Papers

Anatomy for the Acupuncturist Facts & Fiction

1: The head and neck region
Elmar Peuker, Mike Cummings

Elmar T. Peuker senior lecturer Department of Anatomy Clinical Anatomy Division University of Muenster Muenster, Germany Mike Cummings medical director BMAS Correspondence: Elmar Peuker e-peuker@muenster.de

Summary Knowledge of anatomy, and the skill to apply it, is arguably the most important facet of safe and competent acupuncture practice. The authors believe that an acupuncturist should always know where the tip of their needle lies with respect to the relevant anatomy so that vital structures can be avoided and the intended target for stimulation can be reached. Keywords Anatomy, acupuncture points. Introduction This is the first of a series of articles that highlight human anatomy issues relevant to acupuncture practitioners. Whilst the framework of the articles is built around anatomical structures that should be avoided when needling, the aim is not to frighten practitioners, but rather to instil confidence in safe needling techniques. Case reports are used to illustrate potential dangers, but it should be remembered that the complications described are rare, and most are entirely preventable. Some common misconceptions are also discussed. Most textbooks of acupuncture use relative scales to determine the surface localisation of acupuncture points. However, the safest and probably the best way is the orientation on anatomical landmarks. Moreover, it is important to know, what lies beneath the surface, i.e. which morphological structures could be the target of the needling, and, on the other hand, which structures should be avoided (e.g. vessels, nerves etc.). Landmarks and important acupuncture points of the face (figure 1) The nasion lies in the midline and represents the deepest part of the nasal bridge. It is the connection point between the nasal and the frontal bones. Slightly above the nasion between the medial end of the eye-brows an important extra point can be found: ExHN3 (Yin Tang) which is needled in direction of the nasion. It should be noted that there are several numbering systems for extra (non-meridian) points. In the UK Yin Tang is often referred to as EX1. The bony borders of the orbita are completely accessible to palpation. At the junction of the middle and the inner third of the superior orbital margin the supraorbital foramen is located. It represents the exit of the supraorbital artery and the lateral branch of the supraorbital nerve. Just above the supraorbital foramen the point GB14 (Yang Bai) is located. A little bit more medial (medial end of the eyebrow, above the inner corner of the eye) the frontal notch is located where the supratrochlear artery and the medial branch of the supraorbital nerve emerge. The frontal notch is clearly palpable in most cases and represents the bony landmark for BL2 (Zan Zhu). The infraorbital foramen lies about 2cm below the inferior orbital margin, in a vertical line through the supraorbital foramen. The infraorbital artery and nerve leave the skull through this foramen. In most cases the infraorbital foramen can be found in the middle of the total length of the nose and slightly medial to a vertical line through the middle of the pupil when looking straight forward. The stomach points 1 to 4 are located on this vertical line. ST2 (Si Bai) lies just above the infraorbital foramen and is needled about up to 1cm perpendicularly. ST1 can be

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Figure 1 This is an anterior view of the face and head, showing some classical acupuncture points on the left side, and palpable anatomical features on the right. Key to labels: n: nasion; fn: frontal notch; sof: supraorbital foramen; iof: infraorbital foramen; mf: mental foramen. Image courtesy of Primal Pictures Ltd. www.anatomy.tv found on the lower border of the orbit, ST3 is level with the lower border of the nose, and ST4 at the angle of the mouth. In the nasolabial groove and level with the most prominent part of the ala nasi, LI20 (Ying Xiang) can be found, which is needled up to 1cm in the craniomedial direction. The mental foramen also lies on the vertical line through the superior and the inferior orbital foramen. It marks the exit of the mental nerve. General remark on safety (figure 2) The venous system of the face has several connections to the intracerebral venous system. By needling points in this region, infectious agents could be transmitted from the skin surface to the intracerebral regions, causing for example a thrombosis of the cavernous sinus. It is crucial that routine treatment is carried out in a clinically clean manner. Whether or not swab disinfection reduces the possibility of these complications remains unclear, so far. Landmarks and important acupuncture points of the side of the face (figure 3-6) The zygomatic arch represents an important bony landmark. In most cases it is palpable in its whole extent. The second important bony landmark is the mandible. It consists of different parts. The condylar process articulates in the temporomandibular joint. The motion of the condylar process can be felt just in front of the external acoustic meatus. The coronoid process lies anteriorly and on the inner side of the zygomatic

