You are on page 1of 7

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

2

ACUPUNCTURE IN MEDICINE 2003;21(1-2):2-8.
www.medical-acupuncture.co.uk/aimintro.htm

showing some classical acupuncture points on the left side. mf: mental foramen. In the nasolabial groove and level with the most prominent part of the ala nasi. The mental foramen also lies on the vertical line through the superior and the inferior orbital foramen.anatomy. The second important bony landmark is the mandible. www. It is crucial that routine treatment is carried out in a clinically clean manner.co. The coronoid process lies anteriorly and on the inner side of the zygomatic ACUPUNCTURE IN MEDICINE 2003.htm 3 .Papers Figure 1 This is an anterior view of the face and head. Key to labels: n: nasion. and ST4 at the angle of the mouth.medical-acupuncture. causing for example a thrombosis of the cavernous sinus. Image courtesy of Primal Pictures Ltd. and palpable anatomical features on the right. sof: supraorbital foramen. so far.21(1-2):2-8. By needling points in this region. LI20 (Ying Xiang) can be found. fn: frontal notch. ST3 is level with the lower border of the nose.tv found on the lower border of the orbit. 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. www. It marks the exit of the mental nerve. infectious agents could be transmitted from the skin surface to the intracerebral regions.uk/aimintro. The condylar process articulates in the temporomandibular joint. Whether or not swab disinfection reduces the possibility of these complications remains unclear. iof: infraorbital foramen. It consists of different parts. which is needled up to 1cm in the craniomedial direction. General remark on safety (figure 2) The venous system of the face has several connections to the intracerebral venous system. The motion of the condylar process can be felt just in front of the external acoustic meatus.

The ramus and the angle of mandible are covered by a strong masticatory muscle. sov: supraorbital vein. Image courtesy of Primal Pictures Ltd. ST5 can be found on the connection between the anterior border of the masseter and the lower border of the mandible.Papers Figure 2 This is an anterolateral view of the head and neck illustrating the venous system. in a depression behind the ear lobe. 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. Key to labels: cs: cavernous sinus.tv arch. www. Slightly cranial and ventral to the angle of the mandible in most cases a small depression can be palpated in the masseter.co.anatomy. ev: ethmoidal veins. This is related to a divergent course of the muscle fibres and represents the point ST6 (Jia Che). The upper border of the temporal muscle can be easily determined by clenching the teeth. where the pulse of the facial artery often can be palpated. Between the mastoid process and the condylar process of mandible.medical-acupuncture. stv: supratrochlear vein. iov: intraorbital veins.21(1-2):2-8. This depression marks the surface localisation of the point TE17 (Yi Feng). www. In the center of this palpable depression ST7 (Xi Guan) is located. As the 4 ACUPUNCTURE IN MEDICINE 2003.htm . av: angular vein. In the depth of the notch the needle reaches the lateral pterygoid muscle. It is the insertion zone for the temporal muscle. roughly on a vertical line through ST6 and 7. the masseter. the transverse process of the atlas (C1) is palpable.uk/aimintro. the point ST8 (Tou Wei) is located. In the upper border of the temporal muscle. The ramus of mandible connects the processes and the angle of mandible which is usually easy to find.

below the tragus the intertragic notch. www.medical-acupuncture. mn: mandibular notch.21(1-2):2-8. 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. These three points lie over the temporal artery and the auriculotemporal nerve. crp: coronoid process of mandible. In contrast to GB20 (see below) deep needling at TE17 puts the vertebral artery at significant risk of injury. cdp: condylar process of mandible. SI19 (Ting Gong) in a small depression in front of the tragus. The anterior border of the auricle is dominated by the tragus. Image courtesy of Primal Pictures Ltd. rm: ramus of mandible. so TE17 should be needled in an anterior direction.Papers vertebral artery emerges from the transverse foramen of the atlas and turns backwards. am: angle of mandible. tfa: transverse facial artery. especially if the points are needled obliquely in a caudal or cranial direction. tmj: temporomandibular joint. 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.tv ACUPUNCTURE IN MEDICINE 2003.htm 5 . Key to labels: za: zygomatic arch. which are susceptible to injury.co. www. TE21 (Er Men) at the level of the supratragic notch.uk/aimintro. ma: maxillary artery.anatomy. fa: facial artery. Above the tragus we find the supratragic notch.

