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Anatomy for the acupuncturist − facts & fiction


1: the head and neck region
Elmar Peuker and Mike Cummings

Acupunct Med 2003 21: 2-8


doi: 10.1136/aim.21.1-2.2

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Anatomy for the Acupuncturist – Facts & Fiction


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

Elmar T. Peuker Summary


senior lecturer Knowledge of anatomy, and the skill to apply it, is arguably the most important facet of safe and
Department of Anatomy
Clinical Anatomy
competent acupuncture practice. The authors believe that an acupuncturist should always know where the
Division tip of their needle lies with respect to the relevant anatomy so that vital structures can be avoided and the
University of Muenster intended target for stimulation can be reached.
Muenster, Germany

Mike Cummings Keywords


medical director
BMAS
Anatomy, acupuncture points.

Correspondence: Introduction needled in direction of the nasion. It should be


Elmar Peuker
This is the first of a series of articles that noted that there are several numbering systems for
e-peuker@muenster.de highlight human anatomy issues relevant to extra (non-meridian) points. In the UK Yin Tang is
acupuncture practitioners. Whilst the framework often referred to as EX1.
of the articles is built around anatomical structures The bony borders of the orbita are completely
that should be avoided when needling, the aim is accessible to palpation. At the junction of the
not to frighten practitioners, but rather to instil middle and the inner third of the superior orbital
confidence in safe needling techniques. Case margin the supraorbital foramen is located.
reports are used to illustrate potential dangers, but It represents the exit of the supraorbital artery
it should be remembered that the complications and the lateral branch of the supraorbital nerve.
described are rare, and most are entirely Just above the supraorbital foramen the point
preventable. Some common misconceptions are GB14 (Yang Bai) is located.
also discussed. A little bit more medial (medial end of the
Most textbooks of acupuncture use relative eyebrow, above the inner corner of the eye) the
scales to determine the surface localisation of frontal notch is located where the supratrochlear
acupuncture points. However, the safest and artery and the medial branch of the supraorbital
probably the best way is the orientation on nerve emerge. The frontal notch is clearly palpable
anatomical landmarks. Moreover, it is important in most cases and represents the bony landmark
to know, what lies beneath the surface, i.e. which for BL2 (Zan Zhu).
morphological structures could be the target of the The infraorbital foramen lies about 2cm below
needling, and, on the other hand, which structures the inferior orbital margin, in a vertical line
should be avoided (e.g. vessels, nerves etc.). through the supraorbital foramen. The infraorbital
artery and nerve leave the skull through this
Landmarks and important acupuncture points of foramen. In most cases the infraorbital foramen
the face (figure 1) can be found in the middle of the total length of
The nasion lies in the midline and represents the the nose and slightly medial to a vertical line
deepest part of the nasal bridge. It is the through the middle of the pupil when looking
connection point between the nasal and the frontal straight forward. The stomach points 1 to 4 are
bones. Slightly above the nasion – between the located on this vertical line. ST2 (Si Bai) lies just
medial end of the eye-brows an important extra above the infraorbital foramen and is needled
point can be found: ExHN3 (Yin Tang) which is 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 thrombosis of the cavernous sinus. It is crucial that
with the lower border of the nose, and ST4 at the routine treatment is carried out in a clinically clean
angle of the mouth. manner. Whether or not swab disinfection reduces
In the nasolabial groove and level with the the possibility of these complications remains
most prominent part of the ala nasi, LI20 (Ying unclear, so far.
Xiang) can be found, which is needled up to 1cm
in the craniomedial direction. Landmarks and important acupuncture points
The mental foramen also lies on the vertical of the side of the face (figure 3-6)
line through the superior and the inferior orbital The zygomatic arch represents an important bony
foramen. It marks the exit of the mental nerve. landmark. In most cases it is palpable in its whole
extent. The second important bony landmark
General remark on safety (figure 2) is the mandible. It consists of different parts.
The venous system of the face has several The condylar process articulates in the
connections to the intracerebral venous system. temporomandibular joint. The motion of the
By needling points in this region, infectious agents condylar process can be felt just in front of the
could be transmitted from the skin surface to the external acoustic meatus. The coronoid process lies
intracerebral regions, causing for example a 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. border of the zygomatic arch is a soft spot which
The ramus of mandible connects the processes and overlies the mandibular notch. In the center of this
the angle of mandible which is usually easy to find. palpable depression ST7 (Xi Guan) is located. In
The ramus and the angle of mandible are covered by the depth of the notch the needle reaches the
a strong masticatory muscle, the masseter. Slightly lateral pterygoid muscle.
cranial and ventral to the angle of the mandible in In the upper border of the temporal muscle,
most cases a small depression can be palpated in the roughly on a vertical line through ST6 and 7, the
masseter. This is related to a divergent course of the point ST8 (Tou Wei) is located. The upper border
muscle fibres and represents the point ST6 (Jia of the temporal muscle can be easily determined
Che). ST5 can be found on the connection between by clenching the teeth.
the anterior border of the masseter and the lower Between the mastoid process and the condylar
border of the mandible, where the pulse of the facial process of mandible, in a depression behind the
artery often can be palpated. ear lobe, the transverse process of the atlas (C1) is
The triangle between the condylar and the palpable. This depression marks the surface
coronoid process of the mandible and the lower localisation of the point TE17 (Yi Feng). As the

