Stimulated by Jin et al 2017,[1] and Li et al 2020.[2]
The full title of this paper is: Unforgettable Ups and Downs of Acupuncture Anesthesia in China (US English). It is a great title for the subject matter as it drew me in to read the whole paper when I first saw it, despite having plenty of other things to be doing! I missed it in 2017 and only saw it by chance the other day when searching the World Neurosurgery journal for a different paper that had just been published online.[3] I was struggling to find the paper on iatrogenic facial nerve palsy as the list of ‘Articles in Press’ was extensive, so I searched for acupuncture in the journal as a whole, and that is when I found several papers and letters that I hadn’t seen before. Most were letters discussing reports of adverse events,[4–12] including that one reporting a cranial epidural abscess that got me the most hits on this blog,[13] and still holds the record. It got nearly 1500 hits in 2 weeks. I guess most of them from shocked practitioners of scalp acupuncture.
An historical vignette…
So, back to the Ups and Downs paper! This historical vignette answers a lot of my questions about the use of ‘acupuncture anaesthesia’ (AA) in China, and it concisely but importantly sets out the geopolitical backdrop of the 1950’s. China had previously undergone invasion and occupation by Japan, then civil war between the nationalists and the communists, followed eventually by Mao’s cultural revolution.
The country was effectively closed to the outside world and suffering economic hardship. It was in this environment that traditional medicine was encouraged; partly to offset the difficulty in obtaining modern medicines, including most anaesthetic drugs.
The first use of AA for surgery was reported in 1958. Dr Yin from the ENT department of the Shanghai First People’s Hospital performed a tonsillectomy using only acupuncture at LI4 for the procedure. The anaesthetic condition was recorded as ‘good’. Things took off after that, initially in Shanghai but then the use of AA spread. From 1958 to 1965 some 8700 operations were performed throughout China using AA, but after a national conference on the subject held in Shanghai in 1966, the use of AA rose dramatically, and by 1970 over 57 000 operations were recorded across more than 200 units over 26 provinces.
57 000 operations were recorded by 1970
The paper goes on the describe the rise in research on mechanisms of AA, principally led by Professor Han Jisheng in Beijing, and notes that while the use of AA for surgery fell out of favour in the 1980’s, there was no decline in the mechanistic research effort.
There is a section on the use of AA in awake craniotomies – well it is a neurosurgical journal after all, although I struggle to imagine what it would be like to be awake to hear and feel the vibration of a drill on the bone of your skull. It seems that this was the start of awake craniotomies, the first being performed in 1965 under AA, and the advantages of having an awake patient became clear as a result of this. By 1978 they had performed 7469 craniotomies under AA in China, and Dr Chen, who had performed the first, was involved in 4466 of them. That would have kept him quite busy I imagine.
More modern anaesthetic techniques started to take over, and the paper acknowledges that AA was limited by comparison.
Finally, the analgesic effect of acupuncture anesthesia is significantly different compared with modern awake anesthesia. It is unsatisfactory and incomplete, and patients experience serious pain when cutting the scalp, muscles, or meninges, particularly when touching nerve roots.
Finally, a very illuminating paragraph on the political dimension:
The Disappearance of a Political Factor
After the 1980s, the reform and opening of China by Chairman Deng Xiaoping changed the political situation. The “political factor,” which was the main force for the development of acupuncture anesthesia, disappeared. In addition, to obtain “perfectness,” failed operations and data fabrication in acupuncture anesthesia research studies under extreme environments in the past were exposed to the public. As a result, the effectiveness of this technique was again questioned.
But the legacy of AA did not disappear entirely. Acupuncture-assisted anaesthesia (AAA) was developed within neurosurgery in China, and its benefits have been acknowledged within the neurosurgical field.[14,15]
AAA – Acupuncture-Assisted Anaesthesia
Still in the neurosurgical field, I come to the second paper, which is a 3-arm trial of electroacupuncture (EA), manual acupuncture (MA) and no treatment for postoperative constipation following brain tumour surgery (n=150).[2] ST25 was the point used for both EA and MA. The treatments were performed by nurses who had undergone acupuncture training and been certified – this is the first I have heard of this in China.
