Graves’ disease is the most common cause of hyperthyroidism [1]. Thyroidectomy is the oldest treatment method for Graves’ disease and reportedly effective as antithyroid drugs and radioactive iodine [2,3]. Additionally, thyroidectomy is usually indicated for large goiters because radioactive iodine treatment alone is insufficient [3]. Superficial cervical plexus block is a simple method of anesthesia, often used in thyroidectomy due to its optimal analgesic effect [4]. Nevertheless, it can elevate blood pressure and heart rate during surgery due to the sympathetic nerve activity enhancement [4]. Alternatively, acupuncture analgesia is effective in managing intraoperative pain and maintaining hemodynamic stability during surgery, particularly thyroid surgery [5-7]. Nonetheless, the use of acupuncture analgesia in previous studies was limited to two acupuncture points, i.e., Hegu (LI4) and Neiguan (PC6). In this case report, we used electroacupuncture to stimulate five acupuncture points, namely, Hegu (LI4), Neiguan (PC6), Shuitu (ST-10), Quepen (ST12), and Yifeng (SJ17), for acupuncture analgesia combined with medications in thyroidectomy. The pain threshold and β-endorphin levels pre- and post-electroacupuncture were compared. This study was exempted from the Institutional Review Board of National Hospital of Acupuncture, Vietnam (IRB-VN01.026), and was conducted in accordance with the STRICTA guidelines.

A 42-year-old female farmer with a 2-year history of Graves’ disease presented to the hospital for a total thyroidectomy for her grade III goiter based on the World Health Organization classification. Prior to admission, the patient was taking propylthiouracil and maintained euthyroidism with TSH and T4 levels of 0.55 (0.4–4.0 mIU/L) and 7.95 ng/dL (0.8–1.8 ng/dL), respectively. Besides the significantly enlarged goiter, the physical examination results were unremarkable. The patient had a heart rate of 80 beats per minute and blood pressure of 120/70 mmHg. She was suitable for total thyroidectomy with acupuncture analgesia because her thyroid hormone levels were normalized preoperatively. Furthermore, euthyroidism is essential to avoid the risk of complications of thyroidectomy [1].

The patient was placed in the supine position, and her neck was extended to expose the goiter in preparation for the surgery. Acupuncture was performed by a highly experienced senior acupuncturist. Acupuncture areas were sterilized with alcohol. In the present case, five acupuncture points were selected for acupuncture analgesia, namely, Hegu (LI4), Neiguan (PC6), Shuitu (ST10), Quepen (ST12), and Yifeng (SJ17), based on the Traditional Chinese Medicine Meridian theory. Needles were inserted bilaterally at these acupuncture points. At Hegu (LI4), a 6-cm needle was inserted obliquely 45° toward the index finger with 2 cm depth. Another 6-cm needle was inserted obliquely 45° toward the proximal end of the upper limb with 3 cm depth at Neiguan (PC6). Needles with 10 cm length were used at Shuitu (ST10), Quepen (ST12), and Yifeng (SJ17). At Shuitu (ST10), a needle was inserted at 6 cm depth and obliquely 45° toward Qishe (ST11). At Quepen (ST12), a needle was inserted at 5 cm depth and at 15°, directing toward Tiantu (CV22). At Yifeng (SJ17), a needle was inserted obliquely 45° toward the goiter with 6 cm depth. After De-qi, needles were connected and stimulated using an electroacupuncture stimulator M7 (National Hospital of Acupuncture) via the dispersing channel. The stimulus was initiated 25 minutes before the surgery and delivered in continued waves at 100 µA intensity and 10 Hz frequency throughout the surgery. Ten minutes before the surgery, the patient was intravenously administered with diazepam (0.2 mg/kg) and atropine sulfate (0.05 mg/kg) to manage perioperative anxiety. The patient remained alert and conscious intraoperatively, and her blood pressure and heart rate were continuously monitored throughout the operation (Fig. 1). Her pain threshold was assessed using Ugo Basile Analgesy meter (Ugo Basile; Randall–Selitto test) (Fig. 2) before and 25 minutes post-electroacupuncture was started. In this case, the pain threshold was 180 and 520 g/s before and 25 minutes after the acupuncture analgesia. In addition to the level of analgesia and pain threshold, the β-endorphin level was measured in this case. Blood samples were collected before acupuncture analgesia was initiated, 25 minutes post-electroacupuncture, and immediately post-surgery. Before acupuncture analgesia, the β-endorphin level was 38.02 pg/mL and increased to 58.04 pg/mL 25 minutes post-electroacupuncture. The β-endorphin level was 56.80 pg/mL immediately post-surgery. Furthermore, our patient underwent surgery without any complications and fully recovered postoperatively.

