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Journal of Acupuncture Research 2024; 41(2): 135-141

Published online May 31, 2024

https://doi.org/10.13045/jar.24.0004

© Korean Acupuncture & Moxibustion Medicine Society

Performing Ultrasound-Guided Pharmacopuncture and Acupotomy for Nerve Entrapment in the Upper Extremity: A Guide for Teaching Procedural Skills

Taeseong Jeong1,2 , Eunbyul Cho3 , Sungha Kim3 , Seunghyun Oh1,2 , Suhak Kim4 , Jeongsu Park4 , Sungchul Kim1,2

1Department of Acupuncture & Moxibustion Medicine, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea
2Nervous & Muscular System Disease Clinical Research Center, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea
3KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea
4Department of Korean Medicine Rehabilitation, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea

Correspondence to : Sungchul Kim
Department of Acupuncture & Moxibustion Medicine, Wonkwang University Gwangju Korean Medical Hospital, 1140-23 Hoejae-ro, Nam-gu, Gwangju 61729, Korea
E-mail: kscndl@naver.com

Received: April 9, 2024; Revised: May 13, 2024; Accepted: May 27, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The use of ultrasound (US)-guided interventions has rapidly increased in Korean medicine (KM) to ensure the safety and accuracy of invasive procedures, such as pharmacopuncture and acupotomy. Although hands-on training is important for the acquisition of skills, it requires considerable time and cost. A detailed guide on the procedure and treatment regions is needed to ensure hygiene and safety during US-guided procedures in KM practice. In this study, we present the overall procedure, target structures, and treatment approaches of US-guided pharmacopuncture and acupotomy for nerve entrapment in the upper extremities of the cubital and radial tunnel, posterior interosseous nerve, carpal tunnel, and Guyon’s canal syndrome. We believe that the findings of our study will serve as a foundation for future clinical research, practice, and education on US-guided KM procedures. Further research involving US-guided interventions should specify target structures in three-dimension to delineate the treatment areas.

Keywords Acupotomy; Korean medicine; Nerve entrapment; Pharmacopuncture; Ultrasonography

The use of ultrasound (US) to improve accuracy and safety during invasive procedures has rapidly increased in healthcare worldwide [1,2]. It is commonly applied by Korean medicine doctors (KMDs) who use treatment modalities, such as acupuncture, pharmacopuncture, and acupotomy, to stimulate the deeper parts of the body. Recently, US-guided procedures have been increasingly introduced in KMD continuing education to practice popular treatment points [3]. US training is also included in the undergraduate KM curriculum to determine the anatomy of acupuncture points and practice procedures [4,5]. However, despite the high demand for hands-on training in the US, considerable time and cost are required because one instructor can handle only a few students [6]. Instructions on basic US-guided procedures, primarily focusing on the clean needle technique, are needed to guide beginners and facilitate efficient hands-on learning. Lee et al. [7] established a protocol for US-guided acupotomy procedures; however, detailed guidelines for placing the probe in the treatment areas and stimulating specific structures are yet to be established. In this study, we present overall procedure of consecutive US-guided pharmacopuncture and acupotomy, as well as target anatomical structures and real-world techniques for nerve entrapment in the upper extremities, which can be used in KM practice. We have also detailed the steps for the procedure to contribute to the skill acquisition of KMD [8]. This technique is being performed at Wonkwang University Korean Medical Hospital, and the hospital has performed approximately 30,000 clinical procedures using US since 2014.

