Narrative review of ultrasound-guided interventions as diagnostic and therapeutic tool in orofacial pain
Review Article

Narrative review of ultrasound-guided interventions as diagnostic and therapeutic tool in orofacial pain

Muralidhar Thondebhavi1, Suvina N2, Shlok Saxena1

1Apollo Specialty Hospital Jayanagar, Bengaluru, India; 2Vydehi Institute of Medical Sciences, Bengaluru, India

Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Dr. Suvina N. Assistant Professor, Vydehi Institute of Medical sciences, Bengaluru, India. Email: suvi11492@gmail.com.

Background and Objective: Orofacial pain refers to any type of pain in the area bounded by the eyes and the lower mandible including the oral cavity. It is very challenging to diagnose these conditions. Ultrasound-guided interventions help in diagnosis and treatment of these conditions. We describe a narrative review of all related interventions.

Methods: The data was collected from databases (PubMed, EMBASE, Scopus, ISI Web of Knowledge, Cochrane library) using keywords “orofacial pain”, “ultrasound intervention”, “nerve block”, “headache” and “new modalities” and 250 articles were identified and approximately 80 relevant English full text articles were included in this narrative review

Key Content and Findings: Orofacial pain is classified into 6 categories as per International Classification on Orofacial Pain (ICOP). The treatment options have been discussed in overview. Ultrasound interventions namely atlanto-axial and atlanto-occipital joint injection, greater, lesser and least occipital nerve block, infra-orbital nerve block and Stellate ganglion block are being elaborately described in this review. Various approaches of the blocks have reviewed and safest method under ultrasound guidance has been discussed in detail.

Conclusions: Several, diagnostic, and therapeutic indications of nerve blocks have emerged for management of orofacial pain. The use of ultrasound has improved the safety and efficacy of blocks.

Keywords: Ultrasound interventions; orofacial pain; headache; nerve block; idiopathic facial pain

Received: 11 June 2022; Accepted: 23 September 2022; Published: 30 September 2022.

doi: 10.21037/joma-22-19

Introduction

Description of pain in the area bounded by the eyes and lower mandible including the oral cavity is defined as an orofacial pain (Indian Association of Orofacial Pain) (1). Recently, International Classification on Orofacial Pain (ICOP) has been proposed to ameliorate the clinical management and research through comprehensive refined diagnostic criteria (2). In width, six broad categories have been set out with multi-level subcategories.

It is estimated that a vast proportion of all orofacial pains are constituted by dental aches and disorders of temporomandibular joint (3-5). Management of a complex orofacial pains ordinarily requires a collaborative tack of a dentist and a pain physician and is often challenging. The clinician needs to have solid knowledge of the pain conditions that arise from these structures for proper diagnosis and a multidisciplinary approach of management is strongly recommended (6). Contrariwise, advanced imaging modalities for diagnosis and handling of orofacial pains has revolutionized patient care.

The utility of ultrasonography (US) in performing target specific nerve blocks has metamorphosed pain management as they provide radiation free environment with real time visualization of structures to be blocked including joint space, nerve, blood vessels and drug administration (6,7). We present the following article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-22-19/rc).

Objective

Various approaches have been described for ultrasound-guided procedures, like in plane and out of plane approach for cervical medial branch block (7-9). The purpose of this review is to describe and illustrate the basic ultrasound guided approaches used for pain handling in common orofacial pain with better efficacy and safety profile (10).

Methods

The data was collected from all indexed journals from the year 2000 to 2022, with keywords of ultrasound interventions, orofacial pain, various approaches (Table 1).

