Xiao-Jie Sun,Yi-Feng Shen,Yan Jia,Zu-Yun Qiu,Qiao-Yin Zhou,Shi-Liang Li

1Department of Acupuncture and Moxibustion, China-Japan Friendship Hospital, No.2, East Yinghua Road, Chaoyang District,Beijing 100029,China.2.Beijing University of Chinese Medicine,No.11,Bei San Huan Dong Road,Chaoyang District,Beijing 100029,China.3Hospital of Chengdu University of Traditional Chinese Medicine,No.39,Shi-er-qiao Road,Chengdu 610072,China.4Fujian University of Traditional Chinese Medicine,Fuzhou 350122,China.

Abstract

Keywords:Upper back pain,Acupotomy,Ultrasound-guidance,Muscle injury

Background

The rhomboid muscle and serratus posterior superior muscle injury, a dynamic imbalance caused by acute and chronic muscle tissue damage and chronic aseptic inflammation, is common cause of back pain.Patients with upper back pain often complain about severe,repeated pain, which usually take place at night.The pain extends from the thoracic vertebrae to the scapula.Symptoms include a heavy feeling in the scapular spine and rib surfaces, with or without thoracic para-vertebral pain.Most patients present with tenderness on the spine from C6 to T4 (the sixth cervical to the fourth chest vertebrae).The ribs and the scapula spine are positive for tenderness and could be indurated.Pain can be induced by flexion adduction or external rotation of the affected upper extremity.It's mostly caused by long-term abnormal posture,coldness and other reasons.The disease occurs in people who work in the sitting position for prolonged periods at desks,especially workers who are in front of the computer for a long time, in those with poor posture, or in those who pick heavy objects [1].The rhomboid muscle is more susceptible to injury than other back muscles [2].It is often used to treat this disease with anti-inflammatory and analgesic drugs in western medicine, and acupuncture in traditional Chinese medicine.However, the curative effect is average, and the side effect of long-term use with drugs is obvious.

Acupotomy needle is a combination of acupuncture needle and scalpel (Figure 1).Acupotomy treatment involves reaching the adhesion site, loosening the adhesion, scar or contracture.By this way, the elasticity and mobility of muscle tissue can be restored which help to improve the local blood circulation.All these together will relieve the pain efficiently [3-5].But it is easy for clinicians who are not familiar to the special anatomical location of the upper back to cause serious adverse events such as pneumothorax and hemothorax [6].Ultrasound guidance is a useful way to observe the anatomical structures clearly and it also improves the safety of the surgery [7].We present a patient with back pain who was cured by acupotomy with the guidance of ultrasound, focusing on the anatomical ultrasound images and application.

Case presentation

A 56-year-old woman came to our hospital because of right upper back pain for more than 10 years.There was no obvious reason for the pain.The pain was initially mild and gradually increased.The site of the pain was between the medial scapula and spine and it was irregular without relationship with specific time and position.The pian would relieve with rest but aggregate with exertion.Once the pain occured it would be last 2-3 hours each time.Even with acupuncture, external plaster application and physiotherapy the symptom was still obvious.Her Visual Analogue Score (VAS) was 7 and there was a slightly prominent between the fourth and fifth cervical disc.There was no other basic disease of the patient.Comprehensive the symptoms and examination she was diagnosed as rhomboid muscle and serratus posterior superior muscle injury.

Figure 1 Image of acupuncture needle and acupotomy needle.

The patient was performed with ultrasound-guided acupotomy treatment in prone position.Seven treatment points were identified by the method of compression of the positive reaction point performed across C6 to T4 (the sixth cervical to the fourth chest vertebrae) (Figure 2).And then, ultrasound scanning localized four treatment points on the rib surface with three treatment points located between the ribs (Figure 3 and Figure 4).

Figure 2 Acupotomy treatment.We marked 7 treatment points based on the patient's pain points before treatment(A).After ultrasound scans, it was found that 3 points were unsafe between the ribs.Finally, we used 4 treatment points on the rib surface(B).

