Hyemi Yu

Background: Botulinum toxin type A (BoNT-A) injections for glabellar rhytides can rarely lead to persistent blepharoptosis. Current management, including observation and α-adrenergic agonists, is often temporary, highlighting a need for definitive minimally invasive interventions. Methods: This article presents a novel, systematic protocol for ultrasound-guided preseptal hydrodissection. The technique utilizes high-frequency ultrasound with color Doppler to access the sub-orbicularis plane superficial to the orbital septum, where 20 mL of 5% dextrose in water (D5W) is delivered as low-pressure irrigational hydrodissection to establish a confined fluid layer. Results: Application of this protocol in two patients with persistent BoNT-A ptosis refractory to conventional care resulted in progressive improvement. The Marginal Reflex Distance 1 (MRD1) increased from 0 to 4 mm in one patient and normalized in the other, with gains maintained at 3–6 months without additional treatment and no adverse events. Conclusion: This work standardizes a technical protocol for a potential adjunctive intervention in persistent BoNT-A-associated ptosis. The findings are descriptive and hypothesis-generating, positioning the technique for consideration only after standard measures fail. Prospective controlled trials are required to establish efficacy and safety.

Background and Clinical Significance: Psoriasis, a chronic immune-mediated inflammatory disease, can affect musculoskeletal structures, including the Achilles tendon. Achilles pain in psoriasis patients may arise from tendinitis or neuropathic pain due to peripheral nerve dysfunction, such as sural nerve (SN) involvement, a condition frequently misdiagnosed due to limitations in conventional diagnostics. Fascial tissues are critical in nerve compression syndromes. This case explores the application of a novel quantitative Sonoguide Digital Palpation (SDP) protocol and ultrasound (US)-guided hydrodissection (HD) for SN dysfunction mimicking Achilles tendinopathy in a psoriasis patient. Case Presentation: A 41-year-old male with psoriasis presented with acute onset of right heel stiffness and paresthesia. Physical examination, radiographs, and ultrasound were performed. SDP, employing a validated four-criterion diagnostic framework (including fascial mobility quantification and concordant pain provocation), identified crural fascia restriction affecting SN and reproduced patient’s concordant Achilles pain. High-resolution ultrasonography provided key morphological evidence, revealing a 2.6-fold enlargement of the sural nerve’s cross-sectional area (CSA) on the affected side (13 mm²) compared to the asymptomatic side (5 mm²). Notably, a positive Tinel’s sign was elicited over the psoriatic plaque. US-guided HD was performed using 50 cc of 5% dextrose in water (D5W) without local anesthetic below the psoriatic lesion. Post-HD, the patient reported immediate and significant pain relief (Numeric Pain Rating Scale (NPRS) score reduction from 8 to 2), confirming the prompt correction of a clinically important fascial restriction, associated with improved SN mobility, objectively verified by a post-procedure SDP assessment. At 24-month follow-up, sustained symptom relief and complete functional recovery were reported. Conclusions: This case highlights SDP’s ability to objectively visualize and confirm fascial restriction as a cause of nerve dysfunction by quantitatively reproducing concordant pain. The objective finding of nerve swelling provides sonographic substantiation for the functional diagnosis of nerve dysfunction. This integrated diagnostic approach, combining dynamic functional assessment with morphological confirmation, offers a novel paradigm for evaluating peripheral nerve disorders. US-guided HD of the SN with D5W without local anesthetic shows promise as both a diagnostic confirmatory tool and therapeutic intervention for neuropathic Achilles pain in psoriasis patients with SN involvement, aligning with its efficacy in other peripheral neuropathies. The significant nerve swelling (13 mm²) provides robust morphological corroboration of the functional impairment diagnosed by SDP, offering a more comprehensive diagnostic paradigm.

Background and Clinical Significance: Non-palpable migrated contraceptive implants pose significant challenges for removal and are associated with neurovascular complications. Traditional open surgery near nerves is associated with postoperative morbidity. Migrated or deeply embedded implants near critical structures can result in severe complications, such as neuropathy, and their removal typically requires open surgical intervention. Case Presentation: We report a novel, minimally invasive, ultrasound (US)-guided technique for removing a migrated etonogestrel Implanon^® implant that caused ulnar neuropathy. A 38-year-old woman presented with severe neuropathic pain and paresthesia (NPRS 10/10; QuickDASH 55) along her left ulnar nerve following multiple failed removal attempts that induced deep migration. US confirmed the proximity of the implant to the ulnar nerve. Initial US-guided removal exacerbated her symptoms. Hydrodissection (HD) with 50 mL of 5% dextrose in water (D5W) without local anesthetic (LA) was performed to reduce inflammation and achieve separation. The implant migrated proximally during extraction. An additional HD with 50 mL of D5W without LA distally repositioned the implant. Percutaneous stabilization using a 25-gauge needle enabled secure removal. The intact 4 cm implant was extracted under real-time US guidance without open surgery. The patient experienced immediate symptom relief (NPRS 2/10; QuickDASH 4.5 at one month) and full resolution (NPRS 0/10; QuickDASH 0) with no motor deficits at one year. Conclusions: This case represents the first documented percutaneous removal of a nerve-adherent implant using combined US-guided D5W HD and needle stabilization, marking a paradigm shift in the management of such cases. This approach confirms the safety of US-guided foreign body removal using HD for nerve-adjacent implants and demonstrates the efficacy of combining D5W HD with needle stabilization. Surgical morbidity was avoided, while excellent long-term outcomes were achieved.

