Anti-inflammatory and immune regulatory effects of acupuncture after craniotomy: study protocol for a parallel-group randomized controlled trial
Cho et al. Trials
Anti-inflammatory and immune regulatory effects of acupuncture after craniotomy: study protocol for a parallel-group randomized controlled trial
Seung-Yeon Cho 0 1
Seung-Bo Yang 1
Hee Sup Shin 1
Seung Hwan Lee 1
Jun Seok Koh 1
Seungwon Kwon 0
Woo-Sang Jung 0
Sang-Kwan Moon 0
Jung-Mi Park 0 1
Chang-Nam Ko 0 1
Seong-Uk Park 0 1
0 Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University , 26, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447 , Republic of Korea
1 Stroke and Neurological Disorders Center, Kyung Hee University Hospital at Gangdong , 892, Dongnam-ro, Gangdong-gu, Seoul 05278 , Republic of Korea
Background: Despite recent advances in the medical and surgical fields, complications such as infection, pneumonia, or brain swelling may occur after a craniotomy. In some patients, perioperative antibiotic prophylaxis causes adverse effects such as itching, rash, or digestive conditions. Certain patients still develop infections severe enough to require a repeat operation despite antibiotic prophylaxis. Acupuncture has been used to treat inflammatory conditions, and many basic and clinical studies have provided evidence of its anti-inflammatory and immune regulatory effects. The aim of this study is to explore the effects of acupuncture on inflammation and immune function after craniotomy. Methods: This trial will be a single-center, parallel-group clinical trial. Forty patients who underwent craniotomy for an unruptured aneurysm, facial spasm, or a brain tumor will be allocated to either the study or the control group. The study group will receive conventional management as well as acupuncture, electroacupuncture, and intradermal acupuncture, which will start within 48 h of the craniotomy. The patients will receive a total of six sessions within 8 days. The control group will only receive conventional management. The primary outcome measure will be the Creactive protein levels, while the secondary outcomes will be the serum erythrocyte sedimentation rate and the tumor necrosis factor-α, interleukin (IL)-1β, and IL-6 levels measured at four different time points: within 48 h prior to the craniotomy and on days 2, 4, and 7 after surgery. The presence of fever and infection, the use of additional antibiotics, the presence of infection, including pneumonia or urinary tract infection, and safety will also be investigated. Discussion: In this trial, we will observe whether acupuncture has anti-inflammatory and immune regulatory effects after a craniotomy. If our study yields positive results and a placebo-controlled study also finds favorable results following our study, acupuncture could be recommended as an adjunctive therapy after a craniotomy.
Craniotomy; Neurosurgery; Acupuncture; Electroacupuncture; Inflammation; Immune function
A craniotomy is a common surgical procedure
performed to remove brain tumors, blood, or arteriovenous
malformations (AVM), and to clip an aneurysm, or for
microvascular decompression (MVD). Even if the
surgery is performed properly, complications, such as
infection, pneumonia, or brain swelling, may occur after a
craniotomy . Infections are one of the most common
postoperative complications, and impairment of immune
function after surgery has been shown to be associated
with a higher risk of infection as well as other
postoperative complications . C-reactive protein (CRP) is an
indicator of inflammatory processes and its levels rise in
response to surgical procedures or infection. Therefore,
it is commonly used as an index of complications after
surgery [3–7]. A study that investigated the association
between changes in serum proinflammatory and
antiinflammatory cytokine concentrations and postoperative
septic complications reported that the postoperative
increase in interleukin (IL)-6 concentration was
associated with septic morbidity, while an elevated level of the
IL-1 receptor antagonist (IL-1ra) was associated with
postoperative septic shock .
Appropriate antibiotic prophylaxis reduces the
incidence of inflammation, although it may cause adverse
effects such as itching, rash, digestive problems including
diarrhea, or elevation of liver enzyme levels in some
patients. Despite recent advances in the medical and
surgical fields that have improved postoperative results,
certain patients continue to develop severe infections
and require a repeat operation, which is associated with
increased morbidity and mortality [9, 10]. Therefore,
methods that are complementary to conventional
postoperative treatment for reducing inflammation and
regulating immune function are needed.
Acupuncture has been used to treat a variety of
inflammatory conditions including asthma, rhinitis,
inflammatory bowel disease, and rheumatoid arthritis.
