☯ Two Rules of Thumb to Remember When Locating Sacral Foramen

Finding the points located in the sacral foramen (UB 31- 34) can be challenging. When I began studying acupuncture I found locating these points maddening. Because of my experience I spend a lot of time working with students to help them demystify these important points.    

To locate these spaces one needs to palpate through layers of tissue. The foramen feel like soft depressions or "holes" in the bone. The trick to remember is the holes are not similar from one to the next. 

Two good rules of thumb to remember are: 

1. They are not perfectly evenly spaced. Some are close together and others are further away. 
2. The size of the foramen change from one to another. 

It is good the remember that the foramen are not equally sized and equally spaced. The size and space can vary considerably. Remembering the likelihood of the size and spacing varying will make finding and needling these points much easier. 

☯ One Trick to Counting Spinal Vertebra

One of the frustrating aspects of point location is counting the vertebrae. We need to do this when locating the Back Shu points or the Du Mai points.  

The difficulty is created by the fact that the spinous process of each vertebra is at a different angle. There is a natural tendency when counting the vertebrae to imagine each spinous process lying at a 90 degree angle to the body. However, these bony protrusions do not all each lie at a 90 degree angle. 

Many spinous processes emerge from the body at sharper angles, sometimes as much as 45 degrees. When this occurs the spinous process will partially cover the body of the NEXT vertebra. 

This overlapping most often occurs in the midback between T6 and T12. (Right at the levels of the Liver, Gallbladder, Spleen, and Stomach Back Shu points!) 

I have found one technique to counting vertebrae useful in both my personal practice and teaching students. Rather than only looking for the pointy spinous process — palpate the sides of each vertebra with a finger on each side. 

This technique allows you to feel the bodies of each vertebra. It keeps you from being thrown off when the spinous process is overlapping with the body below it. If you use this technique, and also count the spinous processes, the two techniques together make counting the vertebrae and finding the Back Shu Points much, much easier.  

☯ The Modern Day Crisis of St 31

☯ Sternal Foramen and Needling Ren 17 Safely

The Front Mu point of the Pericardium, Ren 17, is an important and frequently used point for many acupuncturists. It is located aligned with 4th intercostal space directly on the body of the sternum. Most texts including, A Manual for Acupuncture, lists no warning around the safety of needling this point. When teaching students I always discuss the possible danger of a sternal foramen. 

Sternal foramen, small holes in the bone, occur in a portion of the population. A hole in the body of the sternum leaves the heart vulnerable and thereby makes needling Ren 17 potentially dangerous. I think it is important for acupuncturist and students to be aware this anatomical variation exists. 

5% of the Population

There have been a variety of studies seeking to determine how frequent foramen appear in the population. Studies have been conducted on cadavers and using radiographic imaging.  Conclusions vary from 4.3% to 6.7% of the population — roughly 5% of the population. One study reports that the majority of the foramen found are located near the 4th rib space (the sternochondral articulation).

The foramen can vary in size. They can range from tiny 2mm spaces all the way to 22mm. Overall the mean size is generally reported to be between 4.5mm to 7mm. These are rather small spaces but much larger than acupuncture needles. There are published photographs of foramen and radiographic images as well. These images depict foramen on the larger end of the spectrum. Nevertheless it is helpful to see how obvious these spaces are in the body structure. 

To Needle Safely

There are two steps we can take when needling Ren 17 to ensure safety for our clients. 

1. Palpate. As acupuncturists, our hands are one of our greatest tools. Before inserting a needle, we ought to take the time to examine and palpate the sternal body. Any dips or softs spots in the body of the sternum will alert us to the possibility of a foramen. The very smallest spaces may not be palpable, but certainly the more dangerous medium to large spaces will be noticeable. In the event of any unusual findings, I recommend choosing another point. 
    
2. Needle Angle. Ren 17 is taught to be needled in a transverse or oblique manner. Given the potential harm of needling through a foramen, one should never needle perpendicularly. I recommend needling at a depth of 0.2-0.3 cun deep and as obliquely as possible. A shallow insertion will prevent the needle from coming near the bone. The more oblique the angle, the greater protection there is to prevent sliding into a small foramen that was not detected upon palpation. 

The combination of palpating and strong oblique insertions are simple precautions to take for our clients. 

I am not looking to be alarmist about Ren 17. It is safely needled by thousands of acupuncturists every day. There are reports in medical literature looking at the frequency of these foramen and urging our field to take them seriously. The greater awareness we have of sternal foramen the greater confidence we can have about needling safely for our clients. 

☯ Why are the Inner UB Points Needled Medially?

All of the Inner UB Shu Points are located in muscle tissue above the lungs. As a result it is important to understand the anatomy of this space and needle accordingly. 

It is recommended to needle the inner line of UB channel (11-23) with an oblique insertion towards the spine. The oblique insertion helps protect from deep needling. But why does the recommendation, “towards the spine," exist? 

Consider a cross-section of the trunk. This allows one to see the shape of the ribs and lungs. The ribs are curved and form an arc between the scapula and the spine. The deepest aspect of this curve is near the spine. 

The inner UB line is just medial to the highest and most superficial aspect of the ribs. If we needle medially from the inner UB line we are needling with the curve towards the area where the lungs are deepest and most protected. 

The back Shu Points are wonderful and powerful points. Using the natural geometry of the body to our advantage we can needle these points safely and with confidence. 

[Note: I discuss needling back UB points further in The Big Picture Book of Point Location V.2]