore called mixed nerves.

<span class="mw-page-title-main">Cryosurgery</span> Cauterization by freezing tissue

Cryosurgery is the use of extreme cold in surgery to destroy abnormal or diseased tissue; thus, it is the surgical application of cryoablation. Cryosurgery has been historically used to treat a number of diseases and disorders, especially a variety of benign and malignant skin conditions.

Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapy. Cryotherapy may be used to treat a variety of tissue lesions. The most prominent use of the term refers to the surgical treatment, specifically known as cryosurgery or cryoablation. Cryosurgery is the application of extremely low temperatures to destroy abnormal or diseased tissue and is used most commonly to treat skin conditions.

Neurotmesis is part of Seddon's classification scheme used to classify nerve damage. It is the most serious nerve injury in the scheme. In this type of injury, both the nerve and the nerve sheath are disrupted. While partial recovery may occur, complete recovery is impossible.

Axonotmesis is an injury to the peripheral nerve of one of the extremities of the body. The axons and their myelin sheath are damaged in this kind of injury, but the endoneurium, perineurium and epineurium remain intact. Motor and sensory functions distal to the point of injury are completely lost over time leading to Wallerian degeneration due to ischemia, or loss of blood supply. Axonotmesis is usually the result of a more severe crush or contusion than neurapraxia.

Neuralgia is pain in the distribution of a nerve or nerves, as in intercostal neuralgia, trigeminal neuralgia, and glossopharyngeal neuralgia.

In medicine, a stinger, also called a burner or nerve pinch injury, is a neurological injury suffered by athletes, mostly in high-contact sports such as ice hockey, rugby, American football, and wrestling. The spine injury is characterized by a shooting or stinging pain that travels down one arm, followed by numbness and weakness in the parts of the arms, including the biceps, deltoid, and spinati muscles. Many athletes in contact sports have suffered stingers, but they are often unreported to medical professionals.

<span class="mw-page-title-main">Brachial plexus injury</span> Medical condition

A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. These nerves originate in the fifth, sixth, seventh and eighth cervical (C5–C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand.

<span class="mw-page-title-main">Radiofrequency ablation</span> Surgical procedure

Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using the heat generated from medium frequency alternating current. RFA is generally conducted in the outpatient setting, using either local anesthetics or twilight anesthesia. When it is delivered via catheter, it is called radiofrequency catheter ablation.

<span class="mw-page-title-main">Cryoablation</span> Process using extreme cold to destroy tissue

Cryoablation is a process that uses extreme cold to destroy tissue. Cryoablation is performed using hollow needles (cryoprobes) through which cooled, thermally conductive fluids are circulated. Cryoprobes are positioned adjacent to the target in such a way that the freezing process will destroy the diseased tissue. Once the probes are in place, the attached cryogenic freezing unit removes heat from ("cools") the tip of the probe and by extension from the surrounding tissues.

<span class="mw-page-title-main">Endoneurium</span> Connective tissue layer around myelinated nerve fibers in peripheral nervous system

The endoneurium is a layer of delicate connective tissue around the myelin sheath of each myelinated nerve fiber in the peripheral nervous system. Its component cells are called endoneurial cells. The endoneuria with their enclosed nerve fibers are bundled into groups called nerve fascicles, each fascicle within its own protective sheath called a perineurium. In sufficiently large nerves multiple fascicles, each with its blood supply and fatty tissue, may be bundled within yet another sheath, the epineurium.

<span class="mw-page-title-main">Nerve injury</span> Damage to nervous tissue

Nerve injury is an injury to a nerve. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve fiber injury and whether there is continuity of the nerve. Usually, however, nerve injuries are classified in five stages, based on the extent of damage to both the nerve and the surrounding connective tissue, since supporting glial cells may be involved.

Neuroregeneration involves the regrowth or repair of nervous tissues, cells or cell products. Neuroregenerative mechanisms may include generation of new neurons, glia, axons, myelin, or synapses. Neuroregeneration differs between the peripheral nervous system (PNS) and the central nervous system (CNS) by the functional mechanisms involved, especially in the extent and speed of repair. When an axon is damaged, the distal segment undergoes Wallerian degeneration, losing its myelin sheath. The proximal segment can either die by apoptosis or undergo the chromatolytic reaction, which is an attempt at repair. In the CNS, synaptic stripping occurs as glial foot processes invade the dead synapse.

<span class="mw-page-title-main">Group C nerve fiber</span> One of three classes of nerve fiber in the central nervous system and peripheral nervous system

Group C nerve fibers are one of three classes of nerve fiber in the central nervous system (CNS) and peripheral nervous system (PNS). The C group fibers are unmyelinated and have a small diameter and low conduction velocity, whereas Groups A and B are myelinated. Group C fibers include postganglionic fibers in the autonomic nervous system (ANS), and nerve fibers at the dorsal roots. These fibers carry sensory information.