Growing evidence indicates that acupuncture significantly
inhibits the inflammatory response . Findings from
several clinical studies support the anti-inflammatory
effects or immunological functions of acupuncture. Patients
with acute pancreatitis, who received 7 days of
electroacupuncture, had higher serum IL-10 and lower CRP levels
. Based on a systematic review by McDonald et al.,
reductions in the erythrocyte sedimentation rate (ESR) and
CRP levels were observed after patients with rheumatoid
arthritis received acupuncture . It has been shown that
the anti-inflammatory effects of acupuncture are mediated
by downregulation of proinflammatory cytokines such as
tumor necrosis factor-alpha (TNF-α), IL-1β, IL-6, and
IL10 . Elevated plasma TNF-α levels in rats exposed to
endotoxin decreased after electroacupuncture at Zusanli
(ST36) . In rats with chronic obstructive pulmonary
disease (COPD), TNF-α and IL-1β levels in the
bronchoalveolar lavage fluid decreased after electroacupuncture
. In rats with spastic cerebral palsy, serum TNF-α,
IL6, CRP, and nitric oxide synthase levels significantly
decreased in the acupuncture group . In experimental
rats with periodontitis, electroacupuncture was seen to
modulate the immune inflammatory response by
decreasing the expression of IL-1β and matrix
metalloproteinase8, and increasing IL-6 messenger ribonucleic acid (mRNA)
expression . In addition, several studies have been
conducted to evaluate the anti-inflammatory effects and
regulation of immunity by acupuncture [19, 20].
However, few acupuncture studies focus on its
antiinflammatory effects and effects on immunity in patients
who have undergone surgery. In a study with
thyroidectomy patients, the plasma CRP levels at the time of
surgery and on days 1 and 3 after surgery were remarkably
lower in the electroacupuncture group compared to the
sham group . In a study of the immune-inflammatory
response of patients undergoing supratentorial
craniotomy, the levels of IL-10 and IL-8 significantly increased,
while the TNF-α, IgM, and IgA levels also changed
significantly after electroacupuncture . However, the effects
of acupuncture on the anti-inflammatory response after a
craniotomy have not been identified. The decrease in the
inflammatory response and regulation of immune
function are important for rapid recovery from, and
prevention of, complications after surgery. The aim of this study
is to explore the anti-inflammatory and immune
regulatory functions of acupuncture after a craniotomy.
This study will be a single-center, parallel-group clinical
trial that will be conducted at the Kyung Hee University
Hospital at Gangdong, Seoul, Korea. The flow chart of
the trial is shown in Fig. 1. The Standard Protocol Items:
Recommendations for Interventional Trials (SPIRIT)
2013 Checklist is given in Additional file 1.
The trial will be carried out in accordance with the
Declaration of Helsinki and the Korean Good Clinical
Practice Guidelines and has been approved by the
Ethical Committee of the Kyung Hee University Hospital
at Gangdong (KHNMC-OH-IRB 2016-01-005). It has been
registered at https://clinicaltrials.gov/ (NCT02761096).
Subject enrollment and allocation
A total of 40 participants will be recruited for this trial.
Patients who underwent a craniotomy for an unruptured
aneurysm, facial spasm, or brain tumor are potential
candidates for the study. After written informed consent
has been obtained, eligible participants will be allocated
Study group (n = 20)
Allocation (n = 40)
Control group (n = 20)
Fig. 1 Study protocol flow chart
to the study group or the control group. Patients who
agree to receive additional acupuncture treatment will
be allocated to the study group, while patients who do
not agree will be allocated to the control group.
Participants must meet all of the following criteria in
order to be included: (1) planning to undergo regular
craniotomy performed for an unruptured aneurysm,
facial spasm, or brain tumor, (2) be aged over 18 years,
(3) agree to acupuncture treatment that can start within
48 h after the craniotomy, and (4) voluntary
participation and provision of a signed Informed Consent Form.
