Unique Presentation of Spasticity in a Patient with Venolymphatic Malformation Successfully Managed with Botox

Case Diagnosis: Spasticity secondary to Venolympatic Malformation (VLM)

Case Description or Program Description: A 32-year-old female with a significant past medical history of superficial forearm mass resection as a child without subsequent care presented with gradual worsening of right forearm pain and spasticity–most notably with elbow flexion and supination. MRI and MRA of the forearm was significant for VLM at the antecubital fossa tracking along the deep flexor compartment in close proximity to the radial nerve, posterior interosseous nerve, and median nerve. Ultrasound showed evidence of median neuritis and atrophy of the pronator teres muscle, concerning for neuropathy.

Setting: Spasticity Clinic

Assessment/Results: On examination, the patient demonstrated spasticity in the right forearm flexors and supinators with contracture in elbow flexion. She underwent resection of the recurrent forearm mass with elbow contracture release with subsequent improvements in her range of motion but with residual pain and spasticity. She was treated with Botox injections in the right biceps, brachialis, brachioradialis, and pronator teres every 4 months afterwards with significant improvement in her symptoms.

Discussion (relevance): This case introduces a unique presentation of spasticity in the setting of an unmanaged VLM, which has not been previously discussed in literature. We suspect the growth of the VLM had caused compressive median neuropathy and mass effect on surrounding musculature that led to this presentation. Spasticity has been shown to occur in the setting of peripheral nerve injury, leading to hyperexcitability of spinal reflexes and increased muscle tone. The multimodal approach of targeted Botox injections with a focused therapy regimen following VLM resection was successful in managing this patient’s spasticity.

Conclusions: Untreated VLM can cause various hematologic, infectious, and structural complications depending on its location. This case serves to highlight spasticity and neuropathy as potential sequelae of VLM and underscore the crucial role that physiatry plays in managing and preventing these complications.