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Elmar T. Peukersenior lecturerDepartment of AnatomyClinical AnatomyDivisionUniversity of MuensterMuenster, Germany

Mike Cummingsmedical directorBMAS

Correspondence:Elmar Peuker

e-peuker@muenster.de

Papers

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

Anatomy for the Acupuncturist – Facts & Fiction1: The head and neck region

Elmar Peuker, Mike Cummings

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

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.

3ACUPUNCTURE IN MEDICINE 2003;21(1-2):2-8.www.medical-acupuncture.co.uk/aimintro.htm

Papers

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

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

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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

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

Papers

5ACUPUNCTURE IN MEDICINE 2003;21(1-2):2-8.www.medical-acupuncture.co.uk/aimintro.htm

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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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

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.

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.

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.

Papers

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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.

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