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vertebral artery emerges from the transverse located in front of the intertragic notch, SI19
foramen of the atlas and turns backwards, so TE17 (Ting Gong) in a small depression in front of the
should be needled in an anterior direction. In tragus, TE21 (Er Men) at the level of the
contrast to GB20 (see below) deep needling at supratragic notch.
TE17 puts the vertebral artery at significant risk These three points lie over the temporal artery
of injury. and the auriculotemporal nerve, which are
The anterior border of the auricle is dominated susceptible to injury, especially if the points are
by the tragus. Above the tragus we find the needled obliquely in a caudal or cranial direction.
supratragic notch, below the tragus the intertragic
notch. In front of the anterior border of the auricle Landmarks and important acupuncture points
and immediately behind the dorsal portion of the of the dorsal region and the neck (figure 7-8)
condylar process of mandible three acupuncture Bony landmarks of the occipital skull are the
points lie on a vertical line: GB2 (Ting Hui) is 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. manoeuvre, though in cervical rotation some
The first palpable spinous process of the movement of C7 may be detected.
cervical spine belongs to C2 (axis). To relax the The relief of the neck is dominated by the
nuchal ligament the head should be slightly trapezius muscle and the sternocleidomastoid
retroflexed. The vertebral spinous processes of C3 muscle. Between the insertions of these two,
and C4 usually are not palpable. The spinous usually a small depression is palpable. The
processes of C5 and C6 can be found in most trapezius and the sternocleidomastoid overlay the
cases, the spinous process of C7 is often the most semispinalis muscle and the spenius muscle,
prominent one. If it remains unclear which and – in the depth – the obliquus capitis superior
spinous process belongs to C6, C7 and T1, three and inferior muscles, as well as the rectus capitis
fingertips of the examining hand are put on the posterior major and minor muscles.
likely processes, and the head of the patient is GV16 (Feng Fu) is located in the midline
flexed and extended. The spinous processes of C7 below the external occipital protuberance. The
and T1 generally do not move during this 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. Figure 5 These are left lateral and posterior
BL10 is needled perpendicularly. In adults views of C1 and C2, with the position of the
with a normal build the distance between the vertebral artery illustrated passing through the
skin surface and the spinal cord is at least 5-6cm. 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
Figure 6 This is a view of the left side of the head always know where the tip of their needle lies
showing a dissection of the temporal and with respect to the relevant anatomy so that vital
zygomatic arch areas. Key to labels: atn: structures can be avoided and so that the intended
auriculotemporal nerve; fn: facial nerve; pd: target for stimulation can be reached.
parotid duct; mn: mandiblar notch; ta: temporal
Reference list
artery; tm: temporalis muscle; za: zygomatic 1. Choo DCA, Yue G. Acute intracranial hemorrhage caused
arch. Image courtesy of Elmar Peuker. by acupuncture. Headache 2000;40(5):397-8.

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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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