uk/aimintro. tm: temporalis muscle. scm: sternocleidomastoid. m: masseter muscle. fa: facial artery. The point lies over the nuchal ligament and (deeper) 6 ACUPUNCTURE IN MEDICINE 2003.medical-acupuncture. The first palpable spinous process of the cervical spine belongs to C2 (axis). av: angular vein. To relax the nuchal ligament the head should be slightly retroflexed.21(1-2):2-8. and the head of the patient is flexed and extended. blood vessels and nerves. The trapezius and the sternocleidomastoid overlay the semispinalis muscle and the spenius muscle.co.Papers Figure 4 This is a view of the left side of the head showing muscles. Key to labels: stv: superficial temporal vessels.anatomy. The vertebral spinous processes of C3 and C4 usually are not palpable. The spinous processes of C7 and T1 generally do not move during this manoeuvre.tv and inferior nuchal lines deriving from it. za: zygomatic arch. Image courtesy of Primal Pictures Ltd. the spinous process of C7 is often the most prominent one. three fingertips of the examining hand are put on the likely processes. and – in the depth – the obliquus capitis superior and inferior muscles. though in cervical rotation some movement of C7 may be detected. as well as some classical acupuncture points. The spinous processes of C5 and C6 can be found in most cases. If it remains unclear which spinous process belongs to C6. The relief of the neck is dominated by the trapezius muscle and the sternocleidomastoid muscle. fp: fascial overlying the parotid. www. www. as well as the rectus capitis posterior major and minor muscles. GV16 (Feng Fu) is located in the midline below the external occipital protuberance.htm . C7 and T1. usually a small depression is palpable. Between the insertions of these two.

to reach the vertebral artery but it takes similar distances as described before. Deep perpendicular or posterior angulation when needling this point risks damaging the vertebral artery. the needling depth should not exceed 3cm.1 Safe treatment is performed when needling upward on the occipital bone or in a caudal direction with the head bent slightly forward. Yue G.21(1-2):2-8. BL10 (Tian Zhu) is also located in the height of the upper border of the spinous process of C2 and about 1-1. The position of the classical acupuncture point TE17 is also shown. Headache 2000. In fact. In adults with a normal build the distance between the skin surface and the spinal cord is at least 5-6cm. Image courtesy of Elmar Peuker. GV15 (Ya Men) lies in the midline above the spinous process of C2. 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.Papers the cerebellomedullary cistern. Figure 5 These are left lateral and posterior views of C1 and C2. www. Reference list 1. ta: temporal artery. with the position of the vertebral artery illustrated passing through the foramina in the transverse process of C1.medical-acupuncture. There have been many warnings on (deep) needling BL10 and GB20: either the medulla or the vertebral artery could be injured. Key to labels: atn: auriculotemporal nerve.5cun from the midline. mn: mandiblar notch. If needling is performed slightly upwards and inwards (in direction of the contralateral eye) GB20 should be one of the safest points. pd: parotid duct. 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. Remember that the spinal cord enters the skull almost in the middle of its base. ACUPUNCTURE IN MEDICINE 2003.anatomy. Key to labels: va: vertebral artery. there has been a report of direct needling into the medulla oblongata at this point. within the trapezius muscle. www. or adults with a very small build. fn: facial nerve. tm: temporalis muscle. Image courtesy of Primal Pictures Ltd. Figure 6 This is a view of the left side of the head showing a dissection of the temporal and zygomatic arch areas.tv In cachectic patients. Choo DCA.co. Needling GB20 very deeply it is possible.htm 7 . Acute intracranial hemorrhage caused by acupuncture. BL10 is needled perpendicularly. not dorsally. at least in principle.uk/aimintro. za: zygomatic arch.40(5):397-8.

and deep muscles and the exposed portions of the vertebral artery on the left. www. sp: spinous process C2. oci: oblique inferior muscle. oci: obliquus capitis inferior. Key to labels: da: dens axis. tm: trapezius muscle. But note that the depth of the artery in these areas is at least 4 to 6cm in the adult. Image courtesy of Elmar Peuker.Papers Figure 7 This is a posterior view of the neck showing superficial muscles and acupuncture points on the right. ocs: obliquus capitis superior. m: mandible.21(1-2):2-8. spl: splenius muscle. scm: sternocleidomastoid muscle. rcpM: rectus capitis posterior major.medical-acupuncture. spc: splenius capitus. mm: masseter muscle.co. va: vertebral artery: arrow: possible needling depth at BL10.uk/aimintro. rcpm: rectus capitis posterior minor. 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. and the distance to the vertebral artery. Key to labels: nl: nuchal ligament. tp: transverse process of C1.tv Figure 8 This is a cross-section of the head and neck at the level of C1. www. sp: spinous process of C2.htm . trap: trapezius. va: vertebral artery.anatomy. Image courtesy of Primal Pictures Ltd. 8 ACUPUNCTURE IN MEDICINE 2003. sem: semispinalis muscle. The ellipses indicate the areas where the vertebral artery may be vulnerable to needling from a posterior approach. Note the potential depth of needling at BL10. ssc: semispinalis capitis.