Stimulated by four recent papers appearing on PubMed.[1–4]
AiM – Acupuncture in Medicinekey to acronyms
CXR – chest x-ray film
NEJM – New England Journal of Medicine
FPL – flexor pollicis longus
IP – interphalangeal (joint)
MCP – metacarpophalangeal (joint)
This week I am focussing on a brace of reports that have been published in recent weeks and are all loosely related.
First of all we have a chance discovery of embedded needle fragments around an elbow. The images in the report are not particularly dramatic, but it reminded me of a letter we published in Acupuncture in Medicine (AiM) in my first issue as editor.
A very gentlemanly senior radiologist from Edinburgh called Arthur had written to me describing a chest x-ray film (CXR) he had reported showing 135 metallic fragments in a man from the Far East. He offered to send me a copy of the CXR, and after consulting with Adrian White, who was studying the safety of acupuncture at the time, I suggested to Arthur that he publish the image in our journal.
I recalled some clinical images in the New England Journal of Medicine (NEJM) that were quite dramatic. They illustrated the use of embedded gold thread around the joints of the hands in rheumatoid arthritis, and around the knees in osteoarthritis. That led me to other reports in NEJM, including one abdominal abscess related to embedded needles, and another of a CXR that predated Arthur’s letter.
To finish this section, the last report attracted a comment in NEJM. This came from three authors who had already described the possible risks of needle migration some years before.
Next up we have a broken needle fragment causing severe back pain that required surgical intervention. A 50-minute laparoscopic procedure successfully removed two corroded needle fragments. The imaging in the report shows one fragment only perhaps 10mm posterior to the inferior vena cava and pointing directly towards it. The same paper lists 11 other publications including 15 cases of broken needles requiring surgical removal.
The third paper on my focus list is from AiM. This is quite an extraordinary case of a tendon rupture apparently caused by acupuncture for trigger thumb. I remember a conversation with the late Dr Peter Baldry in a hotel in Warwick in the mid 90’s. He was quite positive about the effect of needling in trigger finger. Over the years I have treated a few cases with apparent success, but this report is rather worrying, and the details of needling are rather limited. We are told that the needling was painful, 3 sessions were performed, and an image indicates the sites of needling on the flexor surface of the thumb in the creases over the IP and MCP joints. Needling is always painful in this area, and personally I only insert one fine needle (0.2x15mm) into the palpable nodule with minimal manipulation (2 or 3 small movements in and out). I imagine the trauma to the tendon is minimal with a filiform needle, but I guess it is possible that an acupotomy (chisel shaped) needle was used.
The last paper I am highlighting is a little different, but also has an aspect related to needle trauma and safety. This time the focus is on the electric shock sensation that can occur on needling. The authors review ancient texts describing needling sensation, and of course they were written before either nerves or electricity were discovered, but they note that the progression of referred sensations is slow (like insects and ants crawling), and that it is not always distal to the acupuncture point.
They review a handful of cases of nerve injury following acupuncture, and in most the description includes electric shock sensations. They conclude that electric shock sensations should be a warning sign of potential nerve injury rather than a sensation to be sought.
There is no mention of the transient shooting sensation that can be associated with needle penetration of fascia. In my experience this typically runs along the direction of the muscle concerned, and often beyond its attachment; however, it is not likely to run the entire length of a limb in the same way as stimulating a nerve sheath or nerves within.
1 Ota K, Yokoyama H, Takasu A. Discovery of decades‐old acupuncture needle fragments during routine care for an arm injury. Acute Med Surg 2020;7:e588. doi:10.1002/ams2.588
2 Kim HW, Kim SY, Song S, et al. Surgical Treatment for a Broken Acupuncture Needle in the Retroperitoneal Space: A Case Report. Korean J Neurotrauma 2020;16:332. doi:10.13004/kjnt.2020.16.e31
3 Liew SK, Teh KK. Flexor pollicis longus rupture following acupuncture for trigger thumb: a case report. Acupunct Med 2020;:096452842095908. doi:10.1177/0964528420959085
4 Guo Y, Zhu K, Guo J, et al. The Electric Shock during Acupuncture: A Normal Needling Sensation or a Warning Sign. Neural Plast 2020;2020:8834573. doi:10.1155/2020/8834573
5 Wightman AJ. Embedded Needles. Acupunct Med 2000;18:126–7. doi:10.1136/aim.18.2.126
6 Joo Y-B, Park K-S. Gold Thread Acupuncture for Rheumatoid Arthritis. N Engl J Med 2017;377:e27. doi:10.1056/NEJMicm1706737
7 Yoo H-G, Yoo W-H. Acupuncture with Gold Thread for Osteoarthritis of the Knee. N Engl J Med 2013;369:e37. doi:10.1056/nejmicm1202540
8 Studd RC, Stewart PJ. Intraabdominal Abscess after Acupuncture. N Engl J Med 2004;350:1763–1763. doi:10.1056/NEJMicm010431
9 Chiu ES, Austin JHM. Acupuncture-Needle Fragments. N Engl J Med 1995;332:304–304. doi:10.1056/NEJM199502023320505
10 Gerard PS, Wilck E, Schiano T. Images in Clinical Medicine: Acupuncture-Needle Fragments. N Engl J Med 1995;332:1792–4. doi:10.1056/NEJM199506293322617
11 Gerard PS, Wilck E, Schiano T. Imaging implications in the evaluation of permanent needle acupuncture. Clin Imaging 1993;17:36–40. doi:10.1016/0899-7071(93)90011-B
12 Baldry T, Cummings M. Dr Peter Edward Baldry. Acupunct Med 2016;34:406–7. doi:10.1136/acupmed-2016-011203