Acupuncture AE at Huatuojiaji

Stimulated by Jeong et al 2024.[1]

AE – adverse event
IF – impact factor
KMD – Korean medical doctor
CXR – chest x-ray (film)
CT – computed tomography

– key to acronyms

This is an adverse event report detailing a case of haemopneumothorax following needling at Huatuojiaji (paraspinal) points. It was flagged up by a colleague (Martin Allbright). This AE is rare but well recognised, and I have highlighted a more extreme case of haemothorax previously: Hearts lungs and eyes 2022.[2] In this case we have a little more detail than usual concerning the needling, so it makes sense to draw attention to the safety considerations when using these very useful paraspinal points.

The report was published in Heliyon (IF 3.4), an open access journal published by Cellpress. This publisher has been around for some 50 years, and their flagship publication is the journal Cell (IF 45.5). Heliyon, by contrast, started life in 2015.

The authors imply that this is the first report of haemopneumothorax resulting from acupuncture in Korea, but we published a much more dramatic case in Acupuncture in Medicine (IF 2.4) from Daegu, Korea in 2022.[3] Interestingly, one of the authors on this paper comes from the same city in Korea, but from a different hospital and medical specialty, so we cannot really blame them for not realising. I mentioned the previous case at the very end of a blog published on 29^th August 2022.

This case was a 26-year-old man with acute indigestion symptoms who sought treatment at the Woosuk Korean Medicine Hospital, Jeonju, South Korea. He was treated with 6 needles at the Huatuojiaji paraspinal points at T6, T7, and T8. These points are approximately one fingerbreadth either side of the lower border of the spinous process at each level. The KMD used 0.30x60mm needles and inserted them approximately 4 to 5cm deep. It was noted that one of the needles ‘did not touch the spine’.

When the needles were removed, the patient experienced some chest pain when breathing and some shortness of breath, but the symptoms were obviously not too severe, as he was happy to go home. The next morning his symptoms were a bit worse, but he went to work, and only sought help again in the afternoon. CXR showed a small right apical pneumothorax and CT of the chest showed a small amount of blood in the pleural cavity on the right side and some pulmonary haemorrhage on the same side.

I guess the patient was offered a choice between conservative treatment and insertion of a chest tube and he opted for the former. He was treated with oxygen and oral analgesics and discharged after 4 days. He was readmitted again after a further 4 days as his symptoms were persisting and he was diagnosed with a recurrent pneumothorax. Whether this was actually a recurrence or simply persistence of the original condition, it is hard to say. Anyway, he eventually recovered with further conservative inpatient management.

The thoracic laminae in an adult of normal constitution are about 40mm deep to the skin surface, so I would not use a 60mm needle for these points unless my patient was particularly large. I have once used 75mm needles to reach the lamina in the upper thoracic region of a particularly hefty chap where 50mm needles did not reach at some levels, but that is the exception. At 1 fingerbreadth from the midline, paying attention to whether or not your fingers are appropriate for the patient, the nearest lung tissue in a paramedian sagittal plane is rather deep. In this case, one of the needles clearly passed the lateral edge of the lamina.

Whenever using this technique, I check my position and needle angulation carefully at the start, and if I have already contacted lamina with another needle nearby, it can be used as a depth gauge, so you can stop and recheck needle position and angulation if you reach the same depth but have not contacted a bony endpoint. Obviously, you need to allow a certain margin for differences in depth as the laminae overlap each other and so they are not entirely flat. 5mm is probably a sufficient margin in the thoracic region, but this increases a little in the lumbar spine (to ~7mm) due to the prominence of the mammillary processes.

Huatuojiaji paraspinal points principally target multifidi, although many other muscle layers may be present more superficially. For example, at T11 your needle may pass through layers associated with lower trapezius, latissimus dorsi, serratus posterior inferior, longissimus thoracis, and spinalis thoracis, before reaching the most superficial layer of multifidus. There are 3 layers of multifidus at each point and the muscle often retains more tone than the long erector spinae muscle in a patient lying relaxed in the prone position. Therefore, the resistance to advancing a needle is often greater than in other areas of muscle. The feeling as you advance a needle can be reminiscent of the sensation of biting through a piece of halloumi cheese.

In my experience, multifidus is the most common cause of pain from the back being felt at the front and so it is an important muscle to needle when assessing such cases. Other potential causes are deep somatic structures such as facet joints, costovertebral and costotransverse joints as well as deeper layers of iliocostalis (iliocostalis thoracis).

So, in summary, this is an area that is important to needle in some cases but requires extra diligence in terms of position and angulation of the needle when needling the deepest structures.

References

1          Jeong H, Kim JH, Park H, et al. A case report on hemopneumothorax caused by acupuncture at Huatuo–Jiaji points. Heliyon. 2024;10:e34190. doi: 10.1016/j.heliyon.2024.e34190

2          Hanabusa Y, Kubo T, Watadani T, et al. Successful transcatheter arterial embolization for a massive hemothorax caused by acupuncture. Radiol Case Rep. 2022;17:3107–10. doi: 10.1016/j.radcr.2022.05.040

3          Lee SS. Acupuncture-induced hemopneumothorax: a case report. Acupunct Med. 2022;40:559–60. doi: 10.1177/09645284221117843

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Declaration of interests MC