National Cooperative Group of Acupuncture Anesthesia for Neurosurgery*
*Compiled by Hua Shan Hospital, Shanghai First Medical College.
Since the first report of successful brain operation under acupuncture anesthesia in November 1965, 7469 neurosurgical operations have been done under acupuncture anesthesia by 2 neurosurgical units in our country up to the end of 1978. Since March 1975 a nationwide correlative study has been organized. This paper summarizes the correlative study of 4466 cases, including 1865 cases (41.8%) of anterior fossa operations, 1594 cases (35.7%) of temporo-parieto-occipital region operations and 1007 cases (22.5%) of posterior fossa operations.
I. Result in general: Over 90% were successfully performed under acupuncture anesthesia. The degree of success was graded as "excellent" or "good" in 78% of the anterior fossa operations, 73.5% of the temporo-parieto-occipital region operations and 78.9% of the posterior fossa operations. The result of the study showed that acupuncture anesthesia is applicable to cranio-cerebral operation of all localities, especially to anterior and posterior fossa operations. The averaged sum of "excellent" and "good" grades was 76.6%.
II. Selection of cases: Cases conforming to the following conditions are considered suitable for operation under acupuncture anesthesia: (1) the patient, 18 years or older in age, conscious and cooperative, and devoid of obvious mental deficiency, (2) the lesion to be operated on is situated at the cerebral hemisphere, the cerebello-pontine angle or the sellar region, (3) operable lessions include all kinds of brain tumors, vascular anomalies, brain abscesses, certain types of cerebral aneurysms, subacute and chronic intracranial hematomas, as well as lesions of the calvarium and the scalp. It is conditionally contraindicated in comatous patients, deaf-mutes, those mentally disordered or uncooperative, and those with lesions deeply seated or widely extensive. It is also not recommended in cases where hypothermia and hypotensive procedures are necessary.
III. Individual variability: Some of the operation cases underwent a barrage of preoperative studies, including measurement of pain threshold, pain tolerability, cardiac rate, plethysmography, skin temperature, galvanic skin response and pain reaction to venepuncture. Except for the galvanic skin response, all the items were proved to be useful indices for prediction of successful operation, i.e. the correlative rate being about 75%. The result of the study confirms the presence of individual variability, which might be tested preoperatively.
IV. Speciality of puncture point: Three recipes of puncture points are now recommended for anterior fossa operations and two recipes each for temporo-parieto-occipital operations and posterior fossa operations respectively. Statistical study showed no significant difference of effectiveness among these seven groups of puncture points. Some degree of selective specificity of puncture points might be present, but it is not an important factor.
V. Choice of parameters of stimulation: The intensity of stimulus should be gauged by patients' tolerability. As to frequency of stimulation, best results were repeated by applying at 120-400 c/min. for body acupuncture and at 500-100 c/min. for ear acupuncture. Variation of intensity and frequency of stimulation during different stages of surgical operation was able to promote effectiveness and to preclude adaptation. 20-30 minutes of induction period was found to be appropriate.
VI. Advantages of acupuncture anesthesia in cranio-cerebral operations:
(1) The safety factor of operation is increased. Of the 4466 cases, there was not a single accident of death attributable to anesthesia. Post operative complications were notably lessened in comparison with those operated under general anesthesia. For example, in the operations on acoustic neurinoma, pneumonia occured in 35 cases out of 333 (10.5%) under general anesthesia, but only in 9 cases out of 311 (2.8%) under acupuncture anesthesia. For the same reason, acupuncture anesthesia is the method of choice for those patients complicated with cardiac, pulmonary, hepatic or renal dysfunctions, and for those old and debilitated, or under shock condition.
(2) Acupuncture anesthesia causes less embarrassment to physiological functions. Blood pressure, pulse rate and respiration were mostly stable throughout the operation. In 20 cases of acoustic neurinoma operated under general anesthesia, bradypnea occured in 9 cases, temporary cessation of respiration in 2 cases and signs of brain stem or cranial nerve injury were manifested in 4 cases. None occurred in a similar series of cases operated under acupuncture anesthesia.
