人体四肢经穴筋膜基础的医学影像学研究
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摘要
经络学说是中医学基础理论的核心内容,也是当前中医现代化的研究热点领域。半个多世纪以来,围绕着经络实质问题,现代多学科在经络物质基础、经穴的生物学效应、针灸机制等领域开展了广泛研究,揭示了大量与经络有关的生物学效应,提出了多种学说,其中经络实质的“结缔组织学说”在近年日益成为这一领域的研究热点,越来越多的研究证实,结缔组织是经络的解剖学基础。
我们在承担国家863计划“数字化虚拟中国人的数据集构建与海量数据库系统”项目的过程中,通过对人体结缔组织构成的筋膜支架进行标记和计算机三维重建,并结合发育生物学观点,提出遍布全身的结缔组织筋膜支架以干细胞为核心,在神经系统和免疫系统的参与下构成一个新的独立功能系统——支持储备及自体监控系统,对该系统本身机制以及与其他功能系统关系的研究称为筋膜学(Fasciology)。在这一理论指导下,我们曾利用虚拟人数据集成功构建出与中医经络经典记载有很强对应性的影像结构,为经络与结缔组织的解剖学相关提供了重要依据。
本研究尝试采用医学影像学方法,对人体四肢经穴的解剖结构加以观察,结合计算机三维重建技术,重点探索经络走行与筋膜分布密切相关的规律,为揭示经络的解剖学实质提供新的依据。
研究目的
1、通过超声影像学观察,分析针刺作用于筋膜结构的生理学特征,探索四肢经穴分布与筋膜聚集区域的内在规律。
2、采用CT、MRI手段,对人体四肢的结缔组织影像信息进行数字化采集,并把三维重建的结果与中医四肢经络的走行路线相比较,为揭示经络的筋膜学实质提供医学影像学依据。
3、把CT、MRI与三维重建技术相结合引进经络研究领域,为揭示经络与穴位的解剖学实质进行方法学上的创新性研究。
仪器与方法
1、医学超声影像学研究。仪器:荷兰飞利浦公司制造的IU22全身彩色多普勒超声波诊断仪,利用超声波具有实时显像、导向准确、操作简单、无X线损害、价格低廉、灵敏清晰等特点。采用两种电子线阵高频探头,型号分别是:L17-5、L9-3,全自动变频范围17-3HMz。超声是评估针灸对组织所产生的生化效应的理想方法之一,在提供组织形态学和组织生化学影像信息方面的具有独特优势。人体内在可视超声图像下插入针灸针可以清楚地辨别解剖细节,如针所贯穿的组织层面(皮肤、皮下组织,肌肉等)及牵动的范围。方法:将超声探头置于针灸针旁,用针灸针对3例志愿者的曲尺、合谷、足三里等中医穴位进行刺激,观察针灸针在人体内是如何产生组织位移,并对其发挥作用的机制进行分析和总结。
2、16层螺旋CT医学影像学研究。仪器:美国GE公司制造的Lightspeed 16层螺旋CT。方法:对12例人体双下肢进行扫描,扫描层厚7.5～10mm,螺距1.375mm,获得轴位图像,平均每例获取20幅图像,共获得240幅双下肢螺旋CT图像,以DICOM格式保存。按实验设计及解剖学识别,在获取的16层螺旋CT断面图像上标记人体肢体结缔组织的聚集处(肌间隔)作标记点。点的选择位置是在肢体结缔组织聚集处作一等腰三角形,取三角形的中心作为标记点,用红色点标记,而后将获得的CT图像按顺序依次叠加,用红色线条将各点相连,并通过GE16层螺旋CT的ADW4.2影像工作站做三维重建和透明处理后形成一条红色连线,然后将这些连线的走行和分布与中医书籍所记载的经穴的走行与分布进行比较。
3、3.0T MRI医学影像学研究及三维重建。仪器:美国GE公司制造的GESigna Excite 3.0T核磁共振成像系统(MRI)。方法:计划先在志愿者体表标出经络线及穴位,用注满造影剂的塑料管固定在经络线上,然后经过MRI扫描,观察我们所固定及标记在塑料管内造影剂之下人体的组织结构主要是由哪些构成,分析经络的形态学基础。后又收集16例临床病人和志愿者的上下肢核磁共振成像,获取的图像用DICOM格式保存。选取其中右上肢一例,获取MRI横断面图像900张,导入Adobe Photoshop cs软件,逐张将结缔组织聚集处进行标记,而后用MIMICS11.02软件进行三维重建,并将其结果与数字人的重建结果及中医经典经络线进行比较。由于存在软组织与周围组织密度差异的问题,先把MRI的DICOM格式用DICOM查看器转换成BMP格式,将转换好的图片用personal computer机自带的Adobe Photoshop cs7.0图像处理软件进行右上肢软组织的分割,具体步骤是:打开Adobe Photoshop cs7.0图像处理软件,找到要分割的图像并导入,采用套索工具勾画出感兴趣区(肌肉间隔处及软组织聚集处),通过选择反选,剔除其他组织,保存所需兴趣区的图片等手段处理后,即得到所需要的部分(由于手指部位勾画困难,未能标出)。
结果
1、通过实时观察超声波的图像证实,针灸针在行针者实施提插、捻转等动作条件下,志愿者出现酸麻胀等“得气”现象时,发现针灸针刺激的曲池、合谷、足三里等穴位一般均在结缔组织内或结缔组织较为丰富的区域,针灸针提插时可上下带动较深部位的结缔组织、肌腱等并随之运动;捻转针灸针时,可见针灸针周围的结缔组织以针灸针为中心做左右缠绕运动,亦能带动或牵动较多的结缔组织随之运动。另外,我们通过超声图像观察还发现,志愿者的“得气”感一般出现于针灸针尖到达肌外膜时,当针尖到达肌肉层则“得气”感减弱,若针尖停留在肌外膜并增加刺激,“得气”感会进一步增强。
2、利用GE16层螺旋CT的ADW4.2影像工作站,从收集12例CT的图像资料中选择其中一例,对其双下肢部位的结缔组织聚集处进行3D容积重建(3DVolune Rendering),三维重建和透明处理后形成一条红色连线,将这些连线与中医经穴的走行与分布进行比较,结果呈现明显的一致性。将该结果与数字解剖学研究相比较,结果相似,说明无论在人体活体标本和尸体标本上,通过CT的横断面图像进行标记和图像叠加,均可构建出肌间隔之间的连线,其中部分与中医记载的经络走行有很强的相似性。据此认为全身的筋膜有可能是经络的解剖学基础,它作为人体的支持与储备系统,发挥着与中医传统理论中经络作用相似的自体监控作用。