Table 1

Search strategy summary

Ideas Specification
Date of search 28th October, 2021
Databases and other sources searched PubMed, Embase, Ovid Medline, Cochrane, Scopus, ISI Web of knowledge
Search terms used (“nerve block”[MeSH Terms] OR (“nerve”[All Fields] AND “block”[All Fields]) OR “nerve block”[All Fields] OR (“nerve”[All Fields] AND “blocks”[All Fields]) OR “nerve blocks”[All Fields]) AND (“orofacial pain”[MeSH Terms] OR (“orofacial pain ”[All Fields] AND “headache”[All Fields] AND “ultrasound interventions”[All Fields]) OR “orofacial pain syndromes”[All Fields] OR (“oral pain”[All Fields] AND “facial pain”[All Fields]) OR “orofacial pain disorders”[All Fields])(“ultrasound”[All Fields] OR “interventions”[All Fields] OR “us-guided”[All Fields] OR “interventions”[All Fields] OR “interventions”[MeSH Terms] OR “ultrasound-guided”[All Fields] OR “procedures”[All Fields] OR “intervention”[All Fields] OR “interventional”[All Fields] OR “ultrasound intervention”[All Fields] OR “us-guided ”[All Fields] OR “us-guided interventions”[All Fields]) AND (“orofacial pain”[MeSH Terms] OR (“orofacial ”[All Fields] AND “joint”[All Fields] AND “headache”[All Fields]) OR “orofacial pain”[All Fields] OR (“facial pain”[All Fields] AND “syndromes”[All Fields]) OR “orofacial pain”[All Fields])
Time frame 2000–2022
Inclusion and exclusion criteria Clinical trials, research studies, case reports, case series, systematic reviews were included. Studies that irrelevant to the current topic, or did not have the focused question, keywords were excluded
Selection process Two authors MT, SN independently searched indexed databases using MeSH terms and screened the titles and abstracts of the identified studies. Disagreements were solved through mutual discussion between authors and in case of a lack of consensus through discussion involving a third author (SS)

Comprehensive US-guided interventions for orofacial pains

Interventional US for orofacial pain should be performed using a coherent approach to aid patient well-being. The patient position is personalized to block specification to achieve ideal ergonomics. A high-frequency (9–15 MHz) linear array transducer is used for imaging. In-general, relevant anatomy is identified and colour doppler is employed to confirm vascular structures. The pertinent block anatomy, US technique and frequent indications are individually described methodically (Table 2).

Table 2

Overview of classification of orofacial pain

Serial No. Classification Treatment Other interventions available
1 OFP related to dentoalveolar structures Conservative treatment –
2 Myofascial orofacial pain Conservative treatment Trigger point injections with LA and steroid
3 Temporomandibular joint pain Conservative treatment Surgical correction
4 OFP attributed to lesion or disease of cranial nerve: Gasserian ganglion block RFA of Gasserion ganglion
Trigeminal neuralgia Infraorbital nerve block Cryoneurolysis of infraorbital nerve
Glossopharyngeal neuralgia Glossopharyngeal nerve block Surgical correction of styloid process
5 OFP resembling presentation of primary headaches:
Cluster headache Sphenopalatine ganglion block Cryoneurolysis of GON and LON
Occipital headache Greater and lesser occipital nerve block –
Third occipital nerve block –
Cervicogenic headache Atlanto-occipital block RFA of cervical medial branch
Cervical medial branch block –
6 Idiopathic orofacial pain Stellate ganglion block –
Sphenopalatine ganglion block RFA of sphenopalatine ganglion

OFP, orofacial pain; LA, local anesthetics; RFA, radiofrequency ablation; GON, greater occipital nerve; LON, lesser occipital nerve.

Orofacial pains presentation similar to primary headache

Atlanto-axial (AA) and atlanto-occipital (AO) block

AA-AO joint pain often has a variable presentation. They frequently present with an occipital headache. Establishing a diagnosis requires an intraarticular injection of AA/AO joint which is usually therapeutic. Conventionally, fluoroscopic guidance has been the standard of care (11-13). It is however limited by lack of visualization of the vertebral artery (VA) and the dural sleeve thereby possessing an inadvertent threat.

Early, ultrasound approaches for AA/AO injections proclaimed feasibility (13,14). More technically reliable approaches evaluating various patient positions, needle trajectory and different US views have since been described (14,15).

Technique

AA joint injection

Patient is asked to lay in a prone position with a pillow placed underneath the chest to allow for slight head flexion. A high-frequency ultrasound transducer is placed over the occiput. Scanning cranio-caudally, the probe is then aligned in the midline over the cervical spinous processes to identify the first bifid spinous process; that of C2. Probe is then slid laterally to view the AA joint (C1-C2). VA is viewed further laterally and is confirmed by applying color doppler. An in-plane approach is then utilized to place the needle in joint space under vision.

AO joint injection (14)

In a slight head flexed-prone position, the probe is placed longitudinally below the mastoid process. The transducer is then moved medially till C1 transverse process is visualized. A color doppler is then utilized to confirm the VA. A more medial displacement leads to disappearance of the VA from the view as it runs anterior to spinal cord. Further medially the AO joint is then visualized usually corresponding to the midpoint of occipital protuberance and mastoid process. Targeting the joint, the needle is inserted in-plane.

