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Ying Zhang The First Affiliated Hospital of Guangzhou Medical University
Fu Hui Dong China Academy of Traditional Chinese Medicine Institute of Traumatology & Orthopedics
“Minimally Invasive Soft Tissue Technique” uses a needle with a flat, chisel like blade at the end called a ‘Pi needle’ (鈹針), to treat tissue lesions with special techniques. Pi needles penetrate the skin directly to the affected region, then mechanically reduce or decompress the tight fascial tissue, in order to improve pathological changes of nervous system, retention of body fluids and organ dysfunction caused by fascial tissue restrictions.This treatment method can restore the original structure and function of the tissues and organs. The theory of the treatment is based on human anatomy, physiology, pathology, biomechanics, and the minimally invasive techniques of traditional Chinese medicine (TCM), and it integrates acupuncture techniques from TCM, it is a modern version of a traditional diagnosis and treatment system.
Mechanisms of the Technique
Relieving tight fascial tissue: Muscular strain plays an important role in normal bone development. The shape, internal structure, and composition of bones are related to the magnitude and direction of the stress on the bone’s periosteal skin. In our growth and development this is normal. However, when we have physically matured and there is excessive continuous or repeated tensile stress and the muscle or tendon fibers are in a state of tension for a long time, they pull on the surface of the bone where they attach, resulting in stress related hyperplasia of the bone, as with so called “bone spurs” . This technique uses the flat needle to cut or loosen the high-pressure fascia tissue adhered to the bone surface, to change the direction and magni- tude of its force, in order to eliminate the source of the problem. The most clinically relevant disease of this type is “third lumbar transverse process syndrome”. This occurs when the third lumbar vertebra, which is the center of vertebral rotation and forward bending and has multiple muscle attachments, experiences long-term mechanical stress. The stress stimulates mechanical stress at the apex of the vertebrae’s transverse process, resulting in the third lumbar transverse process elongating and being longer than the other lumbar transverse processes. The treatment concept is to eliminate the tight fascial tissue attaching at the apex of the transverse process of the third lumbar vertebra, by using a flat head needle to cut off or reduce the tension.
Relieving pressure in osteo-fibrous canal: An osteo-fibrous tunnel is a canal composed of bone and connective tissue fibers. These structures can be divided into three types: an osteo- fibrous tunnel, a joint fibrous tunnel, and musculotendinous-fibrous tunnel. Nerves, blood vessels, and tendons travel through these areas, and the role of the tunnels is to protect and retain these vessels, nerves and tendons in movement. When something increases the pressure within the canal it can induced abnormal internal structure, and the nerves or vessels within in the canal can be compressed or irritated, producing clinical symptoms at the areas served by the nerves and vessels. This technique can release the tissue contracture and tension in the tunnel structure, reducing the internal pressure, and relieving symptoms. The most common disease caused by this type of structural change is occipital headache. When the structure of the posterior occipital tunnel is abnormal or the tension irritates the greater or lesser occipital nerves and arteries, it can cause pain in the innervated areas of the greater and lesser occipital nerves, producing an occipital headache. Understanding this concept makes clinical treatment simple. We just use a bladed needle to loosen the contracture of the tendon arch of the occipital tendon, reduce the tension on the arch of the occipital tendon, and eliminate the greater and lesser occipi- tal nerve irritation to relieve the neuralgia symptoms.
Editor’s Note: Thefollowing is relating to places where nerves pass over the edges ofbones through a combination ofa notch in the bone and a “tunnel” roofmade ofconnective tissue, like the passage ofthe occipital nerve where it crosses the nuchal like, or the cluneal nerves where they pass the ilia. This is broadened to include areas like the carpal tunnel (“jointfibrous tunnel” below), or compartments bounded entirely by muscle, like the “quadrilateral space”, the area in the armpit through which the brachial plexus passes.