Participants with any of the following conditions will be
excluded: (1) serum CRP level ≥ 1.0 mg/dl before the
craniotomy, (2) a condition other than an unruptured
aneurysm, facial spasm, or brain tumor as an indication
for craniotomy, (3) a craniotomy performed for
infectious brain diseases such as brain abscess or subdural
empyema, (4) medication use that can affect the immune
system or white blood cell (WBC) count, such as
immunosuppressive drugs, steroids, or anticancer drugs or
use of these medications within 1 month prior to the
craniotomy, (5) a history of surgery at the same site, (6)
undergoing emergency surgery, (7) a severe medical
disease, e.g., congestive heart failure, chronic renal failure
or an autoimmune disorder, (8) a pacemaker or an
implantable cardioverter defibrillator, or (9) pregnancy.
The subjects in the study group will receive acupuncture
treatments in addition to conventional treatment before
and after the craniotomy. The conventional treatment
involves general management in the Department of
Neurosurgery and includes stabilizing vital signs, pain
control, perioperative antibiotic prophylaxis, treatment of
infections, and other intravenously administered fluid or
drug therapy required based on the condition of the
The acupuncture intervention will start no more than
48 h after the craniotomy and will be administered once
a day for 6 days (a total of six sessions within 8 days). It
will be given in addition to conventional treatments. All
interventions will be performed by one Korean Medicine
doctor with over 5 years of working experience and a
college education of 6 years. This doctor will be trained
in the study protocol before the start of the trial.
Acupuncture, electroacupuncture, and intradermal
acupuncture will be performed during every session. Sterile
disposable stainless steel acupuncture needles (0.25 mm ×
30 mm; Dong Bang Acupuncture Inc., Chungnam, Korea)
will be used. Acupuncture needles will be inserted
bilaterally at the following acupuncture points: LI4, LI11, PC6,
ST36, GB39 and LR3, and GV20 [12, 15, 18, 21]. If the
GV20 is close to the surgical site, this acupoint may be
excluded. After insertion to a depth of approximately 0.5–
1.5 cm, the needles will be manually stimulated until de
qi, which is a subjective experience in which patients feel
a radiating sensation considered indicative of effective
needling, is achieved.
An electric stimulator (ES-160, ITO Co., Tokyo, Japan)
will be connected to the handle of each needle at LI4,
LI11, ST36, and LR3 and a current of 5 Hz will be
applied. The current intensity will be increased until light
muscle contraction is evident and reaches approximately
70% of the bearable intensity. The needles will be left in
place for 15 min and then removed. The practitioner will
be able to regulate the intensity in response to requests
from the patients.
After the needles are removed, intradermal
acupuncture needles with tape (DB130A; 0.25 mm × 1.5 mm;
Dong Bang Acupuncture Inc., Chungnam, Korea) will be
inserted at the same acupoints (LI4, LI11, PC6, ST36,
GB39, and LR3 bilaterally, and GV20) and left in place
until the next session.
The subjects in the control group will receive
conventional treatment alone before and after the craniotomy
in the Department of Neurosurgery.
The serum CRP level, ESR, TNF-α, IL-1β, and IL-6
levels will be assessed four times: within 48 h before the
surgery, and 2, 4, and 7 days after surgery. A fasting
blood sample (8 ml) will be drawn from the brachial vein
at a fixed time in the morning before breakfast,
centrifuged immediately, and kept in a freezer at −80 °C
before the analysis.
Any fever with a body temperature over 38 °C, the use
of additional antibiotics, and infections, such as
pneumonia or urinary tract infections, will be recorded on
the Case Report Form every day during the study period
Participants who meet any of the following criteria will
be excluded from the study: (1) more than one session
(out of a total of six) missed, (2) need for a repeat
operation or other types of surgery, (3) serious neurological
deficits that develop after the surgery and significantly
worsen level of consciousness and motor skills
compared with the preoperative condition, (4)
nonconventional antibiotics received immediately after surgery, (5)
withdrawal of consent, (6) development of serious
adverse reactions and inability to continue the trial, (7)
worsening condition whereby it is no longer appropriate
for the patient to continue to participate in the study (as
decided by the investigator), or (8) a decision by the
principal investigator that it is not possible for the
patient to participate in the study as planned.
Primary outcome measurement
The change in the serum CRP level from baseline to the
second day after surgery will be compared between the
two groups. CRP is a known indicator of inflammation
Fig. 2 The schedule of enrollment, interventions, and assessments
and is frequently used to support the diagnosis of an
inflammatory process. It has been found to be a better
marker of an acute phase reaction than ESR .