Before the procedure, hand hygiene should be performed, which includes the following six steps: washing of the palms, back of hands, between the fingers, back of the fingers, thumbs, and under nails [9]. Sterile gloves should be worn. When wearing gloves, care should be taken to avoid contamination outside the gloves [9]. The probe is wrapped with a surgical sterile drape to maintain sterility and disinfected with povidone-iodine. The treatment area should be disinfected with povidone-iodine. After drying, the povidone-iodine solution is redisinfected with alcohol swabs. The US marker is placed on the right side of the patient during the transverse scan and cranially during the longitudinal scan. Pharmacopuncture (Scolopendrid, 0.5–1 mL) is performed using a disposable syringe (26 gauge, 60 mm) near the entrapped nerve, followed by acupotomy with manipulation for additional stimulation, which allowed the fluid to diffuse along the needle into the affected area. When approaching a nerve, the needle should be inserted slowly to prevent iatrogenic nerve injury. Moreover, the needle should be retracted if the patient feels any discomfort during the procedure. After the acupotomy is completed, wet cupping is performed for 5 minutes using a cupping cup to loosen the adhesions; remove excess blood, waste, and toxins from the body; and promote blood circulation to the skin and muscles [10]. Subsequently, it should be checked whether bleeding has stopped. If bleeding persists, manual pressure should be applied for approximately 1 minute. Furthermore, once the bleeding stops, an injection care band is applied to the treated area.

Fig. 1 shows sterilization of the treatment area before and after pharmacopuncture and acupotomy. The specific method for adjusting the US screen and tracking the needle for US-guided acupotomy is described in the Supplementary Material 1.

Fig. 1. Overall procedure for ultrasound-guided intervention in Korean medicine. (A) Potadine disinfection of the probe, (B) elbow treatment area, and (C) wrist treatment area. (D) Wet cupping for 5 minutes using a disposable cup after the procedure. (E) After disinfecting the injection site and ensuring that bleeding has stopped, an injection care band is attached.

We have described the instructions for performing US scans, identifying the target structures for pharmacopuncture and acupotomy, and the step-by-step procedures for common nerve entrapment syndromes in the upper extremities (Table 1).

Table 1 . Summary of upper extremity nerve entrapment sites and treatment points

Nerve entrapment in the upper extremityEntrapped nerveAcupuncture points for treatingTarget anatomical structures for acupotomy
Cubital tunnel syndromeUlnar nerveSI 8 (distal)Humeroulnar aponeurotic arcade, Osborne’s ligament, and fascia
Radial tunnel syndromeRadial nerveLU 5Fibrous bands between the brachioradialis and brachialis, fibrous edge of the ECRB (grooves the nerve when the forearm is pronated)
PIN syndromeRadial nerve (PIN)LI 10Arcade of Frohse, supinator
Carpal tunnel syndromeMedian nervePC 7 (distal)Transverse carpal ligament
Guyon’s canal syndromeUlnar nerveHT 7 (distal)Palmar carpal ligament

ECRB, extensor carpi radialis brevis; PIN, posterior interosseous nerve.



1. Cubital tunnel syndrome

While the patient is lying in the supine position, with the forearm supinated, elbow joint extended, and shoulder joint 30–45° abducted, a US examination of the medial elbow is performed using a high-resolution linear array transducer. Moreover, the transducer is applied transversely between the olecranon process and medial epicondyle. The two regions where the ulnar nerve can be compressed are the retroepicondylar groove and humeroulnar aponeurotic arcade, which is the connective tissue between the flexor carpi ulnaris (FCU) and superficial flexor muscles [11]. After identifying the retroepicondylar groove, the probe is moved from 5 mm to 1 cm distally to identify the superficial ulnar collateral artery between the FCU heads and ulnar nerve at the rear [12].

The ulnar nerve is targeted with a pharmacopuncture needle inserted distal to the transducer and advanced out-of-plane to the retroepicondylar groove at an angle of 45–60° from the skin, and approximately 1 mL of Scolopendrid solution is injected. Thereafter, the acupotomy needle blade is positioned parallel to the direction of the nerve (advanced from inferomedial to superolateral) out-of-plane to Osborne’s ligament, fascia, and humeroulnar aponeurotic arcade and stimulated by moving the needle back and forth to diffuse the solution along the needle and into the entrapment lesion (Supplementary Fig. 1).

2. Radial tunnel syndrome

While the patient was lying in the supine position, with the forearm supinated, elbow joint extended, and shoulder joint adducted, US examination of the lateral forearm is performed. The transducer is applied transversely and moved laterally at the level of the elbow crease, such that the radius is at the center. The radial tunnel is the space between the radiocapitellar joint and distal edge of the superficial head of the supinator [13]. The fibrous band at the level of the radial head, which is the structure of the radial tunnel, radial recurrent artery (leash of Henry), fibrous edge of the extensor carpi radialis brevis (ECRB), and arcade of Frohse, are potential sites of radial nerve compression [13,14]. When the transducer is moved distally from the radial nerve between the brachioradialis and brachialis, the nerve branches into the superficial radial nerve and deep branch of the radial nerve before traveling to the arcade of Frohse.