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Figure 2 This is an anterolateral view of the head and neck illustrating the venous system. Key to labels: cs: cavernous sinus; sov: supraorbital vein; stv: supratrochlear vein; ev: ethmoidal veins; iov: intraorbital veins; av: angular vein. Image courtesy of Primal Pictures Ltd. www.anatomy.tv arch. It is the insertion zone for the temporal muscle. The ramus of mandible connects the processes and the angle of mandible which is usually easy to find. The ramus and the angle of mandible are covered by a strong masticatory muscle, the masseter. Slightly cranial and ventral to the angle of the mandible in most cases a small depression can be palpated in the masseter. This is related to a divergent course of the muscle fibres and represents the point ST6 (Jia Che). ST5 can be found on the connection between the anterior border of the masseter and the lower border of the mandible, where the pulse of the facial artery often can be palpated. The triangle between the condylar and the coronoid process of the mandible and the lower border of the zygomatic arch is a soft spot which overlies the mandibular notch. In the center of this palpable depression ST7 (Xi Guan) is located. In the depth of the notch the needle reaches the lateral pterygoid muscle. In the upper border of the temporal muscle, roughly on a vertical line through ST6 and 7, the point ST8 (Tou Wei) is located. The upper border of the temporal muscle can be easily determined by clenching the teeth. Between the mastoid process and the condylar process of mandible, in a depression behind the ear lobe, the transverse process of the atlas (C1) is palpable. This depression marks the surface localisation of the point TE17 (Yi Feng). As the

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vertebral artery emerges from the transverse foramen of the atlas and turns backwards, so TE17 should be needled in an anterior direction. In contrast to GB20 (see below) deep needling at TE17 puts the vertebral artery at significant risk of injury. The anterior border of the auricle is dominated by the tragus. Above the tragus we find the supratragic notch, below the tragus the intertragic notch. In front of the anterior border of the auricle and immediately behind the dorsal portion of the condylar process of mandible three acupuncture points lie on a vertical line: GB2 (Ting Hui) is located in front of the intertragic notch, SI19 (Ting Gong) in a small depression in front of the tragus, TE21 (Er Men) at the level of the supratragic notch. These three points lie over the temporal artery and the auriculotemporal nerve, which are susceptible to injury, especially if the points are needled obliquely in a caudal or cranial direction. Landmarks and important acupuncture points of the dorsal region and the neck (figure 7-8) Bony landmarks of the occipital skull are the external occipital protuberance and the superior

Figure 3 This is a view of the left side of the skull with a display of the arterial system. Key to labels: za: zygomatic arch; tmj: temporomandibular joint; cdp: condylar process of mandible; tfa: transverse facial artery; crp: coronoid process of mandible; mn: mandibular notch; ma: maxillary artery; rm: ramus of mandible; am: angle of mandible; fa: facial artery. Image courtesy of Primal Pictures Ltd. www.anatomy.tv

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Figure 4 This is a view of the left side of the head showing muscles, blood vessels and nerves, as well as some classical acupuncture points. Key to labels: stv: superficial temporal vessels; tm: temporalis muscle; za: zygomatic arch; m: masseter muscle; fp: fascial overlying the parotid; av: angular vein; fa: facial artery; scm: sternocleidomastoid. Image courtesy of Primal Pictures Ltd. www.anatomy.tv and inferior nuchal lines deriving from it. The first palpable spinous process of the cervical spine belongs to C2 (axis). To relax the nuchal ligament the head should be slightly retroflexed. The vertebral spinous processes of C3 and C4 usually are not palpable. The spinous processes of C5 and C6 can be found in most cases, the spinous process of C7 is often the most prominent one. If it remains unclear which spinous process belongs to C6, C7 and T1, three fingertips of the examining hand are put on the likely processes, and the head of the patient is flexed and extended. The spinous processes of C7 and T1 generally do not move during this manoeuvre, though in cervical rotation some movement of C7 may be detected. The relief of the neck is dominated by the trapezius muscle and the sternocleidomastoid muscle. Between the insertions of these two, usually a small depression is palpable. The trapezius and the sternocleidomastoid overlay the semispinalis muscle and the spenius muscle, and in the depth the obliquus capitis superior and inferior muscles, as well as the rectus capitis posterior major and minor muscles. GV16 (Feng Fu) is located in the midline below the external occipital protuberance. The point lies over the nuchal ligament and (deeper)