Reduce interstitial tissue pressure: Within the human body, from structures as small as a cell, to a muscle or organ, up to areas as large as the entire skin of the human body, all of these form closed cavities, and are juxtaposed with one another. The pressure differences inside and outside these cavities maintain the structure and metabolism of the human body. Structural abnormalities, or chronic strain, etc., causes localized tissue disorders, leading to increased pressure within a cavity. In clinical settings, many types of soft tissue injuries belong to this category, such as osteofascial compartment syndrome, swelling leading to joint capsule pressure, intraosseous pressure, and even increased intracranial pressure, etc. The cutting needle can penetrate the cavity wall and reduce the pressure within the cavity, restoring balance to the local tissue metabolism, to achieve the purpose of reducing or relieving symptoms. The most common clinical headache, dizziness, nausea, and vomit- ing are caused by intracranial hypertension. Cervical spondylosis affects the circulation of intracranial fluid, and causes increased intracranial pressure. Clinically, the obstruction of intracranial fluid reflux can be relieved by loosening the soft tissue behind the pillow, thereby relieving clinical manifestations such as headache, dizziness, nausea, and vomiting.
Relieve adhesions between tissues Under normal circumstances, connective tissue layers have varying degrees of movement between them. When there is trauma, chronic strain, or surgical penetration and scarring, the available movement between the layers is often substantially reduced, affecting the functions of the adjacent structures, organs, nerves, blood vessels, etc. Such as restricted movement between the superficial and deep fascia, the joints, or even the organs when the visceral and parietal fascia are affected. Acupuncture manipulation can reduce the adhesion between tissue layers and restore them to a normal physiological state. The most common clinical manifestation of this is the postoperative scar. Scarring can induce the skin and subcutaneous tissue to adhere to one another, resulting in an obvious raised, stiff lesion on the skin. We use a cutting needle to break up the adhesion of the skin and subcutaneous tissue, and the deep incision line will flatten and soften in a short time, its color and hardness will normalize. In other cases, intestinal adhesion after abdominal surgery is also quite typical. This issue plagues surgeons today.
Indications
The technique is applicable to any part of the body for soft tissue injury or chronic strain, local tissue lesions such as soft tissue adhesions, fibrous contracture, increased internal pressure, cyst wall thickening and other pathological changes where non-surgical treatment is ineffective or symptoms recur after treatment.
a)Neck and lower back pain are caused by soft tissue injury, muscle tension at the back of neck leads to cervical dislocation, resulting in the clinical manifestations of nerve root type, verte- bral artery type, and sympathetic cervical spondylosis. Pi needle can relieve the tense and contracted muscles at the back of the neck, combined with TCM bone setting manipulation.
b)3rd lumbar vertebrae transverse process syndrome, calcaneal spur, knee intercondylar protuberance hyperplasia.
c)Bone fiber entrapment of cubital tunnel, tarsal tunnel, ulnar tunnel, and carpal tunnel, resulting in clinical syndromes, like migraine, tenosynovitis, frozen shoulder, cervical and lumbar nerve roots caused by entrapment or extrusion disease.
d)Ganglion cysts, joint pain caused by increased intra-articular pressure, synovitis, bursitis, and myofascitis of various parts of the body, such as ischial tuberosity bursitis, calcaneal tuberosi-ty bursitis, etc.
e)Local tissue adhesions, scars caused by trauma, strain, and surgery. Such as tennis elbow, Levator scapulae syndrome, and sequelae of bone and joint diseases (rheumatism, ankylosing spondylitis, gout, avascular necrosis of bone joint, fibrous stiffness of limb joints, etc.).
Contraindications
a)Patients with fever and infection
b)Patient with hemophilia or with blood coagulation disorders
c)Severe visceral disease attack period, diabetes, mental illness patients
d)Physically weak and uncooperative
e)Patients with infection or redness, swelling, heat, pain, or abscess at the site to be needled
f)The diagnosis is not clear, or there are pathological changes, or changes to the local anatomical structure due to surgery or malformation complicating the procedure.
g)The needled site is close to important organs and cannot pro- tect them
Treatment
Acupuncture needles Bladed needles, the diameter and length of which can be selected according to the location and pathological changes.Typical range is 0.35-0.50mm by 25-50mm.