The needle is inserted distal to the transducer, advanced from lateral to medial, out-of-plane, under real-time US, which is targeted near the radial nerve at an angle of 45–60° from the skin, injecting approximately 1 mL of the solution. The acupotomy needle blade is then positioned parallel to the direction of the nerve to stimulate the fibrous bands between the brachialis and brachioradialis muscles and to diffuse the solution into the entrapment lesion. Furthermore, the fibrous edge of the ECRB cannot be observed in the supine position because it grooves the nerve when the forearm is pronated. Thus, the forearm should be pronated to treat the fibrous edges of the ECRB (Supplementary Fig. 2) [15].

3. Posterior interosseous nerve syndrome

The patient is placed in the supine position with the forearm pronated, elbow joint extended, and shoulder joint adducted. Short-axis views of the lateral and distal elbow creases are obtained. The posterior interosseous nerve (PIN) is compressed primarily at the arcade of Frohse, the proximal ligamentous margin, between the superficial and deep layers of the supinator muscle. The PIN can also be compressed at the distal ligamentous margins of the supinator muscles [15]. PIN is identified between the two layers of the supinator muscle below the brachioradialis muscle [16].

The needle is then inserted distal to the transducer, advanced from distal to proximal, out-of-plane, and targeted near the PIN at an angle of 45–60° from the skin, injecting approximately 1 mL of the solution. Subsequently, the acupotomy needle blade is positioned parallel to the direction of the nerve to stimulate the arcade of Frohse and supinator muscles to diffuse the solution into the entrapped lesions. Since stimulating the PIN can be challenging in determining the patient’s De-qi, as it is primarily a motor nerve, special care should be taken to prevent nerve damage during the procedure (Fig. 2) [15].

Fig. 2. Ultrasound (US)-guided pharmacopuncture and acupotomy for PIN syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near LI10 and (B) US-guided acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near LI10. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. Lat., lateral; ECRL, extensor carpi radialis longus; PIN, posterior interosseous nerve; Med., medial; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; Sup, supinator; NGS, needle guidance solution.

4. Carpal tunnel syndrome

The patient is placed in the supine position with the forearm supinated and the wrist joint extended. The scaphoid and pisiform are bony structures representing the proximal carpal tunnels. The median nerve is a low-echo oval structure beneath the transverse carpal ligament (TCL), which forms the roof of the carpal tunnel [17].

The needle is inserted distal to the transducer, advanced from distal to proximal, out-of-plane, passed through the TCL, and targeted near the median nerve at an angle of 30–45° from the skin, injecting approximately 0.5 mL of the solution. Thereafter, the acupotomy needle blade is positioned parallel to the direction of the nerve to stimulate the TCL and diffuse the solution. Therefore, acupotomy should be performed while monitoring patient discomfort owing to the risk of nerve damage during nerve stimulation (Fig. 3).

Fig. 3. Ultrasound (US)-guided pharmacopuncture and acupotomy for carpal tunnel syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near PC7 and (B) acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near PC7. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane below the TCL, near the median nerve at the level of the proximal carpal tunnel. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for TCL at the level of the proximal carpal tunnel. N, nerve; TCL, transverse carpal ligament; UA, ulnar artery; S, scaphoid; FT, flexor tendons; P, pisiform.

5. Guyon’s canal syndrome

With the patient lying in the supine position, forearm supinated, and wrist joint extended, the transducer is applied transversely between the pisiform and hamate. Guyon’s canal is an oblique fibular tunnel approximately 4 cm long between the hamate hook and pisiform, with the PCL located proximal to the tunnel. The ulnar nerve can be identified by using the ulnar artery as a landmark, as it is located between the hamate and the ulnar artery [18].