Greater occipital nerve block (GON)

GON block has found significant utility in pain medicine as it is supported by evidence in mitigating various orofacial pains such as occipital neuralgia, cervicogenic headache, cluster headache and migraine (16).

GON has been conventionally targeted just medial to the pulsation of the occipital artery at the level of the superior nuchal line. It is however limited by significant variability and multiple branching (17). A more consistent site is where it curves around the obliquus capitis inferior muscle (OCIM) and is an important landmark for visualizing the GON at the C2/C1 level under US guidance (18).

Technique (16)

Position of the patient may vary as per clinician preference. However, a lateral decubitus position may offer greater operator and patient comfort whilst preserving hemodynamics. Keeping the patient head in neutral position and the cervical spine in anteflexion is advised.

A linear high frequency probe is placed over the occipital protuberance. Scanning caudad the bifid spinous process of C2 is recognized. The probe is then moved laterally to visualize the OCIM. The muscle appears hypoechoic, posterior to the lamina of the axis and deep to the semispinalis capitis muscle (SsCM). GON is observed as an oval-shaped hypoechoic structure interposed between OCIM and SsCM. A color doppler is advised to obviate the VA which lies anterior to OCIM and more lateral. An in-plane needling from lateral to medial direction is preferred. Hydrodissection of the intermuscular plane may be desired to expose the nerve.

Third occipital nerve (TON) block and cervical medial branch block

The cervical zygapophysial joints are burdened by the axial load on the cervical spine and undergo constant wear and tear, many-a-time triggering pain. The articular branches of the medial branch from the cervical dorsal rami provide the innervation. Additionally, pain generating nociceptive elements on the facet joint, and capsule has been described (19).

These diarthrodial joints predominantly have a dual innervation from the medial branch above and below its location. The C3-C7 spinal nerves give rise to their respective dorsal rami. The medial branch of C3 has a distinct anatomy. A deeper division supplies the C3-C4 zygapophysial joint. The superficial component of the C3 medial branch is denoted as the TON. It provides articular branches to the C2-C3 zygapophysial joint and subsequently becomes cutaneous to supply suboccipital region.

Blocks performed are diagnostic and generally therapeutic. Failure to achieve analgesia should prompt a repeat confirmatory block at a different instance in time to minimize the false positives (20).

Technique

Cervical medial branch block

Procedure is routinely executed in a prone position which facilitates performance of bilateral injection. A suitable transducer is stationed in the sagittal plane over the cervical spinous processes. The desired cervical level is ascertained. Moving the probe laterally, firstly, the lamina and then the facet joint is identified. The typical sono-image of the facet column is described as the ‘saw sign’. The medial branch can be appreciated as a hyperechoic structure at the deepest point between the articulations. Specific medial branch is then targeted using in-plane needling. The C7 medial branch demonstrates anatomical variation to other medial branches and is located caudad to the C6/C7 facet joint but cranial to superior edge of posterior tubercle of C7 transverse process (21) (Figure 1).

Figure 1 Cervical medial branch block. Orange dot: medial branch nerve; white outline: facet joint.
TON block

In the lateral position, a high frequency linear probe is placed longitudinally over the mastoid parallel to the spine. Probe is then aligned to view the C1-C2 transverse process. A pulsatile VA is located deep in the interstice. Advancing the probe in posterior and caudad direction, the articulation of the arch of atlas and the articular pillar of C2 is noted and centralized. A rotatory movement aids recognition of TON as an oval hypoechoic structure with hyperechoic spots (22,23). Needling is carefully accomplished in the short axis, depositing the drug alongside the nerve.

Orofacial pain attributed to disease or lesion of cranial nerve and branches

Infra-orbital nerve block

A vast majority of neuropathic pain over the face is attributed to infraorbital division of the maxillary nerve (second division of the trigeminal nerve) (24). The nerve provides cutaneous innervation to lower eyelid, lateral side of the nose and the upper lip through its sensory branches, namely the inferior palpebral, the lateral nasal, and the superior labial (18,24,25).

Traditionally, infraorbital nerve block has been performed using anatomical landmarks with varying success (18). Utilization of US has demonstrated higher accuracy with considerable safety (26).

