Inspired by a few rare case reports and a prospective survey.[1–4]
AEs – adverse eventskey to acronyms
WMA – Western medical acupuncture
VP shunt – ventriculoperitoneal shunt (tube connecting one cerebral ventricle to the peritoneal cavity)
CSF – cerebrospinal fluid
VVAVF – vertebra-vertebral arteriovenous fistula
MRA – magnetic resonance angiography
VA – vertebral artery
AV shunt – arteriovenous blood flow (usually associated with AV malformations)
KMD – Korean medical doctor
I was wondering how to finish up another year of blogging and a selection of AE reports came to my rescue. Ensuring safe practice in WMA is one of my (semi-permanent) appraisal development needs, along with writing a weekly research review on this blog, so reporting on the acupuncture AE literature kills two birds with one blog, so to speak.
The first report is a rather serious, worrying, and avoidable AE involving infection around a VP shunt. A 25-year-old woman had suffered meningitis and hydrocephalus as a 5-year-old child. She subsequently had a VP shunt inserted to treat the hydrocephalus. Presumably the meningitis had resulted in a degree of restriction in the normal flow of CSF from the intracranial compartment into the spinal canal.
She sustained a blunt injury to the left parietal region 4 weeks prior to presentation and developed a haematoma under the scalp. While the haematoma was still fluctuant it was evacuated several times by an acupuncturist at a traditional Korean medicine clinic. It was not clear how this was achieved, but it clearly required insertion of some form of needle or needles into the haematoma. Needless to say, this is a risky manoeuvre at the best of times, in terms of infection risk, not least when there is a tube passing through the skull nearby. The haematoma became infected, and the infection spread along the tube into the neck requiring extensive surgical drainage. Whilst blood cultures were positive for Staphylococcus aureus, CSF was fortunately sterile. The patient recovered fully following surgical drainage and antibiotic therapy. Clearly the risk of intracranial spread is even greater in the presence of a VP shunt, and such an intracranial epidural abscess was the subject of my most read blog to date: Cranial epidural abscess.
The second AE is attributed to acupuncture due to onset of symptoms and timing of acupuncture, but such an AE in this location has never been reported before due to acupuncture and spontaneous occurrences are probably more frequent than traumatic ones. The case is of a VVAVF at about C4 and the acupuncture was performed in the ‘posterior lower neck region’ one month prior to diagnosis. The 64-year-old woman had received acupuncture for her neck pain, and the pain resolved, but she had gradually become aware of dizziness and left-sided pulsatile tinnitus. MRA revealed a 5.5mm saccular dilatation of the vertebral artery (VA) and subsequent digital subtraction angiography demonstrated a VA aneurysm of 8.6mm width and 7.2mm height. With slow injection of a contrast medium, most accumulated in the connected venous plexus rather than continuing up the VA indicating a significant AV shunt and therefore VA steal ie blood going into the venous system in preference to going up the VA, where it ought to go.
The problem I have with attributing this to acupuncture is that this section of the VA is not easily accessible from a posterior cervical approach because it lies directly anterior to the posterior column and a needle would have to traverse multiple muscle layers and the cervical nerve roots before reaching the artery – this is likely to be a very painful insertion. A lateral approach would make the VA more accessible to an acupuncture needle, but the closest point, SI16, is used for tinnitus rather than neck pain, which, if anything, might imply that the condition predated the needling.
Anyway, the condition was successfully treated via the endovascular route and the symptoms gradually resolved.
The next paper I have is a prospective survey of AEs from Korea. It is very similar to the SAFA study published by White et al in the BMJ over 20 years ago – the first prospective survey of AEs in acupuncture practice. The survey included 37 490 consultations performed by 222 KMDs. The most common AEs were bleeding (5.25%) and pain at the needle site (3.80%), which were a little higher than in the SAFA study (3.10% and 1.10% respectively). This probably reflects marginally stronger needling styles in East Asia compared with the UK. There were 2 serious AEs: a case of anaphylaxis related to injection of bee venom (pharmacopuncture – 9.1% of treatments in total), successfully treated with epinephrine; and a case of cellulitis in a 27-year-old female treated for shoulder and wrist pain.
The final case is from Japan, and it popped up on PubMed on Christmas eve. The paper took a while to download, and I was surprised to see the pdf file was nearly 70MB. It is a rare case of self-needling in the back of the neck and the needle getting lost because the crimped handle came off. The 55-year-old woman immediately sought help, and the paper is full of the most wonderful images, including 3D CT angiography and intraoperative high-resolution photographs, hence the size of the file. The position and orientation were very similar to that for GB20, but just a little lower, and the 40mm needle passed above the arch of C1 and entered the intradural space passing just lateral to the medulla. The needle had penetrated the adventitia of the right VA.
I guess there is no doubt in this case that acupuncture would have been the cause of a VA injury. Thankfully for this patient, the VA damage was minimal. This is only the second case of VA injury following acupuncture, and the 6th case of intracranial injury caused by needle migration.[7–11]
Not included in the authors’ list is a case from Australia entitled ‘The Self-Pith’. I guess because the needle migrated into the spinal cord between C1 and C2 rather than intracranially.
I have written about related AEs before, and most of the links are listed in a blog from 2020: Spinal epidural haematomas 2020.
1 Kim E. A Pericatheter Abscess Following Acupuncture in a Patient With VP Shunt. Korean J Neurotrauma 2022;18:351–6. doi:10.13004/kjnt.2022.18.e56
2 Koo H-W. Stent-Assisted Coil Embolization of a Vertebro-Vertebral Arteriovenous Fistula Secondary to Oriental Acupuncture: A Case Report. Korean J Neurotrauma 2022;18:361–6. doi:10.13004/kjnt.2022.18.e44
3 Won J, Lee J-H, Bang H, et al. Safety of acupuncture by Korean Medicine Doctors: a prospective, practice-based survey of 37,490 consultations. BMC Complement Med Ther 2022;22:300. doi:10.1186/s12906-022-03782-z
4 Abe D, Hanaoka Y, Kobayashi K, et al. Surgical removal of an intracranially migrated acupuncture needle: a case report and literature review. Nagoya J Med Sci 2022;84:890–9. doi:10.18999/nagjms.84.4.890
5 White A, Hayhoe S, Hart A, et al. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001;323:485–6. doi:10.1136/bmj.323.7311.485
6 Hong S, Park Y, Lee C-N. Lateral Medullary Infarction Caused by Oriental Acupuncture. Eur Neurol 2018;79:63. doi:10.1159/000479963
7 Abumi K, Anbo H, Kaneda K. Migration of an acupuncture needle into the medulla oblongata. Eur Spine J 1996;5:137–9. doi:10.1007/BF00298396
8 Hama Y, Kaji T. A migrated acupuncture needle in the medulla oblongata. Arch Neurol 2004;61:1608. doi:10.1001/archneur.61.10.1608
9 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
10 Fukaya S, Kimura T, Sora S, et al. Medulla oblongata injury caused by an acupuncture needle; warning for serious complications due to a common method of alternative medicine. J Neurol 2011;258:2093–4. doi:10.1007/s00415-011-6072-3
11 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
12 Anderson DW, Datta M. The self-pith. AJNR Am J Neuroradiol 2007;28:714–5.