The needle is inserted medial to the transducer and advanced from medial to lateral, out-of-plane, under real-time ultrasonography, targeting near the ulnar nerve at an angle of 30–45° from the skin. Approximately 0.5 mL of the solution is administered. The acupotomy needle blade is then positioned parallel to the direction of the nerve to stimulate PCL and diffuse the solution into the entrapment lesion. Furthermore, acupotomy should be performed with caution to avoid nerve damage during nerve stimulation (Supplementary Fig. 3).

Although previous clinical KM studies have performed pharmacopuncture on the nerve pathways for nerve entrapment syndromes, none have performed pharmacopuncture while observing the nerve in real-time [19]. The present study provides step-by-step procedures to safely and accurately perform sequential US-guided pharmacopuncture and acupotomy for common upper extremity nerve entrapment with real-time US imaging of the target nerves and nerve-compressing structures. Moreover, US-guided in-plane procedures provide complete view of the needle. However, their usefulness in treating superficial structures is limited by the length of the path of the needle through the structure. The findings of this study suggest the use of US-guided out-of-plane pharmacopuncture and acupotomy with a needle-guiding system for treating of peripheral nerve entrapment syndromes. Although puncturing the peripheral nerves during US-guided axillary block does not lead to neurological deficits [20], the needle tip should be thoroughly examined during the procedure to prevent unnecessary nerve damage. While KM clinical studies have primarily reported treatment sites as acupuncture points on a two-dimensional surface, the use of US allowed the identification of structures stimulated by needle tips. Future clinical studies of US-guided procedures need to specify not only the acupuncture points and anatomy of the treatment area but also the structures targeted by the modalities to better evaluate and describe the effects of stimulating those structures. Furthermore, it is anticipated that standardized protocols will be developed and spread through consensus among experts based on various clinical US studies.

Conceptualization: TJ, EC, Sungchul Kim. Data curation: TJ, Sungchul Kim, SO. Formal analysis: TJ, EC. Funding acquisition: Sungha Kim. Investigation: TJ, EC. Methodology: TJ, EC, Sungchul Kim. Supervision: Sungha Kim, Sungchul Kim. Visualization: TJ, EC. Writing – original draft: TJ, EC. Writing – review & editing: All authors.

The corresponding author participated in the development of the ultrasound device to track the acupuncture needles used in this study but has no financial interest in the device.

The authors have no conflicts of interest to declare.

This work was funded by the Korea Institute of Oriental Medicine (KSN2121211). The funding source had no input regarding the interpretation or publication of the study’s results.

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Article

Short Communication

Journal of Acupuncture Research 2024; 41(2): 135-141

Published online May 31, 2024 https://doi.org/10.13045/jar.24.0004

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

Performing Ultrasound-Guided Pharmacopuncture and Acupotomy for Nerve Entrapment in the Upper Extremity: A Guide for Teaching Procedural Skills

Taeseong Jeong1,2 , Eunbyul Cho3 , Sungha Kim3 , Seunghyun Oh1,2 , Suhak Kim4 , Jeongsu Park4 , Sungchul Kim1,2

1Department of Acupuncture & Moxibustion Medicine, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea
2Nervous & Muscular System Disease Clinical Research Center, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea
3KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea
4Department of Korean Medicine Rehabilitation, Wonkwang University Gwangju Korean Medical Hospital, Gwangju, Korea

Correspondence to:Sungchul Kim
Department of Acupuncture & Moxibustion Medicine, Wonkwang University Gwangju Korean Medical Hospital, 1140-23 Hoejae-ro, Nam-gu, Gwangju 61729, Korea
E-mail: kscndl@naver.com

Received: April 9, 2024; Revised: May 13, 2024; Accepted: May 27, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The use of ultrasound (US)-guided interventions has rapidly increased in Korean medicine (KM) to ensure the safety and accuracy of invasive procedures, such as pharmacopuncture and acupotomy. Although hands-on training is important for the acquisition of skills, it requires considerable time and cost. A detailed guide on the procedure and treatment regions is needed to ensure hygiene and safety during US-guided procedures in KM practice. In this study, we present the overall procedure, target structures, and treatment approaches of US-guided pharmacopuncture and acupotomy for nerve entrapment in the upper extremities of the cubital and radial tunnel, posterior interosseous nerve, carpal tunnel, and Guyon’s canal syndrome. We believe that the findings of our study will serve as a foundation for future clinical research, practice, and education on US-guided KM procedures. Further research involving US-guided interventions should specify target structures in three-dimension to delineate the treatment areas.

