Needle migration in the neck

Adverse events, Clinical practice, Imaging 3 Minutes

Comments by Michael Meinen (MM) and Mike Cummings (MC)

This blog was first published on 24th August 2018 on https://blogs.bmj.com/aim/

Case report

El-Wahsh S, Efendy J & Sheridan M. Migration of self-introduced acupuncture needle into the brainstem. J Neurosci Rural Pract 2018; 9(3): 434 – 436.

Presentation

An elderly man presented to an emergency department after an acupuncture needle (which he had inserted himself) had broken off in the attempt to withdraw it.[1] Exploration of the neck was unsuccessful, and the patient required a CT scan to locate the needle (ultrasound failed to locate it); four days after initial presentation, it had migrated cranially through the foramen magnum and pierced the dura mater with the tip resting in the brainstem. It had to be removed by open surgery, followed by a patch repair of the dura mater. The tip of the needle was angulated. The patient made a good recovery and was free of symptoms at follow-up after a month.

Discussion

Accidental perforations of anatomical structures are well documented as complications of acupuncture.[2] Indeed there are several cases of penetration of the brainstem with acupuncture needles.[3–7] This presentation highlights a few safety issues, and suggests an approach to dealing with such incidents in future..

The location of the needle suggests insertion in the midline at GV16 (Fengfu), which the patient must have performed by touch alone, at a slight upward angle. When patients are taught self-acupuncture, the danger of deep insertion should be discussed in detail, and perhaps self-needling without the ability to see what is being done should be discouraged in potentially dangerous areas such as this. At this point it is salient to remind readers of the BMAS needling policy in the neck.

Above C2 – angle the needle tip towards the palpable occipital bone.

Perpendicular insertion should be avoided.

Below C2 – angle the needle tip towards the cervical articular pillar

(the pars interarticularis and facet joints usually between C3 and C5).

On presentation, the needle (0.25x30mm) was 8mm below the surface of the skin, embedded in the muscles of the neck. The patient had been unsuccessful in his attempt to retrieve the needle. Ultrasound scanning failed to show the needle, and an initial surgical attempt to remove the needle in the emergency department was unsuccessful. The authors felt that manipulations by the patient and doctors had contributed to the needle migration. This suggests that, should a needle break and disappear into the patient’s soft tissue, that neither patient or practitioner should attempt to remove it, but that the patient should be referred, or self-refer, immediately to an emergency department. Again, this needs to be discussed when instructing a patient in self-acupuncture.

It seems that this location is particularly vulnerable to needle migration because of the thickness of muscle and the lack of resistance to needle progression when the tip reaches the spinal canal or brainstem. It seems sensible for the patient to relax the postural muscles of the neck by lying down with the head supported without any pressure on the needle site, while specialist investigation with x ray films and CT is awaited.

References
  1. El-Wahsh S, Efendy J, Sheridan M. Migration of Self-Introduced Acupuncture Needle into the Brainstem. J Neurosci Rural Pract 2018;9:434–6. doi:10.4103/jnrp.jnrp_480_17
  2. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122
  3. Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol 2007;28:714–5.
  4. Choo DC, Yue G. Acute intracranial hemorrhage caused by acupuncture. Headache 2000;40:397–8.
  5. Zhu Y, Xue Z, Xie D, et al. Medulla oblongata hemorrhage after acupuncture: A case report and review of literature. Interdiscip Neurosurg 2018;11:1–3. doi:10.1016/j.inat.2017.09.013
  6. He W, Zhao X, Li Y, et al. Adverse events following acupuncture: a systematic review of the Chinese literature for the years 1956-2010. J Altern Complement Med 2012;18:892–901. doi:10.1089/acm.2011.0825
  7. Miyamoto S, Ide T, Takemura N. Risks and causes of cervical cord and medulla oblongata injuries due to acupuncture. World Neurosurg 2010;73:735–41.pm:20934166

Declaration of interests MM

Declaration of interests MC

Published by bmasmd

I am the salaried Medical Director of the British Medical Acupuncture Society (BMAS) - a registered charity established to stimulate and promote the use and scientific understanding of acupuncture within medicine for the public benefit.

Published