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Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Lateral femoral cutaneous nerve
In a prospective study of 20 consecutive patients with
verified electrophysiological meralgia paresthetica, the pa-
tients received a perineural injection of anesthetic with cor-
ticosteroid. This study described a hydrodissection technique
where the nerve was floated away from the adjacent struc-
tures. Sixteen of the original 20 patients had statistical im-
provement in pain and function. The other four received
another injection. After 2 months, all of the patient’s symp-
toms disappeared completely (16). Similar results were
obtained in a case study of a 45-year-old man with chronic
meralgia paresthetica. Using a similar in-plane injection, the
patient remained symptom free at an 18-month follow-up (13).
Saphenous nerve
FIGURE 1: In-plane ultrasound injection. In a retrospective study of patients with chronic medial
knee pain after total knee replacement, the infrapatellar
Specific Nerve Studies branch of their saphenous nerve was subjected to injection.
They used a hydrodissection technique followed by a corti-
Median nerve costeroid injection. It was a small study of 16 people. Of
Because of the prevalence of CTS, the median nerve has the subjects, 75% improved their Visual Analog Scale (VAS)
been evaluated and studied as a candidate for ultrasound- pain score to less than 3 to 4 from a baseline of 8 out of 10.
guided injections. DeLea et al. (6) performed a prospective There was no blinding and no mention of adverse outcomes.
study of patients with CTS receiving ultrasound-guided me- Because of the size of the group, no statistical analysis was
dian nerve injections after hydrodissection. Pain and vaso- performed (5).
motor changes were significantly reduced with this approach,
and there were no adverse outcomes. It should be noted that Safety
in this study, there was not a control group with which to At the time of this article, there are no studies that eval-
compare. Lee et al. (10) also evaluated patients with CTS uate the safety of the hydrodissection technique for nerve
receiving a corticosteroid injection. They randomized their injections. The most readily available literature focuses on
patients to three groups, in-plane ultrasound injection, out-of- safety of intraneural injections and the rate of accidental
plane ultrasound injections, and landmark-based injections. injections with ultrasound.
The ultrasound groups received hydrodissection to ‘‘peel the To determine the rate of unintentional intraneural in-
nerve off the overlying flexor retinaculum.’’ The in-plane jections, Liu et al. (11) recorded ultrasound on 257 patients
ultrasound-guided injection had statistically improved pain receiving an interscalene or supraclavicular block before
and functional scores compared with the out-of-plane group shoulder arthroscopy. Two blinded anesthesiologists then
and landmark group. The in-plane group also had no nerve reviewed the video and found a 17% incidence of intra-
or vessel injury. Function and pain improved in all three neural trespass. No patient experienced postoperative
groups. Only one of the studies that were reviewed random- neurological complications. Their study mentions that hydro-
ized patients to a hydrodissection group or an injection-only dissection was left at the discretion of the anesthesiologist,
group (7). Patients received a median nerve block before elbow and their Results section does not mention how many times
surgery and were randomized to hydrodissection with D5W or it was used or its correlation with intraneural injections.
to a block with lidocaine alone. Their main outcome measure Hara et al. (8) found a similar incidence of intraneural in-
was time to anesthesia, which showed no statistical change. jection on patients receiving a subgluteal sciatic nerve block
Unfortunately, this study did not look at safety or adverse
events, so one cannot draw conclusions in regard to decreased
nerve injury with hydrodissection from this study.
Ulnar nerve
Since cubital tunnel syndrome is another common pe-
ripheral neuropathy, the ulnar nerve has been researched with
ultrasound-guided injections using nerve hydrodissection as
well. A cadaver study by Kim et al. (9) demonstrated that an
ultrasound-guided hydrodissection technique could separate
the ulnar nerve from the medial epicondyle and the adjacent
connective tissues. A small pilot study of 10 prospective pa-
tients with cubital tunnel syndrome used this approach and
showed improvement in pain, decreased cross-sectional area,
and improved electrophysiological measurements (4). They
also sustained no neurological injuries. FIGURE 2: Out-of-plane ultrasound injection.
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
while undergoing knee arthroscopy. Using similar methods add to patient care. Many who use ultrasound for muscu-
and video reviews, they found a 16.3% rate of injection. loskeletal medicine, this author included, note an improve-
Again, out of 325 patients, they reported no postoperative ment in our practice and care of our patients with this
complications. Their study does not reference the use of technology. Hopefully this article can encourage others to
hydrodissection but would indicate that hydrodissection had publish what they are doing and encourage those with the
been done because of a halo appearance of injectate around means to do more high-level research in the field.
the nerve.
A systematic review by Brull et al. (3) calculated the rate
of neuropathy after a peripheral nerve block to be less than The author declares no conflict of interest and does not
3 in 100. Out of 16 studies evaluating the rate of perma- have any financial disclosures.
nent neurological injury after a nerve block, they found
only one case.
There are fewer studies that evaluate long-term effects of References
inadvertent nerve injections. A case study by Russon and 1. Bigeleisen PE. Nerve puncture and apparent intraneural injection during
ultrasound-guided axillary block does not invariably result in neurologic
Blanco (14) shows a review of an unintended axillary plexus injury. Anesthesiology. 2006; 105:779Y83.
block in a patient undergoing wrist surgery. On a video re- 2. Bokey EL, Keating JP, Zelas P. Hydrodissection: an easy way to dissect an-
view, they determined that the musculocutaneous nerve atomical planes and complex adhesions. Aust. N. Z. J. Surg. 1997; 67:643Y4.
was inadvertently injected. At a 6-month follow-up visit, 3. Brull R, McCartney CJ, Chan VW, El-Beheiry H. Neurologic complica-
the patient exhibited no neurological complaints or deficits. tions after regional anesthesia: contemporary estimates of risk. Anesth.