3、在3.0T MRI实验中,先后尝试采用多种位于体表的经络标记方法实现磁共振显像,并与体内筋膜聚集规律相对比。为此曾用多种造影剂在塑料管内灌注并固定于体表,如专用的磁显葡胺造影剂、鱼肝油溶液、动物脂肪榨取液等。通过十余次实验及各种仪器条件,结果在MRI上均不能充分显像。后通过获取的MRI图像,将分割提取后的肌间隔图像导入MIMICS11.02三维重建软件,调节域值,重建出经络的三维图,并设置经络色彩为黄色,保存STL格式备用;导入整个前臂的MRI数据,重建出前臂的整体外形三维模型,保存STL格式。然后将模型导入到FreeForm Modeling System-自由设计模型系统进行平滑和去除一些过多的细节和噪声,并可将各模型在空间上组合和显示,将前臂设置为透明状,可显示其内经络线的走行,此模型可以放大、缩小和旋转,全方位观察各结构或细节。根据经MIMICS11.02图像处理后的结果,我们发现均能在其他获得的MRI数据上建出数条肢体结缔组织支架和/或连线,且和数字人的重建结果大致相似。由于此项实验工作量极为庞大,加上时间所限,故只完成了一条人右上臂的三维重建。
结论
1、医学超声影像学研究表明,中医用针灸针取穴治疗疾病时,通过提插、捻转等动作行针,可以带动或牵动周边范围的结缔组织,行针所引起的软组织位移,在提插过程中更为明显,此种位移与肌间筋膜的方向相一致。而刺激结缔组织的范围与强度和得气感密切相关,由此初步认为,针灸临床作用机制在于实现对筋膜不同程度的刺激,传统经穴则是筋膜聚集的部位,筋膜学理论和经络学说都把针灸的部位指向筋膜聚集区,从侧面证实了筋膜是经络的解剖学基础。
2、16层螺旋CT的医学影像学研究结论,与中医经穴走行与分布的经典记载非常相近,在不同个体和体质状态下均能实现同样的结果,从形态学角度佐证了经络实质和结缔组织密切相关。该研究方法与基于数字人的经络研究方法基本一致,效果也大致相当,说明通过一定的人为手段标记出人肢体筋膜聚集处,均可构建出中医经典的经络线。
3、3.0T MRI医学影像学研究和图像的MIMICS11.02三维重建,发现四肢经穴大多数位于肌间隔疏松结缔组织聚集处,少数位于神经血管束结缔组织,随着设定阈值的不同,显示范围和数目也会有很大差异,而活体和标本无明显的差异。
上述研究表明,人体四肢重要穴位与结缔组织密切相关;CT、MRI等医学放射影像学手段,配合计算机软件处理,能够在每个人体上重建出和数字人技术类似的结缔组织连线,其中四肢部分的连线与经络经典记载的走行与分布非常相近,据此可认为穴位可能是引起结缔组织中的生物感受器产生较强生物学信息(神经信息、细胞信息、生化信息)的部位。由于几乎所有人体组织器官的间隙均有结缔组织存在,因此从根本上说全身各个部位均是穴位,或者说全身广泛分布的结缔组织中穴位与非穴位只有“量”的不同而没有“质”的区别,而全身的结缔组织支架是经络的解剖学物质基础。这一结论初步解决了传统经络的解剖学定位问题,为揭示针灸疗法的生物学机制提供了重要依据,有力地推动着针灸经络研究从经验医学模式向生物医学模式过渡。
BACKGROUND
The meridian theory,the fundamental basis for Traditional Chinese Medicine (TCM),is becoming the hottest spot in TCM modernization.Extensive researches on the nature,biological effects of channels and points,and the mechanisms underlying the acupuncture have been done for over half a century.Numerous achievements have been made on the elucidation of meridian-associated biological effects and the emergence of novel hypotheses,one of which is "connective tissue theory".More and more evidence reveals that connective tissue lays an anatomical foundation for meridian theory,which is becoming an appealing area in TCM.
Supported by a foundation from National High Technology Research and Development Program of China(863 Program),Database Construction of Digitized Virtual Chinese & Establishment of A Massive Database System,a fascial meshwork composed of connective tissue throughout the human body is marked and reconstructed three-dimensionally(3-D) assisted by computers.In view of the above-mentioned facts along with its developmental origin,we propose a novel independent functional system,namely,supportive reserve & autologous surveillance system,consisting of connective tissue meshwork throughout the human body involving stem cell core,nervous system as well as immune components within it. Fasciology is a subject to study the mechanism underlying this new system and its relationship with other functional systems.Guided by this theory,we successfully constructed the imageological structure corresponding to classic meridian recorded in ancient TCM works using our previously established database of digitized virtual Chinese,which provides important evidence for the correlation of meridian to connective tissue.