Dental anesthesia is the application of anesthesia to dentistry. It includes local anesthetics, sedation, and general anesthesia.

<span class="mw-page-title-main">Nerve injury classification</span> Scheme developed by Seddon and Sunderland

Nerve injury classification assists in prognosis and determination of treatment strategy for nerve injuries. Classification was described by Seddon in 1943 and by Sunderland in 1951. In the lowest degree of nerve the nerve remains intact, but signaling ability is damaged, termed neurapraxia. In the second degree the axon is damaged, but the surrounding connecting tissue remains intact – axonotmesis. The last degree, in which both the axon and connective tissue are damaged, is called neurotmesis.

Nerve allotransplantation is the transplantation of a nerve to a receiver from a donor of the same species. For example, nerve tissue is transplanted from one person to another. Allotransplantation is a commonly used type of transplantation of which nerve repair is one specific aspect.

<span class="mw-page-title-main">Pathophysiology of nerve entrapment</span>

Nerve entrapment involves a cascade of physiological changes caused by compression and tension. Some of these changes are irreversible. The magnitude and duration of the forces determines the extent of injury. In the acute form, mechanical injury and metabolic blocks impede nerve function. In the chronic form, there is a sequence of changes starting with a breakdown of the blood-nerve-barrier, followed by edema with connective tissue changes, followed by diffuse demyelination, and finally followed by axonmetesis. The injury will often be a mixed lesion where mild/moderate compression is a combination of a metabolic block and neuropraxia, while severe compression combines elements of neuropraxia and axonmetesis.

References

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  2. 1 2 3 4 5 Lee L, Epelboym Y (July 2023). "Review of genicular artery embolization, radiofrequency ablation, and cryoneurolysis in the management of osteoarthritis-related knee pain". Diagnostic and Interventional Radiology. 29 (4): 614–620. doi:10.4274/dir.2022.221288. PMC   10679645 . PMID   36960623.
  3. ↑ Gray, Henry (1918). Gray's Anatomy. Philadelphia: Lea & Febiger. ISBN   1-58734-102-6.
  4. ↑ Zhou, L; Kambin, P; Casey, KF; Bonner, FJ; O'Brien, E; Shao, Z; Ou, S (August 1995). "Mechanism research of cryoanalgesia". Neurological Research. 17 (4): 307–311. doi:10.1080/01616412.1995.11740333. PMID   7477749.
  5. ↑ Sunderland (1968). Nerves and Nerve Injuries. Edinburgh & London: Livingstone. p. 180.
  6. ↑ Zhou (2003). "Cryoanalgesia: electrophysiology at different temperatures". Cryobiology. 46 (1): 26–32. doi:10.1016/s0011-2240(02)00160-8. PMID   12623025.
  7. ↑ Seddon HJ (1943). "Three Types of Nerve Injury". Brain. 66 (4): 238–288. doi: 10.1093/brain/66.4.237 .
  8. ↑ Hsu (2013). "Reduction in muscular motility by selective focused cold therapy". Journal of Neural Transmission. 121 (1): 15–20. doi:10.1007/s00702-013-1077-y. PMC   3889817 . PMID   23917804.
  9. ↑ Evans (1981). "Cryoanalgesia: the response to alterations in freeze cycle and temperature". British Journal of Anaesthesia. 53 (11): 1121–1127. doi: 10.1093/bja/53.11.1121 . PMID   7326160.
  10. ↑ Sunderland (1951). "A classification of peripheral nerve injuries producing loss of function". Brain. 74 (4): 491–516. doi:10.1093/brain/74.4.491. PMID   14895767.
  11. ↑ Burnett (2004). "Pathophysiology of peripheral nerve injury: a brief review". Neurosurgical Focus. 16 (5): E1. doi: 10.3171/foc.2004.16.5.2 . PMID   15174821.
  12. 1 2 3 4 Cooper (2001). "The History of Cryosurgery". Journal of the Royal Society of Medicine. 94 (4): 196–201. doi:10.1177/014107680109400416. PMC   1281398 . PMID   11317629.
  13. ↑ Trescott (2003). "Cryoanalgesia in Interventional Pain Management". Pain Physician. 6 (3): 345–360. doi: 10.36076/ppj.2003/6/345 . PMID   16880882.
  14. ↑ Larrey, Dominique Jean (1832). Surgical Memoirs of the campaigns of Russia, Germany and France. Philadelphia: Carey & Lea.
  15. ↑ "The perfect Percryo probe for any procedure" (PDF). HealthTronics. Retrieved April 11, 2015.
  16. ↑ "Iovera Health – How it Works". Myoscience. Archived from the original on April 12, 2015. Retrieved April 11, 2015.
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