(3) It allows timely checking of the operation procedure. In operations on acoustic neurinoma larger than 3 cm in diameter facial nerve was preserved in 80% of 137 cases under acupuncture anesthesia, as compared with 53.3% in 229 cases under general anesthesia. This is attributed to the conscious state of the patient under acupuncture anesthesia, permitting timely examination of the function of the facial nerve during the course of operation.
VII. Unsolved problems and their management
(1) To certain extent the problem of incomplete analgesia remains. To minimize pain, additional measures have to be taken such as 0.1% procaine infiltration along the incision line, application of high frequency (40000-60000/min) stimulus to the puncture points or administering droperidol or haloperidol in addition to the routine use of dolantin.
(2) In anterior fossa operations, reaction to stimuli on meninges and diaphragm sellae was not uncommon. Needling of Neiguan, Taichong, injection of Metoclopramidum, intravenous dripping of 20% mannitol and intravenous injection of atropine and droperidol, together with gentle handling of the tissues at the base of cranial cavity would lead to better control.
VIII. Neurophysiological basis and psychological aspect of acupuncture analgesia. Psychological tests using verbal induction and reading of scales on an oscillography as suggestive stimuli, showed that perceptive power is not related to the effectiveness of acupuncture anesthesia. During preoperative trial needling, changes in pulse rate and skin sensitivity were found to be highly correlated with the psychic state of the patient. In order to ascertain the analgesic effect of needling, in 50 cases we infiltrated the operation field with 0.1% procaine, gave the routine dose of dolantin, and performed craniotomy without acupuncture. The result was that 49 out of the 50 failed. In another series of 50 cases with acupuncture but without procaine infiltration, only 4 failed. In each of 8 cases undergoing chemical analysis of the cerebrospinal fluid before and after acupuncture, the content of morphine-like-substance was found to be increased after the procedure. Electrodes implanted in the head of caudate nucleus in 21 cases of intractable pain recorded non-specific evoked potential during acupuncture analgesia. Needling of the puncture point and electric stimulation of caudate nucleus inhibited the evoked potential of centro-media nucleus of the thalamus. The effect of acupuncture anesthesia therefore appears to be closely incorporated with neurophysiological function.
*Compiled by Hua Shan Hospital, Shanghai First Medical College.
Since the first report of successful brain operation under acupuncture anesthesia in November 1965, 7469 neurosurgical operations have been done under acupuncture anesthesia by 2 neurosurgical units in our country up to the end of 1978. Since March 1975 a nationwide correlative study has been organized. This paper summarizes the correlative study of 4466 cases, including 1865 cases (41.8%) of anterior fossa operations, 1594 cases (35.7%) of temporo-parieto-occipital region operations and 1007 cases (22.5%) of posterior fossa operations.
I. Result in general: Over 90% were successfully performed under acupuncture anesthesia. The degree of success was graded as "excellent" or "good" in 78% of the anterior fossa operations, 73.5% of the temporo-parieto-occipital region operations and 78.9% of the posterior fossa operations. The result of the study showed that acupuncture anesthesia is applicable to cranio-cerebral operation of all localities, especially to anterior and posterior fossa operations. The averaged sum of "excellent" and "good" grades was 76.6%.
II. Selection of cases: Cases conforming to the following conditions are considered suitable for operation under acupuncture anesthesia: (1) the patient, 18 years or older in age, conscious and cooperative, and devoid of obvious mental deficiency, (2) the lesion to be operated on is situated at the cerebral hemisphere, the cerebello-pontine angle or the sellar region, (3) operable lessions include all kinds of brain tumors, vascular anomalies, brain abscesses, certain types of cerebral aneurysms, subacute and chronic intracranial hematomas, as well as lesions of the calvarium and the scalp. It is conditionally contraindicated in comatous patients, deaf-mutes, those mentally disordered or uncooperative, and those with lesions deeply seated or widely extensive. It is also not recommended in cases where hypothermia and hypotensive procedures are necessary.
III. Individual variability: Some of the operation cases underwent a barrage of preoperative studies, including measurement of pain threshold, pain tolerability, cardiac rate, plethysmography, skin temperature, galvanic skin response and pain reaction to venepuncture. Except for the galvanic skin response, all the items were proved to be useful indices for prediction of successful operation, i.e. the correlative rate being about 75%. The result of the study confirms the presence of individual variability, which might be tested preoperatively.