Treatment procedure
Patient position: Depending on the location of the lesion and the method of operation
Needle insertion site: Select the appropriate point according to the lesion site and operation technique. One should avoid insertion too close to vulnerable organs and tissues
Needle insertion method: “Two fast and one slow” method is used; the “two fast” is the rapid insertion and removal of the needle to reduce local pain. When the needle blade reaches the subcutaneous area, the needle needs to be inserted slowly. When necessary, the needle tip can be shaken to stimulate the surrounding sensitive tissues (Nerves, blood vessels, etc.) to produce reflexive avoidance and reduce unnecessary damage to tissues
Needle blade orientation: The blade of the needle should be oriented parallel to the direction of the fibers at various levels in the anatomical area. This is done to avoid unintentional trauma to important tissues.
3.Treatment methods
Longitudinal dredging method: the needle blade is parallel to tissue fiber direction and worked back and forth, in order to free adhesions between tissues. This is mainly applicable to the adhesion between tissues.
Horizontal loosening method: the needle blade is perpendicular to the tissue fibers at the site, and is manipulated to cut tense muscle or tendon fibers or connective tissue. It is mainly applied to reducing the compression in osteo fibrous tunnels.
Cutting method: the needle blade is advanced to the area of the adhesive scar tissue, and different directions and depths are selected for cutting, to reduce the area and degree of tissue adhesion and accelerate the absorption of local lesion tissue as the microtrauma is repaired.
Penetrating and peeling method: the acupuncture needle reaches between the tissues, and then the adhesion between the tissues is separated in a sweeping motion by the blade. This method is mainly suitable for cases where the adhesion area is large but not serious.
Perforation decompression method: When the needle blade reaches the lesion, it punctures the cystic wall or fascia of the lesion, or enlarges the incision as necessary, to accelerate the metabolism and absorption of fluid accumulations. This method is mostly used for intracapsular decompression.
Precautions