Figure 1. Changes in systolic blood pressure and heart rate during surgery.

Figure 2. Ugo Basile Analgesy meter (Ugo Basile).

For > 2,500 years, acupuncture has been extensively used in East Asian countries, including China, Japan, Korea, and Vietnam, and is considered a safe and effective analgesic and anesthetic method internationally [8-10]. Zhang et al. [7] performed a systematic review of 18 randomized controlled studies of acupuncture analgesia in thyroid surgery and found that acupuncture was effective in providing analgesia while maintaining the stability of patients’ hemodynamics intraoperatively.

The mechanism of acupuncture analgesia has been characterized by endogenous opioid pathway activation [11-13]. Acupuncture induces the release of enkephalins and dynorphins, preventing pain messages from ascending the spinothalamic tract, and stimulates the pituitary-hypothalamic complex, provoking the systemic release of β-endorphins into the bloodstream [14,15]. β-Endorphin is an endogenous opioid peptide that preferentially binds to the µ-opioid receptor in the central and peripheral nervous systems to relieve pain. The degree of pain experienced by surgical patients was reported to be associated with the plasma β-endorphin level [16]. We measured the β-endorphin level of the patient and found an approximately 1.5-fold increase in the β-endorphin level post-electroacupuncture for 25 minutes. The β-endorphin level remained elevated throughout the surgery and while the patient was undergoing continuous electroacupuncture stimulation. The patient did not require any exogenous opioids toward the termination of the operation. Clinically, the analgesic effect of electroacupuncture was reflected by an increase in the patient’s pain threshold based on the Randall–Selitto test results, nearly a threefold increase (520 vs. 180 g/s) after the patient was stimulated by electroacupuncture for 25 minutes.

Maintaining hemodynamic stability is essential intraoperatively. Pohodenko–Chudakova [17] reported the suppression of stress response during surgery, reflected by the low level of cortisol of patients receiving acupuncture analgesia in maxillofacial surgery. Moreover, using < 50 Hz frequency for antihypertensive effect was suggested by Lu et al. [18]. Based on these findings, we of 10 Hz frequency for our patient undergoing total thyroidectomy, demonstrated by the stability of blood pressure and heart rate of the patient throughout the surgery.

The choice of acupuncture points is critical to effectively produce a significant analgesic effect, whereas the inappropriate selection of acupuncture points may result in adverse results [18]. The use of two acupuncture points, i.e., Hegu (LI4) and Neiguan (PC6), for acupuncture analgesia in thyroid surgery has been well established based on Zhang et al.’s [7] systematic review. Specifically, stimulating bilateral Hegu (LI4) and Neiguan (PC6) successfully exhibited an analgesic effect for 20 patients undergoing thyroid surgery in Peng et al.’s [5] study. We investigated three additional acupuncture points for acupuncture analgesia in thyroid surgery, i.e., Shuitu (ST10), Quepen (ST12), and Yifeng (SJ17). Shuitu (ST10) belongs to the stomach channel, and stimulation in this area will facilitate the management of swelling and pain in the throat, goiter, and shoulder [19]. Meanwhile, stimulating Queben (ST12), belonging to the stomach channel, relieves pain in neck and chest areas and has a calming effect on the mind [19]. Yifeng (SJ17) is the meeting point of Sanjiao and gall bladder channels, and stimulation in this area can regulate Qi of the whole body [19]. Anatomically, Yifeng (SJ17) is in the proximity of stylomastoid foramen, transmitting the facial nerve. The stimulation of Yifeng (SJ17) can therefore produce an analgesic effect on the cervical area of the facial nerve during thyroid surgery [20].

In conclusion, the findings revealed that stimulating five acupuncture points, namely, Hegu (LI4), Neiguan (PC6), Shuitu (ST10), Quepen (ST12), and Yifeng (SJ17), for acupuncture analgesia combined with adjunct medications is safe to maintain an adequate level of analgesia and hemodynamic stability during thyroidectomy. This has been reflected by an appropriate pain threshold, elevated β-endorphin level, and absence of opioid used intraoperatively. Because this is only a case report, its results cannot be generalized. However, further studies with an adequate sample size are needed to confirm the effectiveness of using five acupuncture points in acupuncture analgesia for thyroid surgery.

The author has no conflicts of interest to declare.

None.

This study was exempted from the Institutional Review Board of National Hospital of Acupuncture, Vietnam (IRB-VN01.026), and was conducted in accordance with the STRICTA guidelines.