HEAD, NECK, AND SPINE
Ultrasound-Guided Nerve Hydrodissection:
What is it? A Review of the Literature
Shane P. Cass, DO
Abstract
Nerve hydrodissection is a technique used when treating peripheral
nerve entrapments. It involves using an anesthetic or solution such as
saline to separate the nerve from the surrounding tissue, fascia, or ad-
jacent structures. There are no high-level studies to determine the need
or effectiveness of hydrodissection or to establish its safety. Low-level
studies do demonstrate some effectiveness and safety for the technique,
but further research is necessary.
Introduction
Because ultrasound has become more widely available
and accessible, clinicians have used the improved resolution
to increase accuracy in their procedures. They also have
used this technology to create novel procedures. One of
the growing areas of musculoskeletal ultrasound to take
advantage of this imaging modality is in the treatment of
peripheral nerve entrapments. Ultrasound has been used
both to diagnose and treat a variety of common condi-
tions such as carpal tunnel syndrome (CTS) and cubital
tunnel syndrome. One frequently referenced technique
while treating peripheral nerves is hydrodissection. The
purpose of this article is to evaluate the available literature
on hydrodissection and determine its level of effectiveness
and safety.
Definition of hydrodissection
The definition of hydrodissection varies widely depending
on the procedure or surgery it is being used for. It has been
described in reoperative therapy for adhesiolysis by intro-
ducing saline under pressure into planes of dissection. This
then helps to remove adhesions by creating previously
nonexistent surgical planes (2). Hydrodissection has been
used to preserve perforating arteries in breast reconstruc-
tion surgery (17). Hydrodissection has been discussed also
Sports Medicine, University of New Mexico, Albuquerque, NM
Address for correspondence: Shane P. Cass, DO, Sports Medicine,
University of New Mexico, 1 University Blvd NE, Albuquerque,
NM 87131; E-mail: shanepcass@gmail.com, scass@salud.unm.edu.
1537-890X/1501/20Y22
Current Sports Medicine Reports
Copyright * 2016 by the American College of Sports Medicine
20 Volume 15 & Number 1 & January/February 2016
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
in the ophthalmological literature to
establish surgical planes in the eye (12).
More applicable for our discussion,
Smith et al. (15) describes a process
of hydrodissection in the treatment of
CTS for delivering injectate around the
nerve. The purpose of the hydrodis-
section in this article was to peel the
median nerve from the surrounding
retinaculum and connective tissue. The
primary goal of the hydrodissection is
to avoid inadvertent direct injection and injury to the nerve.
The secondary goal for many clinicians with this technique
is to separate a potential soft tissue adhesion or obstruction
from the nerve that could be causing an entrapment.
A note on ultrasound injection techniques
To better understand the terminology used in the articles
reviewed, it is important to define the different injection
techniques. There are typically two groups, in-plane in-
jections and out-of-plane injections. With in-plane injections,
the needle enters the skin parallel to the long axis of the
transducer (Fig. 1). With this approach, the needle tip is
completely visualized as it reaches its target. With the out-of-
plane approach, the needle enters the skin perpendicular to
the long axis of the transducer (Fig. 2). With this approach,
the needle appears as a bright dot as it enters the scanning
area of the probe. The in-plane approach is most often used,
as the needle tip can reliably be visualized entering the target.
With the out-of-plane approach, the hyperechoic dot will still
be present, even if the tip of the needle pierces through the
intended target. Despite its limitations, the out-of-plane ap-
proach is still used with difficult and small anatomy where the
needle or probe cannot lie in-plane.
Methods
A literature search for ‘‘nerve hydrodissection’’ in PubMed
and other search engines yielded few articles with hydrodis-
section in the title. In an attempt to look for more evi-
dence, search terms such as ‘‘ultrasound nerve injections’’ and
specific nerve injections were used, for example, ‘‘ulnar nerve
ultrasound injections.’’ The methods were then thoroughly
reviewed to see if a hydrodissection technique, such as the
description by Smith et al. (15), was used.
Ultrasound-Guided Nerve Hydrodissection

FIGURE 1: In-plane ultrasound injection.
Specific Nerve Studies
Median nerve
Because of the prevalence of CTS, the median nerve has
been evaluated and studied as a candidate for ultrasound-
guided injections. DeLea et al. (6) performed a prospective
study of patients with CTS receiving ultrasound-guided me-
dian nerve injections after hydrodissection. Pain and vaso-
motor changes were significantly reduced with this approach,
and there were no adverse outcomes. It should be noted that
in this study, there was not a control group with which to
compare. Lee et al. (10) also evaluated patients with CTS
receiving a corticosteroid injection. They randomized their
patients to three groups, in-plane ultrasound injection, out-of-
plane ultrasound injections, and landmark-based injections.