As this technique has developed a basic theory and there has been technical research of the concept of minimally invasive soft tissue techniques, it has almost lost its original relationship with acupuncture, which has been replaced by a conceptual framework of closed tension reduction and decompression technology. As this is essentially a surgical intervention, the treatment room should have certain requirements, and the operator must master certain aseptic techniques.
Although the technique is derived from acupuncture, which already has the function of reducing tension and decompression, it additionally requires a deep understanding of local ana- tomical structure, physiology, pathology and histology of the human body, an understanding of imaging basics, and a special knowledge of orthopedics and traumatology.
For the technique to be effective, the doctor must not only understand the medical aspects and have experience, but they must also pay attention to the patient’s reaction to the treat- ment, as it is a very important indicator of effectiveness of the method. If the treatment is to be successfully completed coop- eration between doctors and patients is essential.
Precision is a requirement of the technique, so the operator must make a clear diagnosis, specify the location, patholo- gy, and have a detailed plan of treatment, identifying methods to avoid injury to adjacent tissues and structures. Otherwise, in addition to affecting its therapeutic benefit, it will cause unnecessary damage or postoperative complications.
In recent decades, this technique has become favored by many TCM practitioners who specialize in pain management because of its efficacy in pain relief. I would like to use this article for their reference.
軟組織微創術
章 瑛 廣州醫科大學第一附屬醫院
董福慧 中國中醫科學院骨傷科研究所
軟組織微創技術是利用一帶刃的針灸針(可稱鈹針)，穿過皮膚直達病變部位，通過對高張力的筋 膜組織機械性的減張或減壓，改善因其所致的神經 系、體液系及臟器功能的病理變化，恢復組織原有 結構及功能的一種治療方法。軟組織微創理論是以 現代醫學的人體解剖、生理、病理、生物力學以及 中醫微創技術為基礎，並集我國傳統醫學的針刺手法特色於一體的現代傳統診療體系。
一、軟組織微創作用機理
1.解除高應力纖維：肌肉的牽引對骨的正常發育有 重要意義，骨現有的形態和成分都與其止在骨面上 應力的大小及方向有關。由於持續的反复拉應力作用，使肌或腱纖維長期處於緊張狀態，作用於所止 的骨面則產生應力性的“骨質增生”。軟組織微創 技術可利用帶刃的針具切開或緩解止於骨面的高應力纖維，改變其力的方向及大小，達到解除病因的目的。在臨床上最具代表性的疾病如第三腰椎橫突 綜合徵。就是止於腰三橫突尖部的腰背筋膜中層，長期高應力作用，將其腰三橫突拉的比其它腰椎橫 突長，在人體結構及力學關係上就易出現腰三橫突 綜合徵。治療理念則是將止於腰三橫突尖部高應力纖維，利用帶刃針將其切斷或減張即可。
2.減輕骨纖維管內高壓：骨纖維管是由骨組織和其 上橫行的纖維組成的管道。按其組織結構可分為骨 性纖維管、關節纖維管及肌(或腱)纖維管3種。骨纖維管內可有神經及伴隨血管及肌腱等組織通過。人體的骨纖維管主要起保護及固定管內組織的 作用。由於某種原因使其管內壓增高或骨纖維管結 構發生異常時，則會刺激或壓迫管內容物產生支配區臨床表現。軟組織微創則可通過松解攣縮緊張的骨纖維管組織，改變骨纖維管的結構以減輕管內壓力，使管內通行組織能夠順利通過以達緩解症狀的目的。臨床上最常見的這類結構改變所引起的病症如偏頭痛。偏頭痛多是由於位於枕後，其中有 枕大、小神經及枕動脈通過的枕後腱弓骨纖維管 結構異常或內壓增高，壓迫枕大、枕小神經所出現的支配區痛感，明白了這個理念，在臨床上治療就極其簡單了。我們只需要用扁頭帶刃針灸針(鈹針) 將其攣縮的枕後腱弓松解，減輕枕後腱 弓骨纖維管內高壓，使枕大、枕小神經不受刺激或卡壓而緩解症狀。