Keywords: Acupotomy, Korean medicine, Nerve entrapment, Pharmacopuncture, Ultrasonography

INTRODUCTION

The use of ultrasound (US) to improve accuracy and safety during invasive procedures has rapidly increased in healthcare worldwide [1,2]. It is commonly applied by Korean medicine doctors (KMDs) who use treatment modalities, such as acupuncture, pharmacopuncture, and acupotomy, to stimulate the deeper parts of the body. Recently, US-guided procedures have been increasingly introduced in KMD continuing education to practice popular treatment points [3]. US training is also included in the undergraduate KM curriculum to determine the anatomy of acupuncture points and practice procedures [4,5]. However, despite the high demand for hands-on training in the US, considerable time and cost are required because one instructor can handle only a few students [6]. Instructions on basic US-guided procedures, primarily focusing on the clean needle technique, are needed to guide beginners and facilitate efficient hands-on learning. Lee et al. [7] established a protocol for US-guided acupotomy procedures; however, detailed guidelines for placing the probe in the treatment areas and stimulating specific structures are yet to be established. In this study, we present overall procedure of consecutive US-guided pharmacopuncture and acupotomy, as well as target anatomical structures and real-world techniques for nerve entrapment in the upper extremities, which can be used in KM practice. We have also detailed the steps for the procedure to contribute to the skill acquisition of KMD [8]. This technique is being performed at Wonkwang University Korean Medical Hospital, and the hospital has performed approximately 30,000 clinical procedures using US since 2014.

OVERALL PROCEDURE FOR US-GUIDED PHARMACOPUNCTURE AND ACUPOTOMY

Before the procedure, hand hygiene should be performed, which includes the following six steps: washing of the palms, back of hands, between the fingers, back of the fingers, thumbs, and under nails [9]. Sterile gloves should be worn. When wearing gloves, care should be taken to avoid contamination outside the gloves [9]. The probe is wrapped with a surgical sterile drape to maintain sterility and disinfected with povidone-iodine. The treatment area should be disinfected with povidone-iodine. After drying, the povidone-iodine solution is redisinfected with alcohol swabs. The US marker is placed on the right side of the patient during the transverse scan and cranially during the longitudinal scan. Pharmacopuncture (Scolopendrid, 0.5–1 mL) is performed using a disposable syringe (26 gauge, 60 mm) near the entrapped nerve, followed by acupotomy with manipulation for additional stimulation, which allowed the fluid to diffuse along the needle into the affected area. When approaching a nerve, the needle should be inserted slowly to prevent iatrogenic nerve injury. Moreover, the needle should be retracted if the patient feels any discomfort during the procedure. After the acupotomy is completed, wet cupping is performed for 5 minutes using a cupping cup to loosen the adhesions; remove excess blood, waste, and toxins from the body; and promote blood circulation to the skin and muscles [10]. Subsequently, it should be checked whether bleeding has stopped. If bleeding persists, manual pressure should be applied for approximately 1 minute. Furthermore, once the bleeding stops, an injection care band is applied to the treated area.

Fig. 1 shows sterilization of the treatment area before and after pharmacopuncture and acupotomy. The specific method for adjusting the US screen and tracking the needle for US-guided acupotomy is described in the Supplementary Material 1.

Figure 1. Overall procedure for ultrasound-guided intervention in Korean medicine. (A) Potadine disinfection of the probe, (B) elbow treatment area, and (C) wrist treatment area. (D) Wet cupping for 5 minutes using a disposable cup after the procedure. (E) After disinfecting the injection site and ensuring that bleeding has stopped, an injection care band is attached.

US-GUIDED PHARMACOPUNCTURE AND ACUPOTOMY FOR INDIVIDUAL NERVE ENTRAPMENT

We have described the instructions for performing US scans, identifying the target structures for pharmacopuncture and acupotomy, and the step-by-step procedures for common nerve entrapment syndromes in the upper extremities (Table 1).