EA and MA were applied once a day for 20 minutes for 7 days, and patients were asked not to use enemas during this period. EA was applied in 20µs pulses at 15Hz and 5–10mA. It performed slightly better than MA and both were significantly better than no treatment.
References
1 Jin L, Wu J-S, Chen G-B, et al. Unforgettable Ups and Downs of Acupuncture Anesthesia in China. World Neurosurg 2017;102:623–31. doi:10.1016/j.wneu.2017.02.036
2 Li D, Li H, Liu H, et al. Impact of Electroacupuncture Stimulation on Postoperative Constipation for Patients Undergoing Brain Tumor Surgery. J Neurosci Nurs 2020;Publish Ah. doi:10.1097/JNN.0000000000000531
3 Pu JK, Wong SC, So KH, et al. Acupuncture as Part of Iatrogenic Facial Nerve Palsy Rehabilitation-First Report. World Neurosurg Published Online First: 17 May 2020. doi:10.1016/j.wneu.2020.05.079
4 Priola SM, Moghaddamjou A, Ku JC, et al. In reply to Letter to the Editor Regarding “Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature”. World Neurosurg 2019;132:444. doi:10.1016/j.wneu.2019.08.156
5 Priola SM, Moghaddamjou A, Ku JC, et al. In Reply to the Letter to the Editor Regarding “Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature”. World Neurosurg 2019;127:655. doi:10.1016/j.wneu.2019.03.152
6 Wang Q, Tang Q, Zhang K. Letter to the Editor Regarding “Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature”. World Neurosurg 2019;132:443. doi:10.1016/j.wneu.2019.07.174
7 Hu J, Lu H, Han L, et al. Letter to the Editor Regarding “Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature”. World Neurosurg 2019;127:654. doi:10.1016/j.wneu.2019.03.146
8 Eghbal K, Ghaffarpasand F. In Reply to the Letter to the Editor regarding “An Acute Cervical Subdural Hematoma as the Complication of Acupuncture: Case Report and Literature Review”. World Neurosurg 2017;98:858. doi:10.1016/j.wneu.2016.10.126
9 Lu H, Sheng R, Zhang C. A Letter to the Editor regarding “An Acute Cervical Subdural Hematoma as the Complication of Acupuncture: Case Report and Literature Review”. World Neurosurg 2017;98:857. doi:10.1016/j.wneu.2016.10.071
10 Domenicucci M, Marruzzo D, Pesce A, et al. In Reply to the Letter to the Editor Regarding “Acute Spinal Epidural Hematoma After Acupuncture: Case Report and Literature Review”. World Neurosurg 2017;104:1035. doi:10.1016/j.wneu.2017.05.169
11 Ding S, Gan Y, Lu H, et al. Letter to the Editor Regarding “Acute Spinal Epidural Hematoma After Acupuncture: Case Report and Literature Review”. World Neurosurg 2017;104:1034. doi:10.1016/j.wneu.2017.04.165
12 Eghbal K, Ghaffarpasand F. An Acute Cervical Subdural Hematoma as the Complication of Acupuncture: Case Report and Literature Review. World Neurosurg 2016;95:616.e11-616.e13. doi:10.1016/j.wneu.2016.08.090
13 Priola SM, Moghaddamjou A, Ku JC, et al. Acupuncture induced cranial epidural abscess: Case report and review of the literature. World Neurosurg Published Online First: 8 February 2019. doi:10.1016/j.wneu.2019.01.189
14 Asmussen S, Maybauer DM, Chen JD, et al. Effects of acupuncture in anesthesia for craniotomy: A meta-analysis. J Neurosurg Anesthesiol 2017;29:219–27. doi:10.1097/ANA.0000000000000290
15 Xu M, Zhou S-J, Jiang C-C, et al. The Effects of P6 Electrical Acustimulation on Postoperative Nausea and Vomiting in Patients After Infratentorial Craniotomy. J Neurosurg Anesthesiol 2012;24:312–6. doi:10.1097/ANA.0b013e31825eb5ef
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