Inspired by Ikoma et al 2021.[1]
I have mentioned embedded needle fragments and the surgical retrieval of such fragments several times previously on this blog. But this is the first account of successful image-guided percutaneous retrieval of needle fragments using myocardial biopsy forceps.
myocardial biopsy forceps
The report includes 2 cases and comes from Japan. In both cases the patients suffered persistent pain in the region of a ‘lost’ acupuncture needle in the musculature of the back or neck.
These needles were both successfully removed with a minimally invasive technique using biopsy forceps designed for a different purpose. This was a very good result when we consider some of the other cases of needle retrieval that have required more invasive surgery.
I have recorded laparoscopic needle retrieval 3 times previously on this blog:
Laparoscopic needle fragment removal 2019
Needle fragments getting ‘lost’ in the body are certainly rare, and most of us using single-use disposable needles will fortunately never see this adverse event (AE). But we all sometimes worry about it, especially when a needle is noticeably bent on removal. The most dramatic cases involve needles migrating into the brainstem or cervical spinal cord from the neck. Sometimes these are self-administered, and if the individual uses a sewing needle, there is nothing to stop the needle disappearing beneath the skin, unless there is a thread in place I suppose.
A case reported in 2007 from Australia is concisely titled The Self-Pith,[2] and includes a lateral x ray film of the cervical spine with a sewing needle running between the posterior arch of C1 and the spinous process of C2. The tip of the needle appears around 5mm from the posterior aspect of the odontoid process of C2. Remarkably the patient escaped without obvious neurological deficit from penetration of the cord or the bleeding in the area but did require surgery to remove the needle.
The Self-Pith
Another similar case from Japan involved self-needling as well, but with an acupuncture needle that broke inside the neck and ended up in the medulla.[3] The 45mm needle fragment was not seen at surgery until retraction of the left cerebellar tonsil revealed its end. This patient also had an uneventful recovery.
Self-inserted needles have also ended up in the heart, but we should really differentiate between acupuncture and self-harm. The latter may target the area of the heart deliberately.[4,5]
Acupuncture rarely results in needle fragments reaching the heart. Perhaps the most dramatic was a case from Korea in 2005 in which two 50mm needle fragments found their way from the shoulder or upper back of the 49-year-old female patient to the interventricular septum of her heart within 2 hours of the acupuncture treatment.[6]
Somewhat less dramatic but probably more common are the smaller needle fragments that reach the myocardium usually years after they have been deliberated snipped off and left in acupuncture points with the aim of continued stimulation.[7]
I have mentioned this practice, which hopefully now has fallen out of fashion, in 2 previous blogs:
Fatal bilateral pneumothoraces
I can only find one case of pneumothorax that clearly resulted from migration of a needle fragment, and the paper has a lovely image of the needle from video thoracoscopy.[8]
Needle fragments have been found at the nidus for renal calculi,[9] as well as in subcutaneous abscesses.[10] Even a swallowed needle has found its way into the kidney from the duodenum, following acupuncture around the mouth.[11] The handle was still in the duodenum, and it was successfully removed at endoscopy.
Finally, fragments of needle have sometimes found their way into nerves and caused neuropathy. One in the median nerve,[12] and another in the common peroneal.[13]
References
1 Ikoma A, Sonomura T, Shibata N, et al. Image-guided percutaneous removal of intramuscular acupuncture needles using biopsy forceps under computed tomography and fluoroscopy: a report of two cases. Quant Imaging Med Surg 2021;11:4227–30. doi:10.21037/qims-20-1228
2 Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol 2007;28:714–5.
3 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. doi:10.1016/j.wneu.2010.03.020
4 Dwivedi SK, Gupta LC, Narain VS. Self inserted needle in heart–localization by cross-sectional echocardiography. Eur Heart J 1991;12:286–7.
5 Tveskov C, Angelo-Nielsen K. Late cardiac tamponade after self-injury with a needle. Eur Heart J 1993;14:1578. doi:10.1093/eurheartj/14.11.1578
6 Park J-H, Shin HJ, Choo SJ, et al. Successful removal of migrated acupuncture needles in a patient with cardiac tamponade by means of intraoperative transesophageal echocardiographic assistance. J Thorac Cardiovasc Surg 2005;130:210–2. doi:10.1016/j.jtcvs.2004.11.046
7 Song BG, Park JR. Acupuncture needles over the myocardium. Heart Lung Circ 2010;19:480. doi:10.1016/j.hlc.2009.10.010
8 von Riedenauer WB, Baker MK, Brewer RJ. Video-assisted thorascopic removal of migratory acupuncture needle causing pneumothorax. Chest 2007;131:899–901. doi:10.1378/chest.06-1443
9 Keller WJ, Parker SG, Garvin JP. Possible renal complications of acupuncture. JAMA 1972;222:1559.
10 Studd RC, Stewart PJ. Intraabdominal Abscess after Acupuncture. N Engl J Med 2004;350:1763–1763. doi:10.1056/NEJMicm010431
11 Ryu DG, Choi CW, Kim SJ, et al. Endoscopic removal of swallowed acupuncture needle infiltrated into the kidney from the duodenum. Korean J Intern Med 2021;36:475–6. doi:10.3904/kjim.2020.216
12 Southworth SR, Hartwig RH. Foreign body in the median nerve: a complication of acupuncture. J Hand Surg Edinb Scotl 1990;15:111–2. doi:10.1016/0266-7681(90)90063-a
13 Sato M, Katsumoto H, Kawamura K, et al. Peroneal nerve palsy following acupuncture treatment. A case report. J Bone Joint Surg Am 2003;85:916–8. doi:10.2106/00004623-200305000-00024
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