The present study aims to observe the anatomical structure of channels and points in human extremities by medical imageological techniques,and especially to emphasize on the correlation of the meridian pathways to fascial distribution by computer-assisted 3-D reconstruction technique,which facilitates the elucidation of the anatomical nature of fascia.
OBJECTIVES
1.To evaluate the physiological characteristics of fascial structure stimulated by acupuncture,and to explore the intrinsic rules underlying the correlation of the distribution of channels and points in human extremities to fascia-rich areas by using imaging techniques.
2.To record digital imaging information of the connective tissue in human extremities by computer tomography(CT) and magnetic resonance imaging(MRI), and to elucidate the fascial nature of meridian by the comparison of the 3-D reconstructed image with the meridian pathways in human extremities.
3.To establish a novel method for elucidating the anatomical nature of meridian and points by integrating CT,MRI and the 3-D reconstruction technique.
INSTRUMENTS & METHODS
1.Ultrasonographic Imaging
Instruments
1) IU22 Systemic Color Doppler Ultrasonic Diagnosis Apparatus(Dutch Phillips Company) with two electronic linear array high frequency probes,L17-5 and L9-3
2) Acupuncture needles
METHODS
Ultrasonic probes are placed near the acupuncture needles that stimulate such points as Quchi,Hegu and Zusanli in 3 healthy volunteers,which facilitates the explanation of the mechanism underlying acupuncture.
2.Helical CT Imaging
INSTRUMENTS
Light-Speed 16-layered Helical CT Scanner(GE Medical System,USA)
METHODS
Both lower extremities of each of the 12 healthy volunteers are scanned(slice thick 7.5-10 mm) at a pitch of 1.3375mm in an axial plane.20 CT images are obtained for each volunteer(240 images in total) saved in a.DICOM format. According to the experimental design and anatomical signs,connective tissue-rich areas(intermuscular compartments) in human lower extremities are labeled in these 16-layered CT images by an isosceles triangle at each area.The center of gravity of each triangle is marked by a red dot.After stacking these images one by one,link all the dots to form a red line,then,computer-assisted 3-D reconstruction by ADW 4.2 image workstation and transparent processing are performed to analyze the red line, and finally,compare the path of the red line with that of the channels and points recorded in classic ancient TCM works.