Table 1 . Summary of upper extremity nerve entrapment sites and treatment points.

Nerve entrapment in the upper extremityEntrapped nerveAcupuncture points for treatingTarget anatomical structures for acupotomy
Cubital tunnel syndromeUlnar nerveSI 8 (distal)Humeroulnar aponeurotic arcade, Osborne’s ligament, and fascia
Radial tunnel syndromeRadial nerveLU 5Fibrous bands between the brachioradialis and brachialis, fibrous edge of the ECRB (grooves the nerve when the forearm is pronated)
PIN syndromeRadial nerve (PIN)LI 10Arcade of Frohse, supinator
Carpal tunnel syndromeMedian nervePC 7 (distal)Transverse carpal ligament
Guyon’s canal syndromeUlnar nerveHT 7 (distal)Palmar carpal ligament

ECRB, extensor carpi radialis brevis; PIN, posterior interosseous nerve..



1. Cubital tunnel syndrome

While the patient is lying in the supine position, with the forearm supinated, elbow joint extended, and shoulder joint 30–45° abducted, a US examination of the medial elbow is performed using a high-resolution linear array transducer. Moreover, the transducer is applied transversely between the olecranon process and medial epicondyle. The two regions where the ulnar nerve can be compressed are the retroepicondylar groove and humeroulnar aponeurotic arcade, which is the connective tissue between the flexor carpi ulnaris (FCU) and superficial flexor muscles [11]. After identifying the retroepicondylar groove, the probe is moved from 5 mm to 1 cm distally to identify the superficial ulnar collateral artery between the FCU heads and ulnar nerve at the rear [12].

The ulnar nerve is targeted with a pharmacopuncture needle inserted distal to the transducer and advanced out-of-plane to the retroepicondylar groove at an angle of 45–60° from the skin, and approximately 1 mL of Scolopendrid solution is injected. Thereafter, the acupotomy needle blade is positioned parallel to the direction of the nerve (advanced from inferomedial to superolateral) out-of-plane to Osborne’s ligament, fascia, and humeroulnar aponeurotic arcade and stimulated by moving the needle back and forth to diffuse the solution along the needle and into the entrapment lesion (Supplementary Fig. 1).

2. Radial tunnel syndrome

While the patient was lying in the supine position, with the forearm supinated, elbow joint extended, and shoulder joint adducted, US examination of the lateral forearm is performed. The transducer is applied transversely and moved laterally at the level of the elbow crease, such that the radius is at the center. The radial tunnel is the space between the radiocapitellar joint and distal edge of the superficial head of the supinator [13]. The fibrous band at the level of the radial head, which is the structure of the radial tunnel, radial recurrent artery (leash of Henry), fibrous edge of the extensor carpi radialis brevis (ECRB), and arcade of Frohse, are potential sites of radial nerve compression [13,14]. When the transducer is moved distally from the radial nerve between the brachioradialis and brachialis, the nerve branches into the superficial radial nerve and deep branch of the radial nerve before traveling to the arcade of Frohse.

The needle is inserted distal to the transducer, advanced from lateral to medial, out-of-plane, under real-time US, which is targeted near the radial nerve at an angle of 45–60° from the skin, injecting approximately 1 mL of the solution. The acupotomy needle blade is then positioned parallel to the direction of the nerve to stimulate the fibrous bands between the brachialis and brachioradialis muscles and to diffuse the solution into the entrapment lesion. Furthermore, the fibrous edge of the ECRB cannot be observed in the supine position because it grooves the nerve when the forearm is pronated. Thus, the forearm should be pronated to treat the fibrous edges of the ECRB (Supplementary Fig. 2) [15].

3. Posterior interosseous nerve syndrome

The patient is placed in the supine position with the forearm pronated, elbow joint extended, and shoulder joint adducted. Short-axis views of the lateral and distal elbow creases are obtained. The posterior interosseous nerve (PIN) is compressed primarily at the arcade of Frohse, the proximal ligamentous margin, between the superficial and deep layers of the supinator muscle. The PIN can also be compressed at the distal ligamentous margins of the supinator muscles [15]. PIN is identified between the two layers of the supinator muscle below the brachioradialis muscle [16].