The ultrasound groups received hydrodissection to ‘‘peel the
nerve off the overlying flexor retinaculum.’’ The in-plane
ultrasound-guided injection had statistically improved pain
and functional scores compared with the out-of-plane group
and landmark group. The in-plane group also had no nerve
or vessel injury. Function and pain improved in all three
groups. Only one of the studies that were reviewed random-
ized patients to a hydrodissection group or an injection-only
group (7). Patients received a median nerve block before elbow
surgery and were randomized to hydrodissection with D5W or
to a block with lidocaine alone. Their main outcome measure
was time to anesthesia, which showed no statistical change.
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.
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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
In a retrospective study of patients with chronic medial
knee pain after total knee replacement, the infrapatellar
branch of their saphenous nerve was subjected to injection.
They used a hydrodissection technique followed by a corti-
costeroid injection. It was a small study of 16 people. Of
the subjects, 75% improved their Visual Analog Scale (VAS)
pain score to less than 3 to 4 from a baseline of 8 out of 10.
There was no blinding and no mention of adverse outcomes.
Because of the size of the group, no statistical analysis was
performed (5).
Safety
At the time of this article, there are no studies that eval-
uate the safety of the hydrodissection technique for nerve
injections. The most readily available literature focuses on
safety of intraneural injections and the rate of accidental
injections with ultrasound.
To determine the rate of unintentional intraneural in-
jections, Liu et al. (11) recorded ultrasound on 257 patients
receiving an interscalene or supraclavicular block before
shoulder arthroscopy. Two blinded anesthesiologists then
reviewed the video and found a 17% incidence of intra-
neural trespass. No patient experienced postoperative
neurological complications. Their study mentions that hydro-
dissection was left at the discretion of the anesthesiologist,
and their Results section does not mention how many times
it was used or its correlation with intraneural injections.
Hara et al. (8) found a similar incidence of intraneural in-
jection on patients receiving a subgluteal sciatic nerve block
FIGURE 2: Out-of-plane ultrasound injection.
Current Sports Medicine Reports 21
while undergoing knee arthroscopy. Using similar methods
and video reviews, they found a 16.3% rate of injection.
Again, out of 325 patients, they reported no postoperative
complications. Their study does not reference the use of
hydrodissection but would indicate that hydrodissection had
been done because of a halo appearance of injectate around
the nerve.
A systematic review by Brull et al. (3) calculated the rate
of neuropathy after a peripheral nerve block to be less than
3 in 100. Out of 16 studies evaluating the rate of perma-
nent neurological injury after a nerve block, they found
only one case.
There are fewer studies that evaluate long-term effects of
inadvertent nerve injections. A case study by Russon and
Blanco (14) shows a review of an unintended axillary plexus
block in a patient undergoing wrist surgery. On a video re-
view, they determined that the musculocutaneous nerve
was inadvertently injected. At a 6-month follow-up visit,
the patient exhibited no neurological complaints or deficits.
Bigeleisen (1) studied 26 patients undergoing an axillary
plexus block for thumb surgery over a course of 6 months.
They had sensory and motor testing before and 5 and
20 min after block placement and 6 months after their
nerve block. Of the 26 patients, 22 had inadvertent injec-
tion of at least one nerve. At the 6-month follow-up visit,
their sensory and motor testing was unchanged compared
with their baseline.
Conclusions
Despite the widespread use of the hydrodissection tech-
nique, which is referenced often in articles, very limited high-
quality data exists to determine its effectiveness. Most of the
available research consists of case reports and retrospective
studies. This low-level evidence does demonstrate that this
technique could be effective. However, there is often lack of
randomization and blinding, leading to inevitable selection
bias. None of the studies reviewed evaluated an ultrasound-
guided steroid injection with and without hydrodissection
and with a control group. This would seem to be essential to
determine if this is a necessary part of the procedure or if it is
only necessary to deliver injectate around the nerve.
A major rationale for using the hydrodissection technique
is to decrease the risk of inadvertent nerve injection and
subsequent injury during these procedures. The current lit-
erature would indicate a possible 16% to 17% inadvertent
injection rate with ultrasound guidance (8,11). However,
neither of these two studies indicated the role of hydrodis-
section in its outcomes or results. All of the studies re-
viewed in the anesthesiology literature show little to no
adverse effect of inadvertent nerve injection, short or long
term. One could make the argument from this evidence that
this may be a relatively safe procedure.
With the changing landscape of medicine, especially in
our payer systems and value-based care, it is crucial that we
establish effectiveness for treatments that many of us feel
22 Volume 15 & Number 1 & January/February 2016
Copyright © 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
add to patient care. Many who use ultrasound for muscu-
loskeletal medicine, this author included, note an improve-
ment in our practice and care of our patients with this
technology. Hopefully this article can encourage others to
publish what they are doing and encourage those with the
means to do more high-level research in the field.
The author declares no conflict of interest and does not
have any financial disclosures.
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Ultrasound-Guided Nerve Hydrodissection