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the cerebellomedullary cistern. In fact, there has been a report of direct needling into the medulla oblongata at this point.1 Safe treatment is performed when needling upward on the occipital bone or in a caudal direction with the head bent slightly forward. GV15 (Ya Men) lies in the midline above the spinous process of C2. BL10 (Tian Zhu) is also located in the height of the upper border of the spinous process of C2 and about 1-1.5cun from the midline, within the trapezius muscle. GB20 (Feng Chi) lies at about the same level as GV16 in an almost triangular depression between the insertions of the trapezius and sternocleidomastoid muscles at the lower edge of the occiput. There have been many warnings on (deep) needling BL10 and GB20: either the medulla or the vertebral artery could be injured. BL10 is needled perpendicularly. In adults with a normal build the distance between the skin surface and the spinal cord is at least 5-6cm.

Figure 5 These are left lateral and posterior views of C1 and C2, with the position of the vertebral artery illustrated passing through the foramina in the transverse process of C1. The position of the classical acupuncture point TE17 is also shown. Deep perpendicular or posterior angulation when needling this point risks damaging the vertebral artery. Key to labels: va: vertebral artery. Image courtesy of Primal Pictures Ltd. www.anatomy.tv In cachectic patients, or adults with a very small build, the needling depth should not exceed 3cm. Remember that the spinal cord enters the skull almost in the middle of its base, not dorsally. Needling GB20 very deeply it is possible, at least in principle, to reach the vertebral artery but it takes similar distances as described before. If needling is performed slightly upwards and inwards (in direction of the contralateral eye) GB20 should be one of the safest points. Conclusion The authors believe that an acupuncturist should always know where the tip of their needle lies with respect to the relevant anatomy so that vital structures can be avoided and so that the intended target for stimulation can be reached.
Reference list 1. Choo DCA, Yue G. Acute intracranial hemorrhage caused by acupuncture. Headache 2000;40(5):397-8.

Figure 6 This is a view of the left side of the head showing a dissection of the temporal and zygomatic arch areas. Key to labels: atn: auriculotemporal nerve; fn: facial nerve; pd: parotid duct; mn: mandiblar notch; ta: temporal artery; tm: temporalis muscle; za: zygomatic arch. Image courtesy of Elmar Peuker.

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Figure 7 This is a posterior view of the neck showing superficial muscles and acupuncture points on the right, and deep muscles and the exposed portions of the vertebral artery on the left. The ellipses indicate the areas where the vertebral artery may be vulnerable to needling from a posterior approach. But note that the depth of the artery in these areas is at least 4 to 6cm in the adult. Key to labels: nl: nuchal ligament; ssc: semispinalis capitis; spc: splenius capitus; trap: trapezius; ocs: obliquus capitis superior; rcpM: rectus capitis posterior major; rcpm: rectus capitis posterior minor; tp: transverse process of C1; va: vertebral artery; oci: obliquus capitis inferior; sp: spinous process of C2. Image courtesy of Primal Pictures Ltd. www.anatomy.tv

Figure 8 This is a cross-section of the head and neck at the level of C1. Note the potential depth of needling at BL10, and the distance to the vertebral artery. Note that the vertebral artery runs more posteriorly above this level as it curves around the posterior aspect of the superior articular process of C1. Key to labels: da: dens axis; m: mandible; mm: masseter muscle; oci: oblique inferior muscle; scm: sternocleidomastoid muscle; sem: semispinalis muscle; spl: splenius muscle; sp: spinous process C2; tm: trapezius muscle; va: vertebral artery: arrow: possible needling depth at BL10. Image courtesy of Elmar Peuker.

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