Inspired by a variety of recent case reports.
AEs – adverse events
PDP – personal development plan
CXR – chest x ray film
SPs – spinous processes
BP – blood pressure
mmHg – millimetres of mercury (units of fluid pressure)
HR – heart rate
bpm – beats per minute
THA – total hip arthroplasty
IBD – inflammatory bowel disease
ESI – epidural steroid injection– key to acronyms
One of my annual appraisal PDP items is to ‘ensure safe practice’ by publishing any AEs that I am directly involved with, and by reporting published serious AEs on this blog.
So, for the last blog of 2024, I have accumulated a set of recent AE cases along with a paper that actually supports the safety of using acupuncture pre-operatively. So, after the drama of some serious AEs we can end the year on more of an upbeat note.
The first case, comes from the US and is of a relatively straightforward apical pneumothorax.[1] A 28-year-old woman had a sudden onset of severe right-sided pleuritic chest pain at some time following acupuncture to the right side of the chest. There are no other details of the acupuncture, although the authors note that several attempts were made to get this information. It is not confirmed even whether or not the acupuncture occurred on the same day. The initial CXR confirmed a right-sided apical pneumothorax and no mediastinal shift. The measurement of the size of the pneumothorax is not reported and there is no reproduction of this film in the report. Later the patient became more short of breath and a second CXR revealed an apical right-sided pneumothorax of 38mm. We are told that this film shows mediastinal shift to the left, but this is hard to judge without seeing the initial film and because the patient has a thoracic scoliosis. In a normal CXR the radio-opacity of the lower cervical SPs are generally seen relatively central in the radiolucency of the trachea. In this second CXR, the trachea is clearly seen to the right of these SPs suggesting that any shift is towards the side of the pneumothorax rather than away from it. A left shift, of course, would suggest the development of a right-sided tension pneumothorax, which constitutes a medical emergency. The team used the second film and the symptomatic deterioration in the patient to justify insertion of a small-bore chest drain. The third CXR shows a smaller pneumothorax and a more central trachea, that is a trachea that has shifted slightly to the left compared with the previous film.
It is of course highly likely that acupuncture was responsible for this AE, although I think it is a little overly dramatic to suggest that a tension pneumothorax was developing in this case, and it probably could have been treated by aspiration and inhaled O2. In any event, the patient had the chest drain removed after 2 days and was sent home with a pneumothorax of less than 20mm.
The second case comes from China and is a little more dramatic.[2] A 69-year-old woman received acupuncture just below the xiphisternum during a treatment for heart palpitations. Ten minutes later the patient lost consciousness. On regaining consciousness her symptoms were considerably worse, and she was transferred to a local hospital where her BP was measured at 75/42 mmHg and her HR was 90 bpm. This was a case of insipient cardiac tamponade complicated by imaging that revealed a pericardial mass, which delayed definitive pericardiocentesis. Finally, 450mls was drained from the pericardium, and the mass was suspected to be an intracardiac haematoma (presumably within the cardiac muscle wall rather than within a chamber). Anyway, it had disappeared by day 3, and the patient was eventually discharged home with outpatient follow-up for echocardiography. The latter was unremarkable, and the patient was noted to have no difficulties with her activities of daily living.
Case 3 is only the second ever report of pyoderma gangrenosum occurring at the site of needling.[3] During rehabilitation following THA, a physiotherapist performed dry needling in the ipsilateral hip region close to the surgical scar. The skin broke down at the site of needling and did not recover despite use of dressings, topical and systemic antibiotics, systemic steroids, and admission to a dermatology ward. The hip prosthesis was not infected. The condition improved rapidly after treatment was switched to cyclosporin and a topical combination of fusidic acid and betamethasone. The first case of pyoderma gangrenosum occurring at the site of acupuncture needling was published in 2000 and involved a 48-year-old woman with an abdominal wall lesion and suspected IBD.[4]
The next 3 AEs are all related to migrating needle fragments, which ended up in the head of the pancreas,[5] the right ventricle,[6] and the lung respectively.[7] The latter case was most surprising as the needle was intact, with its handle attached, and so unlikely to migrate within tissues. The patient was an 8-year-old girl who had been in a coma following a car accident, and who had a tracheostomy. She received acupuncture during rehabilitation and developed a sudden onset of a productive cough with shortness of breath. The needle (including the handle) was about 25mm long, and it seems likely that the needle found its way to the right lower lobe via the tracheostomy. It was removed successfully via thoracoscopy. I guess this is one rare example of where shorter needles may actually be riskier.
Finally, to finish on a more upbeat note, the last paper I am highlighting is a large retrospective cohort study from South Korea focussing on risk factors for post-operative infection following elective lumbar fusion surgery.[8] The key risk factors being studied were acupuncture and ESI performed pre-operatively.
I am relieved to report that pre-operative acupuncture was not a risk even if performed within 2 weeks of surgery. On the other hand, ESI was associated with an increased risk, but only when performed with 2 weeks of surgery. Increasing age and male sex were also associated with increased risk of infection.
I will pre-record a webinar and post it on the members area of the BMAS website so that you can see all the drama in images (see: BMAS Blog Webinars 2024).
References
1 Arora H, Sivasubramanian D, Sivakumar S, et al. Navigating the Needles: Unveiling the Risks of Acupuncture: A Case Report. Clin Case Rep. 2024;12:e9637. doi: 10.1002/ccr3.9637
2 Chen W, Gao X, Li H. Case Report: Massive intrapericardial hematoma following acupuncture therapy. Front Cardiovasc Med. 2024;11:1433945. doi: 10.3389/fcvm.2024.1433945
3 Cornette H, Demey P, Verhelst L, et al. Dry Needling: A Possible Detrimental Treatment After Total Hip Arthroplasty. Cureus. 2024;16:e72053. doi: 10.7759/cureus.72053
4 Castro-Durán J, Martín-Armada M, Jiménez-Alonso J. Pyoderma gangrenosum induced by acupuncture in a patient with ulcerative colitis. Arch Intern Med. 2000;160:2394. doi: 10.1001/archinte.160.15.2394
5 Kim KH, Jo S, Song S. Laparoscopic removal of a broken acupuncture needle in pancreatic head: a case report. J Surg Case Rep. 2024;2024:rjae714. doi: 10.1093/jscr/rjae714
6 Marini NS, Lauar MCV, Oliveira MG, et al. Migration of metallic acupuncture threads from the breast to the right ventricle: a case report. Einstein Sao Paulo Braz. 2024;22:eRC1280. doi: 10.31744/einstein_journal/2024RC1280
7 Shen L, Ke S, Jing X. Acupuncture needle in the lung presents as severe pneumonia in a child in coma. Pediatr Pulmonol. Published Online First: 22 October 2024. doi: 10.1002/ppul.27353
8 Sung S, Kwon J-W, Lee S-B, et al. Effect of Preoperative Acupuncture and Epidural Steroid Injection on Early Postoperative Infection After Lumbar Spinal Fusion. J Bone Joint Surg Am. Published Online First: 10 December 2024. doi: 10.2106/JBJS.23.00721
Declaration of interests MC