Figure 3 Ultrasonic image of the acupotomy treatment point between the ribs.

Figure 4 Contrast the acupotomy treatment point on the rib surface and between the ribs

Figure 5 The process of the acupotomy treatment

After labeling and routine iodophor disinfection,local anesthetic injection (local anesthesia with lidocaine) was administered to the rib surface, but not into the intercostal space.

Ultrasound-guided acupotomy treatment was performed with four safe treatment points on the surface of the rib and the operator's left thumb pressed on the fixed position of the medial edge of the scapula.At the same time, the right hand-held I-type 4 acupotomy was placed so that the needle body was perpendicular to the medial edge of the scapula(Figure 5).The bone surface was determined by the left hand pressing the hand,and acupotomy was pierced into the skin until it reached the bone surface of the scapula,and the blade edge was slowly moved to the medial edge of the scapula.At this position,acupotomy of 3-4 mm was gently performed, and then cut to the bone edge, to cut off a small amount of diamond-shaped muscle attachment point fibers.This was done to fully reduce the tension and loosen the lesions such as scars and fibrosis which may exist,with 4-5 times per point.Whenever there was a feeling of looseness under the hand, the needle was pulled out, the skin was pressed,and the blood was stopped.Aseptic dressing was then applied.

With ultrasound-guided acupotomy treatment, the pain of the patient was relieved significantly, and the VAS score decreased from 7 to 2.The patient received the same treatment one week after.The pain disappeared completely one month after the last treatment.

Discussion

Due to improper selection of treatment sites, there are many adverse events during needle acupuncture and acupuncture treatment.It is essential to make clear the depth, direction and angle of the needle in the acupotomy or acupuncture when perform the operation.The lung is 10-20 mm under the skin of the scapula or the midline of the clavicle.It is easily to cause pneumothorax if acupotomy or acupuncture is performed without accuracy of depth, direction and angle of the needle.Serious adverse events such as iatrogenic injury leading to pneumothorax and hemothorax have been reported[8,9].

The traditional acupotomy treatment involves a“blind knife” treatment, that is, a closed treatment including cutting, peeling, and dredging performed without internal visualization, requiring the doctor to rely on his own clinical experience with differences in resistance encountered by the hand during acupotomy.With“needle sense”,“empty feeling”,and the patient's intraoperative sensory feedback to guide the operation,the operator combines the resistance encountered during needle surgery with his knowledge of the anatomy to avoid nerves and blood vessels and reach the target tissue.This requires the practitioners to have a very solid knowledge base and excellent technology[7, 10].However, due to the complex structure of the human body and the possible abnormalities in the physiological and pathological structure in some patients, the chances of injury to the vital structures during surgery are still high.Chen has reported the pneumothorax and hemothorax in the rhomboid muscle and serratus posterior superior muscle injury after“blind knife” treatment[6], emphasizing the need for special attention to precision during acupotomy.Therefore, prevention of iatrogenic complications is essential.

Visualization of acupuncture and acupotomy is the best way to improve the safety of the acupotomy operation.Treatment of the points such as those found in this case (three treatment points located between the ribs) without ultrasound guidance can easily lead to pneumothorax.With the development of ultrasound technology, ultrasound guidance for acupotomy and acupuncture has been suggested[7,10,11].Ultrasound visualization can be performed before treatment,during local anesthesia, for the localization of the treatment points, acupotomy release, and for the real-time visualization of the acupuncture operation.Ultrasound scanning can be used to clearly observe the anatomical structures to avoid blood vessels, nerves,and organ tissues, distinguish diseased tissues, assist with diagnosis, and accurately locate the therapeutic targets.Additionally, it can monitor the trend and spread of drugs after injection, and improve the safety of release targets.Acupotomy may be accurately released in the anesthetized position to reduce the pain when it is ultrasound guided.

Conclusion

In summary, ultrasound guidance not only improves the safety of invasive treatment, but also reduces the pain caused by the realization of target treatment,promotes the development of therapeutic effects,contributes significantly to teaching and research, and enables acupotomy therapy to be more precise and standardized.