Can a single-needle periosteal acupuncture approach achieve more than a stellate ganglion block? Two case reports

Background

The sympathetic supply to the head, neck and upper limb originates from dorsal spinal segments T1 to T9, passing through the stellate ganglion (C5-T1). ¹ A sympathetic block by injection of the stellate ganglion may be beneficial in circulatory problems of the upper extremities like arterial embolism and inadvertent intra-arterial drug injection. It produces upper extremity arterial relaxation, which enhances blood flow and increases the peripheral temperature. ²

Case report 1

A 34-year-old male drug addict presented to the pain clinic 2 weeks after an inadvertent intra-arterial injection. He presented with pain and swelling in his left hand with gangrenous fingertips after failed medical treatment. The patient received a stellate ganglion block (SGB) which was performed by injecting 10 ml of 0.25% bupivacaine at the level of Chassaignac’s tubercle (C6). We found trivial analgesia (the visual analogue scale (VAS) score decreased from 9 to 8) despite the occurrence of Horner’s syndrome. Two days later, the patient’s VAS was 9 with increased signs of ischemia (swelling and increased areas of blackish discoloration) despite medical treatment. The patient received a second block and was asked to follow up. Two days later, the patient was still complaining of the same symptoms and was unable to sleep because of pain. In our institution, we have >20 years’ experience with pain management using different acupuncture modalities, so we decided to do periosteal acupuncture for this patient. We applied our acupuncture technique involving fine pricking of the tubercle of the transverse process of C6 using a sterile single-use stainless steel acupuncture needle (Cloud and Dragon®, 5 cm, 30 G) for 30 seconds. After a while, the patient reported decreased pain severity, and on examination, the hand became warmer and less swollen. The session lasted for 10 minutes with pricking of C6 for 10 seconds every 2 minutes. After 2 days, the patient was satisfied with the improvement in this pain, and there was regression of swelling and distal migration of darkness. The patient received five sessions (once every 2 days) with regression of gangrenous areas on the fingertips, which were nevertheless later amputated.

Case report 2

A 25-year-old male patient was referred to our pain clinic after an inadvertent intra-arterial injection that led to ischemia and severe pain in the thumb and the index and middle fingers. After 6 hours, he received a SGB in the emergency room with rapid improvement of pain and ischemia except for the distal phalanx of the middle finger, which was still cyanosed and painful. The patient received a second SGB on the second day under ultrasound guidance with little improvement of his pain. On the third day, the patient’s VAS score was 9, with cyanosis of the distal phalanx of the middle finger. The perfusion index (PI), measured from the distal phalanx of the middle finger using a Datex Ohmeda (Tuffsat^®) instrument, was 0.04. We then tried fine needling of the periosteum of the C6 tubercle. After 30 seconds the VAS score was 5 and PI was 0.08, after 2 minutes the VAS score was 3 and PI was 1.1, and after 10 minutes the VAS score was 3 and PI was 1.1. Three days later, the patient came back seeking another session of acupuncture. On examination, we found improvement in his cyanosis and pain (VAS score 2, PI 1.2). The patient received the second session, which was followed by an improvement in the VAS score (ranging from 0 to 1) and an increased in the PI to 1.4. We asked the patient to re-attend 3 days later, but he did not come back until 1 week later. At that point, he reported having no pain at all, and the bluish discoloration had nearly disappeared.

Comment

Our pain clinic at Suez Canal Univer-sity Hospital has been interested in the use of acupuncture for pain management alongside other modalities. Acupunc-ture treatments are often based on traditional Chinese medicine (TCM) concepts.^3,4 Periosteal pecking was first described by Felix Mann ⁵ as a treatment that involves needling the periosteum to achieve strong acupuncture stimulation. Mann described improvement of upper limb pain and ischemia by periosteal needling of the cervical articular pillar of the fifth cervical vertebra. Given that the nervous system is believed to be the main substrate for acupuncture action, we choose to do periosteal needling at C6 as we think that it is the nearest easily palpable point to the stellate ganglion. Rapid improvement in pain after about 1 minute and an improvement in swelling after about 5 minutes of acupuncture was noticed for the first patient. When we repeated the same technique with the second patient, rapid improvement in pain and ischemia was noticed. This technique has the advantage of being easily accomplished in the sitting position, which may be beneficial for patients who cannot lie supine.

Conclusion

Although no firm conclusions can be drawn from these uncontrolled case reports, we believe that periosteal acupuncture at the level of C6 can produce a therapeutic effect that may be more than or at least similar to that produced by conventional SGB. Further research is required to confirm our results.