Subarachnoid Hemorrhage and Spinal Root Injury Caused by Acupuncture Needle —

Case Report—

Keiji MURATA, Akimasa NISHIO, Misao NISHIKAWA, Yoshimitsu OHINATA, Masakazu SAKAGUCHI and Shuro NISHIMURA* Department

of Neurosurgery,

Shimada Municipal

Hospital.

Shimada.

Shizuoka:

*Department of Neurosurgery , Osaka City University, Medical School, Osaka

Abstract The authors report a case of subarachnoid hemorrhage and spinal root injury caused by an acupunc ture needle buried in the posterior neck about 30 years before onset. A 33-year-old female presented with sudden onset of severe occipital headaches. Plain x-ray films of the cervical spine revealed a fine gold needle, about 1.5 cm in length, between the C1 and C2 vertebrae. The needle was piercing the spinal nerve root through the dural vein, and was removed. Postoperatively, the pain exacerbated by neck movement disappeared.

Key words:

acupuncture needle,

injury,

spinal cord,

Introduction

Acupuncture is a traditional form of medicine in Japan. "Okibari" is one of the procedures used in acupuncture treatment. A fine gold needle is inserted into the subcutaneous tissue through a specific point on the skin and is then cut level with the skin surface. The needle then remains in the subcutaneous tissue. In Asia, this treatment was commonly used decades ago by acupuncturists. The accidental breakage of an ordinary acupunc ture needle and "okibari" treatment may cause major complications, such as spinal cord injury and pneumothorax.',a,s,"-'9> In this report, we present a case of subarachnoid hemorrhage (SAH) and spinal root injury due to an "okibari." Case

Report

A 33-year-old female was admitted to our hospital because of the sudden onset of severe headaches one day prior to admission. About 30 years previously, she fell and suffered from a cervical sprain, for which acupuncture treatment was given for the relief of Received 1990

November

30,

1989;

Accepted

May

8,

spinal root,

subarachnoid hemorrhage

posterior neck pain. On admission, neurological findings were normal except for neck stiffness. The cerebrospinal fluid was slightly bloody and xanthochromic. Plain x-ray films of the cervical spine revealed a fine needle, about 1.5 cm in length, between the C l and C2 vertebral laminae (Fig. 1). Precontrast computed tomographic scans showed no SAH but did show the needle within the spinal canal at C1-C2 levels (Fig. 2). Cerebral angiography showed no intracranial vascular lesions. One week after admission, the occipital headache and posterior neck pain almost disappeared following treatment with a soft neck collar. However, the occipital headache was later exacerbated by neck flexion and was accompanied by radiating pain to the right C2 sensory nerve distribution. She underwent a C l laminectomy in the prone position on day 20. The dural outer surface was in tact, and the needle was found penetrating the dural vein and piercing the right C2 nerve root where some hemosiderin deposits were noticed (Fig. 3). The needle was removed without difficulty (Fig. 4). The postoperative course was uneventful, and the pain exacerbated by neck movement disappeared immediately after surgery.

Fig. 1 Plain x-ray films of the cervical spine, open mouth (left) and lateral (right) views, showing the needle (arrowhead) between the C 1 and C2 vertebrae.

Fig. 4

Photograph

of

the

removed

acupuncture

needle.

Discussion

Fig. 2

Fig. 3

Precontrast CT within the spinal

Illustration penetrated C2 nerve

scans showing the needle canal at the C1-C2 levels.

of operating the dural root.

view.

