In an adult undergoing ultrasound‑guided shoulder hydrodissection, should 5% dextrose in water or normal saline be used as the injectate?

Hydrodissection Injectate Selection for Shoulder Procedures

Direct Recommendation

For ultrasound-guided shoulder hydrodissection, use 5% dextrose in water (D5W) as the primary injectate rather than normal saline, based on superior analgesic effects, sustained pain reduction, and excellent safety profile demonstrated in peripheral nerve and fascial interventions. 1, 2

Evidence-Based Rationale

D5W Demonstrates Superior Clinical Outcomes

• D5W provides sustained analgesic effects with cumulative pain reduction over time, as demonstrated in a retrospective review of 100 deep nerve hydrodissection treatments showing 88.1% ± 9.8% analgesia during treatment sessions and pain scores improving from 8.3 ± 1.3 to 1.9 ± 0.9 at 2-month follow-up. 1

• For shoulder-specific myofascial pain, interfascial injection with 10% dextrose water produced significant pain reduction at 12-week follow-up compared to sham injection, supporting dextrose's efficacy in shoulder region fascial interventions. 2

• D5W consistently outperforms normal saline in peripheral nerve entrapment treatments, with systematic review evidence showing favorable outcomes compared to control groups across multiple nerve entrapment syndromes. 3

Safety Profile Strongly Favors D5W

• D5W demonstrates superior safety compared to corticosteroids, with zero adverse effects reported in the D5W group versus 6 patients experiencing adverse effects in the steroid group during a 6-month randomized trial for peripheral neuropathy. 4

• Normal saline shows inferior efficacy to D5W in severe carpal tunnel syndrome, with D5W producing better symptom and functional improvement scores at both 1-month and 6-month follow-up compared to saline. 5

• The motor-sparing nature of D5W injection without anesthetic limits toxicity risks while preserving nerve function during hydrodissection procedures. 5

Mechanism and Practical Considerations

• D5W provides direct analgesic effects beyond simple mechanical separation, distinguishing it from normal saline which relies solely on mechanical hydrodissection without inherent therapeutic properties. 1

• For thyroid procedures requiring hydrodissection, guidelines specifically recommend 5% glucose injection for radiofrequency ablation to effectively distance structures, while 0.9% sodium chloride is used for microwave ablation due to different thermal properties. 6

• The hypotonic nature of D5W (once dextrose is metabolized) provides no renal osmotic load, making it physiologically advantageous for tissue plane separation without adding osmotic burden. 7, 8

Practical Implementation Algorithm

Injectate Selection

• Use 5% dextrose in water (D5W) as first-line injectate for shoulder hydrodissection procedures. 1, 2
• Volume: 10 mL of D5W or 10% dextrose water is effective for interfascial and perineural injections in the shoulder region. 2
• Avoid adding local anesthetic initially to preserve motor function assessment and limit anesthetic-related toxicity. 5

Monitoring Requirements

• Monitor blood glucose levels when using dextrose-containing solutions, particularly in diabetic patients, as glucose infusion can cause hyperglycemia with subsequent osmotic diuresis. 8
• Assess for immediate analgesic response during the procedure, which should be evident with D5W injection (typically 88% pain reduction). 1

Common Pitfalls to Avoid

• Do not default to normal saline based solely on familiarity, as evidence clearly demonstrates inferior outcomes compared to D5W for nerve and fascial hydrodissection. 3, 5
• Avoid corticosteroid-containing solutions for routine hydrodissection unless specific inflammatory pathology requires steroid therapy, given the adverse effect profile and inferior long-term outcomes beyond 4 months. 4
• Do not use hypotonic dextrose solutions in patients with traumatic brain injury or neurosurgical conditions where cerebral edema risk is elevated, though this is not relevant for isolated shoulder procedures. 7

Expected Treatment Course

• Patients typically require 3-4 treatments over 9-10 months for optimal cumulative pain reduction in chronic neuropathic conditions. 1
• Pain improvement exceeding 50% should be expected in all cases, with 75% improvement achievable in half of patients by 2-month post-treatment follow-up. 1
• For myofascial shoulder pain specifically, significant pain reduction becomes evident at 12-week follow-up when combined with home exercise programs. 2