Infraorbital nerve block establishes to be an eminent tool in the arsenal of every pain physician.

Technique

In supine position, US probe is placed horizontally just beside the nose and slid laterally to locate a depression of the infraorbital foramen as exhibited by a disruption in the hyperechoic line. In the foramen, nerve is located and its relation to infraorbital artery is verified using color doppler. Needle is then guided in-plane to approximate the nerve and the drug is deposited (Figure 2).

Figure 2 Infraorbital nerve block. Above red line is skin and subcutaneous fat, below yellow line is maxilla bony prominence. Red arrow: infraorbital artery; yellow arrow: infraorbital nerve; purple arrow: infraorbital foramen.

Idiopathic orofacial pain

Stellate ganglion block (SGB)

Stellate ganglion is a sympathetic ganglion formed by the fusion of the inferior cervical and first thoracic ganglion. SGB is routinely used in complex regional pain syndrome (CRPS) and peripheral vascular disease, for diagnosis and management of sympathetically mediated pain (27).

Historically, SGB has been performed using landmark guidance by palpating the Chassaignac’s tubercle (anterior tubercle of the transverse process of C6) (28,29). However, the safety of this approach has been questioned as tight vascular space surrounds the sympathetic chain, risking inadvertent vascular puncture. US guidance has now widely replaced other imaging modalities for performing blocks. It owes its superiority to visualization of soft tissues and less radiation exposure.

Literature supports the safety and effectiveness of SGB using US guidance (30,31).

Technique

Patient is placed in supine posture with head turned to the opposite side of the block.

The lower neck is scanned in short axis. Prevertebral fascia, longus colli muscle and chassaignac’s tubercle are identified. Carotid artery, Inferior thyroid artery and VA are visualised and confirmed using color doppler. Needle is guided in plane to lie in the fascial plane beneath the prevertebral fascia and anterior to the sheath covering longus colli with intent to block the ganglion.

Care must be taken to avoid deposition of the injectate anterior to prevertebral fascia, which could cause hoarseness of voice due to involvement of vagus nerve or recurrent laryngeal nerve (Figure 3).

Figure 3 Stellate ganglion block. IJV, internal jugular vein (blue outline); CA, carotid artery (red outline); AT, anterior tubercle; PT, posterior tubercle; C6 NR, sixth cervical nerve root (yellow outline); LC, lateral cord (orange outline).

Peripheral neuromodulation

Direct stimulation of peripheral nerves induces decreased excitability, increased electrical threshold and transient slowing of conduction velocity (32). Improved outcomes have been demonstrated with neuromodulation in patient with occipital and trigeminal neuralgia (33-35). There is, however, an associated paraesthesia on stimulation which is mediated by Aβ fibres and is in accordance with the gate control theory of pain.

Stimulating electrodes are introduced through a needle beside the focused nerve under local anaesthesia. Initially temporary neurostimulation is applied. Subsequently, programmable, rechargeable generator is permanently implanted by creating a subcutaneous pocket, and permanent settings are done.

Complication

Performing nerve block in proximity of neuro-vascular structures demands expertise and can be technically challenging. Localised as well as systemic complications have been described. Central neuraxial spread of the drug and vascular injections can often lead to devastating outcomes. Use of advanced imaging such as US guidance is recommended to avert complications. Sterility must be emphasised to avoid infections. It is recommended to perform the above interventions in a controlled environment with availability of emergency drugs and equipment with advocated monitoring.

Conclusions

Several, diagnostic, and therapeutic indications of nerve blocks have emerged for management of orofacial pain. Ultrasound guidance has revamped operator performance and revolutionized patient care, making it a standard of care. Understanding relevant sono-anatomy will help pain physicians overcome the barriers and implement US guidance to in their clinical practice.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mythili Kalladka) for the series “Orofacial Pain: Diagnostic and Therapeutic Topicals, Nerve Blocks and Trigger Point Injection” published in Journal of Oral and Maxillofacial Anesthesia. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-22-19/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-22-19/coif). The series “Orofacial Pain: Diagnostic and Therapeutic Topicals, Nerve Blocks and Trigger Point Injection” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/joma-22-19
Cite this article as: Thondebhavi M, Suvina N, Saxena S. Narrative review of ultrasound-guided interventions as diagnostic and therapeutic tool in orofacial pain. J Oral Maxillofac Anesth 2022;1:30.

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