3.MRI & 3-D Reconstruction
INSTRUMENTS
GE 3.0T Sigma Advantage MR Scanner(GE Medical System,USA)
METHODS
We first mark the meridian line and acupuncture points on the body surface of the volunteers,and then fix plastic tubes full of contrast medium along the meridian line.MRI scanning is performed to observe the composition of the tissue underlying the labeled line and points for further analysis of the morphological nature of meridian.We also collect MRI images of the extremities from 16 patients and volunteers,of which 900 images about one right upper extremity are processed by Adobe Photoshop CS,and then 3-D reconstructed by MIMICS 11.02 software,and finally,compare our result with that resulting from both virtual human reconstruction and meridian line described in classic ancient TCM works.
Due to the difference in density between soft tissues and the surrounding tissues,.DICOM files are transformed into.BMP format by DICON viewer. Subdivide the transformed pictures by Adobe Photoshop CS.Open the selected file, outline the target area(intermuscular compartments and soft tissue-rich areas),delete other tissues,and save what you are interested in except those in the fingers because of technical difficulties.
RESULTS
1.When stimulated by the back-and-forth and twisting movement of acupuncture needles at Quchi,Hegu and Zusanli in volunteers,a phenomenon called "De Qi",a feeling of sour,distension and numbness,appears.Results from ultrasonic observation show that these points are either within connective tissue or in connective tissue-rich areas.The connective tissue around the needles,deeper connective tissue and tendons beneath the points shift with the movement of the needles.In addition, the feeling of "De Qi" occurs when the needle tip touches the epimysium.Increased stimulation here reinforces the feeling,whereas poor "De Qi" is present elsewhere.
2.Using GE 16-layered Helical CT as well as ADW4.2 image workstation, image data about the connective tissue-rich areas of both lower extremities from one of the 12 subjects are processed by 3-D volume rendering,3-D reconstruction and lucidification to form a red line,which is highly consistent with the corresponding meridian channel,and with the result from digital anatomical findings.The above-mentioned facts suggest that the line connecting successive points within intermuscular compartment labeled in cross-sectioned CT images shows strong similarity to the corresponding meridian channel described in classic TCM works either in living human bodies or in cadaver specimen.In view of this,the systemic fascia may be the nature of meridian channels and points,which forms a supportive and reserving system whose function is similar to TCM meridian channels.
3.Superficial meridian channels are labeled by MRI,and then compared with the in vivo fascia-gathering areas.Insufficient imaging is achieved although many contrast agents including gadopentetic acid,cod-liver oil,solution extracted from animal fat are perfused into plastic tubes.Process these images as described above to reconstruct a 3-D model of one forearm saved in.STL format.The data are introduced to Free-Form Modeling System for further modification by removal of redundant details and noises.After spatial integration and lucidification of the model, the meridian channel is clearly displayed.The model can be viewed in zoom in/out and spiral status in details.According to the data processed by MIMICS11.02,more connective tissue meshwork and/or the links that are consistent with those from digital human can be constructed.Due to the extremely huge work load as well as limited time,only one human right forearm is 3-D reconstructed in the present study.
CONCLUSIONS
1.Results from ultrasonic imaging show that the connective tissue around the needles beneath the acupuncture points shift with the movement of the needles (back-and-forth insertion and twisting).The displacement is consistent with the orientation of the intermuscular fascia.Stimulation of these areas is closely associated with "De Oi".Therefore,we consider that the mechanism underlying clinical acupuncture is primarily dependent on the stimuli of different intensities.Fascia is usually present in acupuncture points.These facts support the fascial basis of the meridian channels on the other hand.
2.Results from 16-layered Helical CT show highly consistent with the corresponding meridian channels described in classic TCM works and with the findings from digital human regardless of individuality and physical status of the body,suggesting that classic meridian channels can be outlined by artificially labeling the fascia-rich areas in human extremities.
3.According to MRI images processed by MIMICS11.02,most of the points in the extremities occur with the areas rich in loose connective tissue within intermuscular compartments.They seldom appear in the connective tissue surrounding nerves and blood vessels.The display ranges and number vary obviously with the preset thresholds.No prominent differences appear between living bodies and dead bodies.
The above research indicates that 1) important acupuncture points in human extremities be closely associated with connective tissue;and 2) connective tissue could be reconstructed by integration of CT,MRI and computer-assisted techniques to form a line which is highly consistent with that recorded in classic TCM works, suggesting that points might be the place where strong biological information arises from biosensors in the connective tissue.Since connective tissue exists in almost all the spaces among human organs,points are primarily regarded to be present anywhere,that is to say,points are different from non-points only in their quantity, but not in the quality of connective tissue.The systemic connective tissue meshwork constitutes the anatomical nature of the meridian.Our finding preliminarily resolves the debate about the anatomical positioning of traditional meridian channels and points,which provides important evidence for the elucidation of the mechanism underlying acupuncture therapy.Our study may facilitate the transition of the study of acupuncture from experience pattern to biomedical model.