Non-palpable migrated contraceptive implants (3-5%) pose significant removal challenges and neurovascular risks. Traditional open surgery near nerves carries postoperative morbidity. We report a novel minimally invasive ultrasound (US)-guided removal of a migrated etonogestrel Implanon® implant causing ulnar neuropathy. A 38-year-old woman presented with severe neuropathic pain and paresthesia (Numeric Pain Rating Scale [NPRS] 10/10; Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH] 55) along her left ulnar nerve after multiple failed removal attempts elsewhere induced deep migration. US confirmed the implant adjacent to the ulnar nerve within the medial arm neurovascular bundle, with direct nerve contact on dynamic imaging. Initial US-guided removal exacerbated symptoms, prompting hydrodissection (HD) using 50 mL dextrose 5% in water (D5W) without local anesthetic (LA) to reduce inflammation and achieve mechanical separation. Despite pain reduction, the slippery implant iatrogenically migrated proximally during extraction, confirmed fluoroscopically and sonographically. Additional HD (50 mL D5W) repositioned the implant distally. Percutaneous stabilization of the proximal tip with a 25-gauge needle then enabled secure grasping and complete extraction through the original incision under real-time US-guidance. The intact 4-cm implant was retrieved without open surgery. Immediate pain reduction (NPRS 2/10) and functional improvement (QuickDASH 4.5 at one month) occurred, with complete symptom resolution (NPRS 0/10; QuickDASH 0) and no motor deficits sustained at one year. This first documented percutaneous removal of a nerve-adherent implant using combined US-guided D5W HD and needle stabilization achieved durable success while avoiding open surgery, signifying a paradigm shift and possibly confirming: (1) safety of US-guided HD for nerve-adjacent implants, (2) efficacy of combined D5W HD and needle stabilization, and (3) elimination of surgical morbidity.

Background and Clinical Significance: Radial nerve palsy typically presents as wrist drop due to nerve compression, with conventional management often yielding prolonged recovery. We report a case where ultrasound-guided hydrodissection (HD) with 5% dextrose in water (D5W) achieved immediate functional restoration, suggesting neurapraxia as the underlying pathology. Case Presentation: A 54-year-old diabetic female presented with acute left wrist drop without trauma. Examination confirmed radial nerve palsy (MRC grade 0 wrist extension), while radiographs ruled out structural causes. Ultrasound revealed fascicular swelling at the spiral groove. Under real-time guidance, 50 mL D5W (no local anesthetic) was injected to hydrodissect the radial nerve. Immediate post-procedure assessment showed restored wrist extension (medical research council (MRC) grade 4+). At one- and three-month follow-ups, the patient maintained complete resolution of symptoms and normal function. Conclusions: This case highlights two key findings: (1) HD with D5W can serve as both a diagnostic tool (confirming reversible neurapraxia through immediate response) and therapeutic intervention, and (2) early HD may circumvent prolonged disability associated with conservative management. The absence of electrodiagnostic studies limits objective severity assessment, though ultrasound localized the lesion. While promising, these observations require validation through controlled trials comparing HD to standard care, particularly in diabetic patients with heightened compression susceptibility. Technical considerations—including optimal injectate volume and the role of adjuvant therapies—warrant further investigation. US-guided HD with D5W emerges as a minimally invasive, surgery-sparing option for acute compressive radial neuropathies, with potential to redefine treatment paradigms when applied at symptom onset.

Introduction: Radial nerve palsy, often manifesting as wrist drop, is a peripheral neuropathy typically resulting from compression. While conservative management is often employed, recovery can be prolonged. It has been commonly taught that cases like this involve a conduction block, which significantly limits diagnostic physical examination or electrodiagnosis. However, if hydrodissection (HD) can immediately restore function, it may indicate that the injury is merely neurapraxia, and highlight its degree of reversibility, profoundly influencing the course of recovery. We present a case of acute radial nerve palsy successfully treated with ultrasound-guided (US-guided) HD. Case Presentation: A 54-year-old woman with diabetes presented with sudden onset of left wrist drop with no apparent trauma. Physical examination revealed an inability to actively extend her wrist, and plain radiographs were unremarkable. Given the clinical presentation suggestive of radial nerve palsy, US-guided HD was performed at the proximal spiral groove using 50 mL of 5% dextrose in water (D5W) with no local anesthetic (LA). Immediate post-procedural assessment showed marked improvement in wrist extension. At one-month follow-up, the patient reported complete resolution of wrist drop and restoration of normal daily activities, with no loss of work, which was maintained at a three-month telephone review. Electrodiagnostic studies were not performed due to the retrospective nature of this case report. Discussion: This case demonstrates the potential for rapid and nearly complete clinical recovery from acute compressive radial nerve palsy following a single US-guided HD injection using D5W without LA, confirming the presence of neuropraxia and its nearly complete reversibility. However, an electromyogram (EMG) showing the pattern of motor fiber recruitment post injection was not available. Conclusion: US-guided HD with D5W with no LA may be a promising therapeutic option for selected patients with acute compressive radial nerve palsy. However, further research - including controlled trials and electrodiagnostic confirmation - is needed to determine the frequency in which immediate diagnostic and therapeutic HD with D5W is expected to be therapeutically valuable in altering function and optimizing rehabilitation