Secondary outcome measurement
The secondary outcome measures are as follows:
1. The difference in CRP level changes (pre versus post) between the two groups
2. Serum ESR: ESR is surrogate marker of an acute phase inflammatory reaction 
3. TNF-α, IL-1β, and IL-6: TNF-α, IL-1β, and IL-6 are
cytokines that are related to inflammation and
immune regulation [23–25]. After samples are
collected, they will be centrifuged for 15 min at
1000 × g and stored in a freezer at −80 °C until they
are ready for processing and analysis. The Quantikine®
ELISA kit (R&D systems, Inc., Minneapolis, MN,
USA) will be used to determine the concentrations of
TNF-α, IL-1β, and IL-6 in the samples and the data
will be analyzed. All the samples will be discarded
after the analysis.
4. The number of days for which the patient had a
body temperature greater than 38 °C
5. Antibiotic use in addition to the conventional
antibiotics prescribed after the surgery
6. Pneumonia diagnosed by symptoms such as fever, cough or sputum production, findings on a chest radiograph, or sputum culture
7. Urinary tract infection diagnosed by symptoms such
as fever, dysuria, increased urinary frequency with
chills, and from results of the urine analysis
8. Other symptoms and findings consistent with an infection
Any adverse events or abnormalities will be recorded on
the Case Report Forms. Severity will be quantified as
mild, moderate, or severe. The occurrence of events
during or after the intervention will be categorized as
unrelated, possibly related, or related.
If any serious adverse events occur, the study will be
stopped immediately and appropriate action will be
taken. This will be reported promptly to the Institutional
Review Board in accordance with the protocol.
Sample size estimation
The primary outcome, the change in serum CRP level
from baseline to the second day after surgery, was used
to calculate the sample size. Power analysis indicated
that a sample size of 16 subjects per group will be
required to detect a serum CRP difference of 3.2 mg/dl
with a standard deviation of 3.190 with 80% power and a
significance level of 5% in a two-tailed (or two-sided) t
test. We plan to enroll a total of 40 participants with 20
in the study group and 20 in the control group allowing
for a 20% withdrawal rate. The sample size was
calculated using the followig formula :
The statistical analyses will be performed by a researcher
who is blinded to the allocation. Following the
perprotocol (PP) principle, all the data will be analyzed
using SPSS software (version 18.0, SPSS Inc., Chicago,
IL, USA) and the results will be presented as mean ±
standard deviation (SD) or number (%).
In order to compare the change in serum CRP levels
from baseline to the second day after surgery, the
average number of days that fever occurred and the number
of additional antibiotics used between the two groups,
either a t test or a Mann-Whitney U test will be used.
The differences in pre and postoperative blood test
results between the two groups will be compared using a
generalized linear mixed model (GLMM). To compare
events due to infections such as pneumonia, urinary
tract infection or other diseases, either the chi2-test or
the Fisher’s exact test will be used. If the data are not
normally distributed, nonparametric methods will be
used. Confidence limits of 95% will be calculated, and
the results with a p value < 0.05 will be considered
In this study, we aim to explore the possibility that
treatment with acupuncture after a craniotomy has
antiinflammatory and immune regulatory effects. Subjects will
be assigned to either the study group or the control group
on a voluntary basis. If our results suggest efficacy and if a
placebo-controlled study also yields favorable results,
acupuncture could be recommended as an adjunctive therapy
after a craniotomy as it could possibly reduce inflammatory
and immune responses after a craniotomy.
Additional file 1: SPIRIT Checklist. (DOCX 60 kb)
SY Cho wrote the paper, while SB Yang designed the protocol. HS Shin, SH Lee,
and JS Koh consulted on the design. S Kwon, WS Jung, SK Moon, JM Park, and
CN Ko reviewed the protocol. SU Park contributed to the conception and
design, and approved the final version of the paper. All authors read and
approved the final manuscript.
Consent for publication
All authors, investigators give their content to publication.
Ethics approval and consent to participate
This trial has been approved by the Ethical Committee of the Kyung Hee
University Hospital at Gangdong (KHNMC-OH-IRB 2016-01-005). Informed
consent will be obtained from all potential subjects.
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