我们在承担国家863计划“数字化虚拟中国人的数据集构建与海量数据库系统”项目的过程中,通过对人体结缔组织构成的筋膜支架进行标记和计算机三维重建,并结合发育生物学观点,提出遍布全身的结缔组织筋膜支架以干细胞为核心,在神经系统和免疫系统的参与下构成一个新的独立功能系统——支持储备及自体监控系统,对该系统本身机制以及与其他功能系统关系的研究称为筋膜学(Fasciology)。在这一理论指导下,我们曾利用虚拟人数据集成功构建出与中医经络经典记载有很强对应性的影像结构,为经络与结缔组织的解剖学相关提供了重要依据。
本研究尝试采用医学影像学方法,对人体四肢经穴的解剖结构加以观察,结合计算机三维重建技术,重点探索经络走行与筋膜分布密切相关的规律,为揭示经络的解剖学实质提供新的依据。
研究目的
1、通过超声影像学观察,分析针刺作用于筋膜结构的生理学特征,探索四肢经穴分布与筋膜聚集区域的内在规律。
2、采用CT、MRI手段,对人体四肢的结缔组织影像信息进行数字化采集,并把三维重建的结果与中医四肢经络的走行路线相比较,为揭示经络的筋膜学实质提供医学影像学依据。
3、把CT、MRI与三维重建技术相结合引进经络研究领域,为揭示经络与穴位的解剖学实质进行方法学上的创新性研究。
仪器与方法
1、医学超声影像学研究。仪器:荷兰飞利浦公司制造的IU22全身彩色多普勒超声波诊断仪,利用超声波具有实时显像、导向准确、操作简单、无X线损害、价格低廉、灵敏清晰等特点。采用两种电子线阵高频探头,型号分别是:L17-5、L9-3,全自动变频范围17-3HMz。超声是评估针灸对组织所产生的生化效应的理想方法之一,在提供组织形态学和组织生化学影像信息方面的具有独特优势。人体内在可视超声图像下插入针灸针可以清楚地辨别解剖细节,如针所贯穿的组织层面(皮肤、皮下组织,肌肉等)及牵动的范围。方法:将超声探头置于针灸针旁,用针灸针对3例志愿者的曲尺、合谷、足三里等中医穴位进行刺激,观察针灸针在人体内是如何产生组织位移,并对其发挥作用的机制进行分析和总结。
2、16层螺旋CT医学影像学研究。仪器:美国GE公司制造的Lightspeed 16层螺旋CT。方法:对12例人体双下肢进行扫描,扫描层厚7.5～10mm,螺距1.375mm,获得轴位图像,平均每例获取20幅图像,共获得240幅双下肢螺旋CT图像,以DICOM格式保存。按实验设计及解剖学识别,在获取的16层螺旋CT断面图像上标记人体肢体结缔组织的聚集处(肌间隔)作标记点。点的选择位置是在肢体结缔组织聚集处作一等腰三角形,取三角形的中心作为标记点,用红色点标记,而后将获得的CT图像按顺序依次叠加,用红色线条将各点相连,并通过GE16层螺旋CT的ADW4.2影像工作站做三维重建和透明处理后形成一条红色连线,然后将这些连线的走行和分布与中医书籍所记载的经穴的走行与分布进行比较。
3、3.0T MRI医学影像学研究及三维重建。仪器:美国GE公司制造的GESigna Excite 3.0T核磁共振成像系统(MRI)。方法:计划先在志愿者体表标出经络线及穴位,用注满造影剂的塑料管固定在经络线上,然后经过MRI扫描,观察我们所固定及标记在塑料管内造影剂之下人体的组织结构主要是由哪些构成,分析经络的形态学基础。后又收集16例临床病人和志愿者的上下肢核磁共振成像,获取的图像用DICOM格式保存。选取其中右上肢一例,获取MRI横断面图像900张,导入Adobe Photoshop cs软件,逐张将结缔组织聚集处进行标记,而后用MIMICS11.02软件进行三维重建,并将其结果与数字人的重建结果及中医经典经络线进行比较。由于存在软组织与周围组织密度差异的问题,先把MRI的DICOM格式用DICOM查看器转换成BMP格式,将转换好的图片用personal computer机自带的Adobe Photoshop cs7.0图像处理软件进行右上肢软组织的分割,具体步骤是:打开Adobe Photoshop cs7.0图像处理软件,找到要分割的图像并导入,采用套索工具勾画出感兴趣区(肌肉间隔处及软组织聚集处),通过选择反选,剔除其他组织,保存所需兴趣区的图片等手段处理后,即得到所需要的部分(由于手指部位勾画困难,未能标出)。
结果
1、通过实时观察超声波的图像证实,针灸针在行针者实施提插、捻转等动作条件下,志愿者出现酸麻胀等“得气”现象时,发现针灸针刺激的曲池、合谷、足三里等穴位一般均在结缔组织内或结缔组织较为丰富的区域,针灸针提插时可上下带动较深部位的结缔组织、肌腱等并随之运动;捻转针灸针时,可见针灸针周围的结缔组织以针灸针为中心做左右缠绕运动,亦能带动或牵动较多的结缔组织随之运动。另外,我们通过超声图像观察还发现,志愿者的“得气”感一般出现于针灸针尖到达肌外膜时,当针尖到达肌肉层则“得气”感减弱,若针尖停留在肌外膜并增加刺激,“得气”感会进一步增强。
