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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
e-peuker@muenster.de 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
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

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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
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

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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.
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

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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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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.

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.
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.

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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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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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http://aim.bmj.com/content/21/1-2/2

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