IV. Speciality of puncture point: Three recipes of puncture points are now recommended for anterior fossa operations and two recipes each for temporo-parieto-occipital operations and posterior fossa operations respectively. Statistical study showed no significant difference of effectiveness among these seven groups of puncture points. Some degree of selective specificity of puncture points might be present, but it is not an important factor.
V. Choice of parameters of stimulation: The intensity of stimulus should be gauged by patients' tolerability. As to frequency of stimulation, best results were repeated by applying at 120-400 c/min. for body acupuncture and at 500-100 c/min. for ear acupuncture. Variation of intensity and frequency of stimulation during different stages of surgical operation was able to promote effectiveness and to preclude adaptation. 20-30 minutes of induction period was found to be appropriate.
VI. Advantages of acupuncture anesthesia in cranio-cerebral operations:
(1) The safety factor of operation is increased. Of the 4466 cases, there was not a single accident of death attributable to anesthesia. Post operative complications were notably lessened in comparison with those operated under general anesthesia. For example, in the operations on acoustic neurinoma, pneumonia occured in 35 cases out of 333 (10.5%) under general anesthesia, but only in 9 cases out of 311 (2.8%) under acupuncture anesthesia. For the same reason, acupuncture anesthesia is the method of choice for those patients complicated with cardiac, pulmonary, hepatic or renal dysfunctions, and for those old and debilitated, or under shock condition.
(2) Acupuncture anesthesia causes less embarrassment to physiological functions. Blood pressure, pulse rate and respiration were mostly stable throughout the operation. In 20 cases of acoustic neurinoma operated under general anesthesia, bradypnea occured in 9 cases, temporary cessation of respiration in 2 cases and signs of brain stem or cranial nerve injury were manifested in 4 cases. None occurred in a similar series of cases operated under acupuncture anesthesia.
(3) It allows timely checking of the operation procedure. In operations on acoustic neurinoma larger than 3 cm in diameter facial nerve was preserved in 80% of 137 cases under acupuncture anesthesia, as compared with 53.3% in 229 cases under general anesthesia. This is attributed to the conscious state of the patient under acupuncture anesthesia, permitting timely examination of the function of the facial nerve during the course of operation.
VII. Unsolved problems and their management
(1) To certain extent the problem of incomplete analgesia remains. To minimize pain, additional measures have to be taken such as 0.1% procaine infiltration along the incision line, application of high frequency (40000-60000/min) stimulus to the puncture points or administering droperidol or haloperidol in addition to the routine use of dolantin.
(2) In anterior fossa operations, reaction to stimuli on meninges and diaphragm sellae was not uncommon. Needling of Neiguan, Taichong, injection of Metoclopramidum, intravenous dripping of 20% mannitol and intravenous injection of atropine and droperidol, together with gentle handling of the tissues at the base of cranial cavity would lead to better control.
VIII. Neurophysiological basis and psychological aspect of acupuncture analgesia. Psychological tests using verbal induction and reading of scales on an oscillography as suggestive stimuli, showed that perceptive power is not related to the effectiveness of acupuncture anesthesia. During preoperative trial needling, changes in pulse rate and skin sensitivity were found to be highly correlated with the psychic state of the patient. In order to ascertain the analgesic effect of needling, in 50 cases we infiltrated the operation field with 0.1% procaine, gave the routine dose of dolantin, and performed craniotomy without acupuncture. The result was that 49 out of the 50 failed. In another series of 50 cases with acupuncture but without procaine infiltration, only 4 failed. In each of 8 cases undergoing chemical analysis of the cerebrospinal fluid before and after acupuncture, the content of morphine-like-substance was found to be increased after the procedure. Electrodes implanted in the head of caudate nucleus in 21 cases of intractable pain recorded non-specific evoked potential during acupuncture analgesia. Needling of the puncture point and electric stimulation of caudate nucleus inhibited the evoked potential of centro-media nucleus of the thalamus. The effect of acupuncture anesthesia therefore appears to be closely incorporated with neurophysiological function.
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