2、利用GE16层螺旋CT的ADW4.2影像工作站,从收集12例CT的图像资料中选择其中一例,对其双下肢部位的结缔组织聚集处进行3D容积重建(3DVolune Rendering),三维重建和透明处理后形成一条红色连线,将这些连线与中医经穴的走行与分布进行比较,结果呈现明显的一致性。将该结果与数字解剖学研究相比较,结果相似,说明无论在人体活体标本和尸体标本上,通过CT的横断面图像进行标记和图像叠加,均可构建出肌间隔之间的连线,其中部分与中医记载的经络走行有很强的相似性。据此认为全身的筋膜有可能是经络的解剖学基础,它作为人体的支持与储备系统,发挥着与中医传统理论中经络作用相似的自体监控作用。
3、在3.0T MRI实验中,先后尝试采用多种位于体表的经络标记方法实现磁共振显像,并与体内筋膜聚集规律相对比。为此曾用多种造影剂在塑料管内灌注并固定于体表,如专用的磁显葡胺造影剂、鱼肝油溶液、动物脂肪榨取液等。通过十余次实验及各种仪器条件,结果在MRI上均不能充分显像。后通过获取的MRI图像,将分割提取后的肌间隔图像导入MIMICS11.02三维重建软件,调节域值,重建出经络的三维图,并设置经络色彩为黄色,保存STL格式备用;导入整个前臂的MRI数据,重建出前臂的整体外形三维模型,保存STL格式。然后将模型导入到FreeForm Modeling System-自由设计模型系统进行平滑和去除一些过多的细节和噪声,并可将各模型在空间上组合和显示,将前臂设置为透明状,可显示其内经络线的走行,此模型可以放大、缩小和旋转,全方位观察各结构或细节。根据经MIMICS11.02图像处理后的结果,我们发现均能在其他获得的MRI数据上建出数条肢体结缔组织支架和/或连线,且和数字人的重建结果大致相似。由于此项实验工作量极为庞大,加上时间所限,故只完成了一条人右上臂的三维重建。
结论
1、医学超声影像学研究表明,中医用针灸针取穴治疗疾病时,通过提插、捻转等动作行针,可以带动或牵动周边范围的结缔组织,行针所引起的软组织位移,在提插过程中更为明显,此种位移与肌间筋膜的方向相一致。而刺激结缔组织的范围与强度和得气感密切相关,由此初步认为,针灸临床作用机制在于实现对筋膜不同程度的刺激,传统经穴则是筋膜聚集的部位,筋膜学理论和经络学说都把针灸的部位指向筋膜聚集区,从侧面证实了筋膜是经络的解剖学基础。
2、16层螺旋CT的医学影像学研究结论,与中医经穴走行与分布的经典记载非常相近,在不同个体和体质状态下均能实现同样的结果,从形态学角度佐证了经络实质和结缔组织密切相关。该研究方法与基于数字人的经络研究方法基本一致,效果也大致相当,说明通过一定的人为手段标记出人肢体筋膜聚集处,均可构建出中医经典的经络线。
3、3.0T MRI医学影像学研究和图像的MIMICS11.02三维重建,发现四肢经穴大多数位于肌间隔疏松结缔组织聚集处,少数位于神经血管束结缔组织,随着设定阈值的不同,显示范围和数目也会有很大差异,而活体和标本无明显的差异。
上述研究表明,人体四肢重要穴位与结缔组织密切相关;CT、MRI等医学放射影像学手段,配合计算机软件处理,能够在每个人体上重建出和数字人技术类似的结缔组织连线,其中四肢部分的连线与经络经典记载的走行与分布非常相近,据此可认为穴位可能是引起结缔组织中的生物感受器产生较强生物学信息(神经信息、细胞信息、生化信息)的部位。由于几乎所有人体组织器官的间隙均有结缔组织存在,因此从根本上说全身各个部位均是穴位,或者说全身广泛分布的结缔组织中穴位与非穴位只有“量”的不同而没有“质”的区别,而全身的结缔组织支架是经络的解剖学物质基础。这一结论初步解决了传统经络的解剖学定位问题,为揭示针灸疗法的生物学机制提供了重要依据,有力地推动着针灸经络研究从经验医学模式向生物医学模式过渡。
BACKGROUND
The meridian theory,the fundamental basis for Traditional Chinese Medicine (TCM),is becoming the hottest spot in TCM modernization.Extensive researches on the nature,biological effects of channels and points,and the mechanisms underlying the acupuncture have been done for over half a century.Numerous achievements have been made on the elucidation of meridian-associated biological effects and the emergence of novel hypotheses,one of which is "connective tissue theory".More and more evidence reveals that connective tissue lays an anatomical foundation for meridian theory,which is becoming an appealing area in TCM.