3．減組織內壓：在人體結構裡，小到一個細胞， 一塊肌肉，一個臟器，大到人體的皮囊，都是以一個個密閉的腔體，彼此並列或腔中套腔的形式存在。腔(囊)內、外壓差的存在維持著人體的結構及新陳代謝。結構異常或慢性勞損等等，使局部組織代謝紊亂引起腔(囊)內壓增高，在臨床上有很多類軟組織傷病都屬這個範疇之內。如骨筋膜間室綜合徵，關節囊內壓、骨內壓、甚至是顱內壓增高等等。可通過鈹針穿透整個腔(囊)壁，使其腔內高壓得以減低，恢復局部組織代謝平衡失調的現象，達到減輕或解除症狀的目的。臨床上最常見的顱內高壓所致的頭痛、頭 暈、噁心、嘔吐等症,多因頸椎病影響了顱內體液回流，使顱內壓力增高，臨床上通過對枕後軟組織松解緩解顱內體液回流受阻，減輕顱內高壓的現象，使頭痛、頭暈、噁心、嘔吐等臨床表現得到緩解。
4.解除組織間的粘連：正常情況下，人體各組織，彼此之間均有不同程度的活動空間。由於外 傷、長期慢性勞損或手術等等，使所受損組織間活動範圍減小甚到受限。影響彼此間組織的功能。例如肌束與肌束膜之間，肌肉外膜之間，關節與關節間，甚至臟器與臟器之間、體腔的髒層與壁層之間的運動受限等等。通過針法或手法的松解可減輕兩組織間粘連，使其恢復正常的生理狀態。臨床上最常見的就是術後切口，術後傷口 因瘢痕使皮膚與皮下組織粘連，在皮膚上出現一條明顯刀口痕跡，我們通過鈹針將其皮膚與皮下 組織平行鬆開，深陷的刀口線會在短時間內變平，其顏色及硬度也會隨之往正常方向發展。另外腹部手術後出現的腸粘連，也是一個典型的髒器與臟器間的粘連表現。這個手術後遺症目前仍 困擾著外科手術醫生。
二、適應證
適應於全身任何部位由於軟組織損傷或慢性勞損， 且局部組織已有器質性改變(即軟組織間粘連形成、纖維攣縮、內壓增高、囊壁增厚等病理改變，非手術療法無效或症狀反復發作者)引起的臨床症狀。
1.軟組織損傷引起的頸、腰痛，如頸後肌群緊張引起的頸椎錯位而出現的神經根型、椎動脈型及交感型頸椎病的臨床表現，可通過松解頸後緊張攣縮的肌肉，再配合適當牽引下正骨手法進行治療；
2 ．腰三橫突綜合徵、跟骨骨刺、膝關節內髁間隆起增生等病症；
3.肘管、踝管、尺管、腕管等骨纖維卡壓引起的臨床綜合徵，偏頭痛、腱鞘炎、肩周炎以及頸、腰神 經根在不同部位被周圍組織卡壓或擠壓引起的相關病症；
4. 腱鞘囊腫、關節內壓增高引起的關節脹痛，全身各部位引起的滑膜炎、滑囊炎、肌筋膜炎，如坐骨 結節滑囊炎、跟骨結節滑囊炎等；
5. 由外傷、勞損、手術後引起的局部組織粘連、瘢 痕等。如網球肘、肩胛提肌損傷，及骨關節內科疾病的後遺症(風濕、強直性脊柱炎、痛風、骨關節 缺血性壞死、四肢關節纖維性僵硬等)。
三、禁忌證
1 發熱、感染病人；
2 患血友病及有出血傾向或凝血機制障礙者；
3 嚴重的內髒病變發作期、糖尿病、精神病患者；
4 體格虛弱、不合作者；
5 施術部位有感染或有紅、腫、熱、痛、膿腫者；
6 診斷不明確，操作部位、病理變化及局剖解剖結 構(先天畸形或手術後) 複雜者；
7 施術部位鄰近有重要器官且無法保護者。
四、治療方法 一)所用針具
帶刃的針灸針(鈹針)，直徑及長度可根據部位及病理變化選用0.35-0.50*25-50型號。
二) 治療步驟
1.患者體位：根據病變部位及施術方式不同，可採取不同的體位進行操作；
2.進針部位：根據病變部位及施術手法選擇合適的部位，須有利於避讓重要組織的部位作為進針點；
3.進針方法：採用兩快一慢的方法，即進皮及出針 快以減輕局部疼痛，當針刃達皮下後，則需緩慢進 針，必要時可抖動針尖以刺激周圍較敏感的組織 (神經、血管等)產生反射性的避讓作用，以減少對組織的不必要損傷；
4.針刃方向：根據各部位層次的不同，按照以避讓重要組織為原則使其針刃與組織方向平行。
三) 治療方法
1.縱行疏通法：針刃與施術組織纖維方向平行，將組織與組織間的粘連鬆開,主要適應於組織間的粘連；
2.橫行松解法：針刃與施術部位的組織纖維垂直，切斷緊張的肌或腱纖維。主要適應於減輕骨纖維管 內高壓及高應力的纖維組織；
3.切割法：針刃達病變組織，根據瘢痕粘連組織的大小選擇不同方向及深度行切割手法，以減少組織粘連的面積及程度，促進局部病變組織的吸收；
4.通透剝離法：針體到達組織與組織間，利用針體分離兩組織間的粘連。此法主要適於粘連面積較大但程度不嚴重的組織間粘連；
5.穿孔減壓法： 針刃達病變組織，可刺破病變部位的囊壁或肌筋膜，必要時可擴大囊壁的切口，加速組織間的代謝及吸收。此法多用於囊內減壓。
四) 注意事項
1. 軟組織微創技術隨著其基礎理論及技術研究的不斷發展，其作用幾乎以失去原有的針刺功能，而被 閉合性的減張、減壓技術所取代。故其治療室應具 備一定的要求，且術者須掌握一定的無菌技術操作。
2. 軟組織微創技術雖來源於針刺，但已具備了減張、減壓的功能，術者除具有針刺手法的技巧外，更須熟練掌握人體的局部解剖、生理、病理及組織學等現代醫學知識，須具備一定的微創技術及影像學基礎，特別是骨傷科的基本知識及技術。
3. 對於軟組織微創，在施術中，醫者除自己所具備的醫學知識及微創經驗外，患者施術部位的感覺是醫生施術方式一個十分重要的指標，若須成功地完成治療，醫患之間的配合是必不可少的。
4. 精準是軟組織微創的特點，即施術醫生必須明確診斷、明確部位、明確病理變化、明確施術方法、明確避讓相鄰重要組織的方法及所要達到施術的目的，否則除影響其治療效果外，將會引起不必要的損傷，甚者出現術後並發症。
軟組織微創技術近幾十年，由於其在治痛方面的特效，吸引了眾多從事疼症治療的中醫師學習，謹以此文供他們參考。