The needle is then inserted distal to the transducer, advanced from distal to proximal, out-of-plane, and targeted near the PIN at an angle of 45–60° from the skin, injecting approximately 1 mL of the solution. Subsequently, the acupotomy needle blade is positioned parallel to the direction of the nerve to stimulate the arcade of Frohse and supinator muscles to diffuse the solution into the entrapped lesions. Since stimulating the PIN can be challenging in determining the patient’s De-qi, as it is primarily a motor nerve, special care should be taken to prevent nerve damage during the procedure (Fig. 2) [15].

Figure 2. Ultrasound (US)-guided pharmacopuncture and acupotomy for PIN syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near LI10 and (B) US-guided acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near LI10. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. Lat., lateral; ECRL, extensor carpi radialis longus; PIN, posterior interosseous nerve; Med., medial; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; Sup, supinator; NGS, needle guidance solution.

4. Carpal tunnel syndrome

The patient is placed in the supine position with the forearm supinated and the wrist joint extended. The scaphoid and pisiform are bony structures representing the proximal carpal tunnels. The median nerve is a low-echo oval structure beneath the transverse carpal ligament (TCL), which forms the roof of the carpal tunnel [17].

The needle is inserted distal to the transducer, advanced from distal to proximal, out-of-plane, passed through the TCL, and targeted near the median nerve at an angle of 30–45° from the skin, injecting approximately 0.5 mL of the solution. Thereafter, the acupotomy needle blade is positioned parallel to the direction of the nerve to stimulate the TCL and diffuse the solution. Therefore, acupotomy should be performed while monitoring patient discomfort owing to the risk of nerve damage during nerve stimulation (Fig. 3).

Figure 3. Ultrasound (US)-guided pharmacopuncture and acupotomy for carpal tunnel syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near PC7 and (B) acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near PC7. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane below the TCL, near the median nerve at the level of the proximal carpal tunnel. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for TCL at the level of the proximal carpal tunnel. N, nerve; TCL, transverse carpal ligament; UA, ulnar artery; S, scaphoid; FT, flexor tendons; P, pisiform.

5. Guyon’s canal syndrome

With the patient lying in the supine position, forearm supinated, and wrist joint extended, the transducer is applied transversely between the pisiform and hamate. Guyon’s canal is an oblique fibular tunnel approximately 4 cm long between the hamate hook and pisiform, with the PCL located proximal to the tunnel. The ulnar nerve can be identified by using the ulnar artery as a landmark, as it is located between the hamate and the ulnar artery [18].

The needle is inserted medial to the transducer and advanced from medial to lateral, out-of-plane, under real-time ultrasonography, targeting near the ulnar nerve at an angle of 30–45° from the skin. Approximately 0.5 mL of the solution is administered. The acupotomy needle blade is then positioned parallel to the direction of the nerve to stimulate PCL and diffuse the solution into the entrapment lesion. Furthermore, acupotomy should be performed with caution to avoid nerve damage during nerve stimulation (Supplementary Fig. 3).

Although previous clinical KM studies have performed pharmacopuncture on the nerve pathways for nerve entrapment syndromes, none have performed pharmacopuncture while observing the nerve in real-time [19]. The present study provides step-by-step procedures to safely and accurately perform sequential US-guided pharmacopuncture and acupotomy for common upper extremity nerve entrapment with real-time US imaging of the target nerves and nerve-compressing structures. Moreover, US-guided in-plane procedures provide complete view of the needle. However, their usefulness in treating superficial structures is limited by the length of the path of the needle through the structure. The findings of this study suggest the use of US-guided out-of-plane pharmacopuncture and acupotomy with a needle-guiding system for treating of peripheral nerve entrapment syndromes. Although puncturing the peripheral nerves during US-guided axillary block does not lead to neurological deficits [20], the needle tip should be thoroughly examined during the procedure to prevent unnecessary nerve damage. While KM clinical studies have primarily reported treatment sites as acupuncture points on a two-dimensional surface, the use of US allowed the identification of structures stimulated by needle tips. Future clinical studies of US-guided procedures need to specify not only the acupuncture points and anatomy of the treatment area but also the structures targeted by the modalities to better evaluate and describe the effects of stimulating those structures. Furthermore, it is anticipated that standardized protocols will be developed and spread through consensus among experts based on various clinical US studies.