Supported by a foundation from National High Technology Research and Development Program of China(863 Program),Database Construction of Digitized Virtual Chinese & Establishment of A Massive Database System,a fascial meshwork composed of connective tissue throughout the human body is marked and reconstructed three-dimensionally(3-D) assisted by computers.In view of the above-mentioned facts along with its developmental origin,we propose a novel independent functional system,namely,supportive reserve & autologous surveillance system,consisting of connective tissue meshwork throughout the human body involving stem cell core,nervous system as well as immune components within it. Fasciology is a subject to study the mechanism underlying this new system and its relationship with other functional systems.Guided by this theory,we successfully constructed the imageological structure corresponding to classic meridian recorded in ancient TCM works using our previously established database of digitized virtual Chinese,which provides important evidence for the correlation of meridian to connective tissue.
The present study aims to observe the anatomical structure of channels and points in human extremities by medical imageological techniques,and especially to emphasize on the correlation of the meridian pathways to fascial distribution by computer-assisted 3-D reconstruction technique,which facilitates the elucidation of the anatomical nature of fascia.
OBJECTIVES
1.To evaluate the physiological characteristics of fascial structure stimulated by acupuncture,and to explore the intrinsic rules underlying the correlation of the distribution of channels and points in human extremities to fascia-rich areas by using imaging techniques.
2.To record digital imaging information of the connective tissue in human extremities by computer tomography(CT) and magnetic resonance imaging(MRI), and to elucidate the fascial nature of meridian by the comparison of the 3-D reconstructed image with the meridian pathways in human extremities.
3.To establish a novel method for elucidating the anatomical nature of meridian and points by integrating CT,MRI and the 3-D reconstruction technique.
INSTRUMENTS & METHODS
1.Ultrasonographic Imaging
Instruments
1) IU22 Systemic Color Doppler Ultrasonic Diagnosis Apparatus(Dutch Phillips Company) with two electronic linear array high frequency probes,L17-5 and L9-3
2) Acupuncture needles
METHODS
Ultrasonic probes are placed near the acupuncture needles that stimulate such points as Quchi,Hegu and Zusanli in 3 healthy volunteers,which facilitates the explanation of the mechanism underlying acupuncture.
2.Helical CT Imaging
INSTRUMENTS
Light-Speed 16-layered Helical CT Scanner(GE Medical System,USA)
METHODS
Both lower extremities of each of the 12 healthy volunteers are scanned(slice thick 7.5-10 mm) at a pitch of 1.3375mm in an axial plane.20 CT images are obtained for each volunteer(240 images in total) saved in a.DICOM format. According to the experimental design and anatomical signs,connective tissue-rich areas(intermuscular compartments) in human lower extremities are labeled in these 16-layered CT images by an isosceles triangle at each area.The center of gravity of each triangle is marked by a red dot.After stacking these images one by one,link all the dots to form a red line,then,computer-assisted 3-D reconstruction by ADW 4.2 image workstation and transparent processing are performed to analyze the red line, and finally,compare the path of the red line with that of the channels and points recorded in classic ancient TCM works.
3.MRI & 3-D Reconstruction
INSTRUMENTS
GE 3.0T Sigma Advantage MR Scanner(GE Medical System,USA)
METHODS
We first mark the meridian line and acupuncture points on the body surface of the volunteers,and then fix plastic tubes full of contrast medium along the meridian line.MRI scanning is performed to observe the composition of the tissue underlying the labeled line and points for further analysis of the morphological nature of meridian.We also collect MRI images of the extremities from 16 patients and volunteers,of which 900 images about one right upper extremity are processed by Adobe Photoshop CS,and then 3-D reconstructed by MIMICS 11.02 software,and finally,compare our result with that resulting from both virtual human reconstruction and meridian line described in classic ancient TCM works.