Analg. 2007; 104:965Y74.
Bigeleisen (1) studied 26 patients undergoing an axillary
4. Choi CK, Lee HS, Kwon JY, Lee WJ. Clinical implications of real-time
plexus block for thumb surgery over a course of 6 months. visualized ultrasound-guided injection for the treatment of ulnar neuropathy
They had sensory and motor testing before and 5 and at the elbow: a pilot study. Aust. N. Z. J. Surg. 2015; 39:176Y82.
20 min after block placement and 6 months after their 5. Clendenen S, Greengrass R, Whalen J, O’Conner MI. Infrapatellar saphe-
nerve block. Of the 26 patients, 22 had inadvertent injec- nous neuralgia after TKA can be improved with ultrasound-guided local
treatments. Clin. Orthop. Relat. Res. 2015; 473:119Y25.
tion of at least one nerve. At the 6-month follow-up visit,
6. DeLea SL, Chavez-Chiang NR, Poole JL, et al. Sonographically-guided
their sensory and motor testing was unchanged compared hydrodissection and corticosteroid injection for scleroderma hand. Clin.
with their baseline. Rheumatol. 2011; 30:805Y13.
7. Dufour E, Donat N, Jaziri S, et al. Ultrasound-guided perineural circumfer-
Conclusions ential median nerve block with and without prior dextrose 5% hydrodis-
section: a prospective randomized double-blinded noninferiority trial. Anesth.
Despite the widespread use of the hydrodissection tech- Analg. 2012; 115:728Y33.
nique, which is referenced often in articles, very limited high- 8. Hara K, Sakura S, Yokokawa N, Tadenuma S. Incidence and effects of
quality data exists to determine its effectiveness. Most of the unintentional intraneural injection during ultrasound-guided subgluteal sci-
available research consists of case reports and retrospective atic nerve block. Reg. Anesth. Pain Med. 2012; 37:289Y93.
studies. This low-level evidence does demonstrate that this 9. Kim JM, Oh HM, Kim MW. Real-time visualization of ultrasonography
guided cubital tunnel injection: A cadaveric study. Ann. Rehabil. Med. 2012;
technique could be effective. However, there is often lack of 36:496Y500.
randomization and blinding, leading to inevitable selection 10. Lee JY, Park Y, Park KD, et al. Effectiveness of ultrasound-guided carpal
bias. None of the studies reviewed evaluated an ultrasound- tunnel injection using in-plane ulnar approach: a prospective, randomized,
single-blinded study. Medicine. 2014; 93:1Y6.
guided steroid injection with and without hydrodissection
11. Liu SS, YaDeau JT, Shaw PM, et al. Incidence of unintentional intraneural
and with a control group. This would seem to be essential to injection and postoperative neurological complications with ultrasound-
determine if this is a necessary part of the procedure or if it is guided interscalene and supraclavicular nerve blocks. Anaesthesia. 2011;
only necessary to deliver injectate around the nerve. 66:168Y74.
A major rationale for using the hydrodissection technique 12. Malavazzi GR, Nery RG. Visco-fracture technique for soft lens cataract
removal. J. Cataract Refract. Surg. 2011; 27:11Y2.
is to decrease the risk of inadvertent nerve injection and
13. Mulvaney S. Ultrasound-guided percutaneous neuroplasty of the lateral
subsequent injury during these procedures. The current lit- femoral cutaneous nerve for the treatment of meralgia paresthetica: a case
erature would indicate a possible 16% to 17% inadvertent report and description of a new ultrasound-guided technique. Curr. Sports
injection rate with ultrasound guidance (8,11). However, Med. Rep. 2011; 10:99Y104.
neither of these two studies indicated the role of hydrodis- 14. Russon K, Blanco R. Accidental intraneural injection into the musculocu-
taneous nerve visualized with ultrasound. Anesth. Analg. 2007; 105:1504Y5.
section in its outcomes or results. All of the studies re-
15. Smith J, Wisniewski SJ, Finoff JT, Payne JM. Sonographically guided carpal
viewed in the anesthesiology literature show little to no tunnel injections, the ulnar approach. J. Ultrasound Med. 2008; 27:1485Y90.
adverse effect of inadvertent nerve injection, short or long 16. Tagliafico A, Serafini G, Lacelli F, et al. Ultrasound-guided treatment of
term. One could make the argument from this evidence that meralgia paresthetica (lateral femoral cutaneous neuropathy): technical de-
this may be a relatively safe procedure. scription and results of treatment in 20 consecutive patients. J. Ultrasound
Med. 2011; 30:1341Y6.
With the changing landscape of medicine, especially in
17. Ting J, Rozen W, Morsi A. Improving the subfascial dissection of perforators
our payer systems and value-based care, it is crucial that we during deep inferior epigastric artery perforator flap harvest: the hydrodis-
establish effectiveness for treatments that many of us feel section technique. Plast. Reconstr. Surg. 2010; 126:87eY9.
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.