SUPPLEMENTARY MATERIALS

AUTHOR CONTRIBUTIONS

Conceptualization: TJ, EC, Sungchul Kim. Data curation: TJ, Sungchul Kim, SO. Formal analysis: TJ, EC. Funding acquisition: Sungha Kim. Investigation: TJ, EC. Methodology: TJ, EC, Sungchul Kim. Supervision: Sungha Kim, Sungchul Kim. Visualization: TJ, EC. Writing – original draft: TJ, EC. Writing – review & editing: All authors.

CONFLICTS OF INTEREST

The corresponding author participated in the development of the ultrasound device to track the acupuncture needles used in this study but has no financial interest in the device.

The authors have no conflicts of interest to declare.

FUNDING

This work was funded by the Korea Institute of Oriental Medicine (KSN2121211). The funding source had no input regarding the interpretation or publication of the study’s results.

ETHICAL STATEMENT

The figures were acquired from the authors who participated in this study and provided voluntary consent for publication.

Fig 1.

Figure 1.Overall procedure for ultrasound-guided intervention in Korean medicine. (A) Potadine disinfection of the probe, (B) elbow treatment area, and (C) wrist treatment area. (D) Wet cupping for 5 minutes using a disposable cup after the procedure. (E) After disinfecting the injection site and ensuring that bleeding has stopped, an injection care band is attached.
Journal of Acupuncture Research 2024; 41: 135-141https://doi.org/10.13045/jar.24.0004

Fig 2.

Figure 2.Ultrasound (US)-guided pharmacopuncture and acupotomy for PIN syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near LI10 and (B) US-guided acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near LI10. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for a deep branch of radial nerve exiting the supinator muscle as the PIN. Lat., lateral; ECRL, extensor carpi radialis longus; PIN, posterior interosseous nerve; Med., medial; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; Sup, supinator; NGS, needle guidance solution.
Journal of Acupuncture Research 2024; 41: 135-141https://doi.org/10.13045/jar.24.0004

Fig 3.

Figure 3.Ultrasound (US)-guided pharmacopuncture and acupotomy for carpal tunnel syndrome. (A) Performing US-guided pharmacopuncture (26 gauge, 60 mm, FDN81; Dongbang Medical Co., Ltd.) out-of-plane near PC7 and (B) acupotomy (0.5 × 50 mm, DO0550; Dongbang Medical Co., Ltd.) out-of-plane near PC7. (C) US short-axis view of performing the US-guided pharmacopuncture out-of-plane below the TCL, near the median nerve at the level of the proximal carpal tunnel. (D) US short-axis view of performing the US-guided acupotomy out-of-plane for TCL at the level of the proximal carpal tunnel. N, nerve; TCL, transverse carpal ligament; UA, ulnar artery; S, scaphoid; FT, flexor tendons; P, pisiform.
Journal of Acupuncture Research 2024; 41: 135-141https://doi.org/10.13045/jar.24.0004

Table 1 . Summary of upper extremity nerve entrapment sites and treatment points.

Nerve entrapment in the upper extremityEntrapped nerveAcupuncture points for treatingTarget anatomical structures for acupotomy
Cubital tunnel syndromeUlnar nerveSI 8 (distal)Humeroulnar aponeurotic arcade, Osborne’s ligament, and fascia
Radial tunnel syndromeRadial nerveLU 5Fibrous bands between the brachioradialis and brachialis, fibrous edge of the ECRB (grooves the nerve when the forearm is pronated)
PIN syndromeRadial nerve (PIN)LI 10Arcade of Frohse, supinator
Carpal tunnel syndromeMedian nervePC 7 (distal)Transverse carpal ligament
Guyon’s canal syndromeUlnar nerveHT 7 (distal)Palmar carpal ligament

ECRB, extensor carpi radialis brevis; PIN, posterior interosseous nerve..


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May 31, 2024 Vol.41 No.2, pp. 75~142

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