Due to the difference in density between soft tissues and the surrounding tissues,.DICOM files are transformed into.BMP format by DICON viewer. Subdivide the transformed pictures by Adobe Photoshop CS.Open the selected file, outline the target area(intermuscular compartments and soft tissue-rich areas),delete other tissues,and save what you are interested in except those in the fingers because of technical difficulties.
RESULTS
1.When stimulated by the back-and-forth and twisting movement of acupuncture needles at Quchi,Hegu and Zusanli in volunteers,a phenomenon called "De Qi",a feeling of sour,distension and numbness,appears.Results from ultrasonic observation show that these points are either within connective tissue or in connective tissue-rich areas.The connective tissue around the needles,deeper connective tissue and tendons beneath the points shift with the movement of the needles.In addition, the feeling of "De Qi" occurs when the needle tip touches the epimysium.Increased stimulation here reinforces the feeling,whereas poor "De Qi" is present elsewhere.
2.Using GE 16-layered Helical CT as well as ADW4.2 image workstation, image data about the connective tissue-rich areas of both lower extremities from one of the 12 subjects are processed by 3-D volume rendering,3-D reconstruction and lucidification to form a red line,which is highly consistent with the corresponding meridian channel,and with the result from digital anatomical findings.The above-mentioned facts suggest that the line connecting successive points within intermuscular compartment labeled in cross-sectioned CT images shows strong similarity to the corresponding meridian channel described in classic TCM works either in living human bodies or in cadaver specimen.In view of this,the systemic fascia may be the nature of meridian channels and points,which forms a supportive and reserving system whose function is similar to TCM meridian channels.
3.Superficial meridian channels are labeled by MRI,and then compared with the in vivo fascia-gathering areas.Insufficient imaging is achieved although many contrast agents including gadopentetic acid,cod-liver oil,solution extracted from animal fat are perfused into plastic tubes.Process these images as described above to reconstruct a 3-D model of one forearm saved in.STL format.The data are introduced to Free-Form Modeling System for further modification by removal of redundant details and noises.After spatial integration and lucidification of the model, the meridian channel is clearly displayed.The model can be viewed in zoom in/out and spiral status in details.According to the data processed by MIMICS11.02,more connective tissue meshwork and/or the links that are consistent with those from digital human can be constructed.Due to the extremely huge work load as well as limited time,only one human right forearm is 3-D reconstructed in the present study.
CONCLUSIONS
1.Results from ultrasonic imaging show that the connective tissue around the needles beneath the acupuncture points shift with the movement of the needles (back-and-forth insertion and twisting).The displacement is consistent with the orientation of the intermuscular fascia.Stimulation of these areas is closely associated with "De Oi".Therefore,we consider that the mechanism underlying clinical acupuncture is primarily dependent on the stimuli of different intensities.Fascia is usually present in acupuncture points.These facts support the fascial basis of the meridian channels on the other hand.
2.Results from 16-layered Helical CT show highly consistent with the corresponding meridian channels described in classic TCM works and with the findings from digital human regardless of individuality and physical status of the body,suggesting that classic meridian channels can be outlined by artificially labeling the fascia-rich areas in human extremities.
3.According to MRI images processed by MIMICS11.02,most of the points in the extremities occur with the areas rich in loose connective tissue within intermuscular compartments.They seldom appear in the connective tissue surrounding nerves and blood vessels.The display ranges and number vary obviously with the preset thresholds.No prominent differences appear between living bodies and dead bodies.
The above research indicates that 1) important acupuncture points in human extremities be closely associated with connective tissue;and 2) connective tissue could be reconstructed by integration of CT,MRI and computer-assisted techniques to form a line which is highly consistent with that recorded in classic TCM works, suggesting that points might be the place where strong biological information arises from biosensors in the connective tissue.Since connective tissue exists in almost all the spaces among human organs,points are primarily regarded to be present anywhere,that is to say,points are different from non-points only in their quantity, but not in the quality of connective tissue.The systemic connective tissue meshwork constitutes the anatomical nature of the meridian.Our finding preliminarily resolves the debate about the anatomical positioning of traditional meridian channels and points,which provides important evidence for the elucidation of the mechanism underlying acupuncture therapy.Our study may facilitate the transition of the study of acupuncture from experience pattern to biomedical model.
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