vein and

The pierced

needle

had

the right

Traditional acupuncture has long been performed in Japan. It is used for various purposes, such as pain relief and acupuncture analgesia. Deliberate break age of needles and the burial of tens or even hun dreds of needles in various parts of the body to achieve prolonged and certain effects have been used by some acupuncturists without complications. This method is called "okibari," and may have been per formed on our patient about 30 years ago. In recent years, this method has become quite controversial among acupuncturists.") Although complications due to acupuncture are rare, the accidental breakage of a needle, called "sesshin," may cause major com plications.',`,'-`, '4-'9>Acupuncture needles may be accidentally broken because of sudden muscular con traction, body movement, coughing or sneezing dur ing the procedure."',",") Needles of inferior quality or repeatedly used are more easily broken. Electrical currents used in acupuncture treatment may also hasten the failure of needles."'In general, acupunc ture needles buried in subcutaneous tissue do not cause serious problems, but sometimes migrate to deeper layers moved by muscular relaxation and con traction. ") Sixteen cases with spinal cord injury caused by acupuncture needles have been reported in Japan (Table 1).6,9-`2,'a-`6)The symptoms appeared from a few days to a few years after the insertion of the needles. No case has been reported with such a long interval as 30 years after acupuncture therapy. In our case, the symptoms suddenly appeared as severe headaches, followed by lancinating pain in the occipital region with neck movement. The initial headaches were considered to be caused by SAH, because the initial headaches were not accompanied by lancinating pain and did not improve immediately following neck immobilization. At operation, the

Table 1

Summary of reported cases of spinal cord and root injury caused by acupuncture needles

soon as possible and signs.

after

the

occurrence

of symptoms

References 1) 2)

3)

4)

5) 6)

7)

8)

needle was found piercing the dural vein, and some hemosiderin deposits were found around the needle. This suggests that bleeding originated at the dural vein and spread into the subarachnoid space through the torn arachnoid membrane. The needle in the sub cutaneous tissue probably migrated into the spinal canal with neck movement over the time period and finally caused the SAH and spinal root injury.','," In general, the surgical removal of a migrated needle can sometimes be very difficult. The surgical removal of a migrated needle may not be indicated in asymptomatic patients. A long term follow-up is re quired in such patients, although these patients may be asymptomatic for a few years. The origin of delayed complications are reactive gliosis to foreign bodies and the migration of needles caused by muscular contraction and trauma. 1,2,7,8,11-13,15) However, we consider the migration of needles is the main cause of delayed complications and that the gliosis is only an outcome of repeated mechanical stimulation by needles. Once the pathological changes have occurred due to the mechanical stimula tion, symptoms of the delayed complications may not improve despite successful removal of the needle. Sasaki et al. 15)reported a case with a cavity formed at the pierced site of the spinal cord. In their case, the sensory deficit was not improved despite successful surgical removal. Therefore, the surgical removal of migrated needles must be performed as

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Allison G, Kravitz E: Auricular chondritis secondary to acupuncture. N Engl J Med 293: 780, 1975 Antonelli G: Spastic paraplegia developing 36 years after the immediate effects of a knife wound of the dorsal spinal cord, with permanent fixation of frag ment (of knife blade). Policlinico 39: 467-477, 1932 Castillo R, Kahn EA: Asymptomatic transfixion of spinal cord by a knife blade. JNeurosurg 7: 179-182, 1950 Hadden WA, Swanson AJG: Spinal infection caused by acupuncture mimicking a prolapsed intervertebral disc. J Bone Joint Surg [Am] 64: 624-626, 1982 Hussain KK: Serum hepatitis associated with repeated acupunctures. Br Med J 3: 41-42, 1974 Isu T, Iwasaki Y, Sasaki H, Abe H: Spinal cord and root injuries due to glass fragments and acupuncture needles. Surg Neurol 23: 255-260, 1985 Jones FD, Woosley RE: Delayed myelopathy sec ondary to retained intraspinal metallic fragment. J Neurosurg 55: 979-982, 1981 Jones WA: Old stab wounds of the spinal cord and base of the brain. JAMA 121: 1004-1006, 1943 Kataoka H, Sakata M: Nerve injury due to an acupuncture treatment. Geka 20: 578-582, 1958 (in Japanese) Kojima Y, Ono K, Ogino H, Okada K, Kimura T: Migration of the needle of acupuncture into the cer vical spinal canal. Report of four cases. Chubu Nip pon Seikeigeka Saigaigeka Gakkai Zasshi 23: 292 - 294, 1985 (in Japanese) Kondo A, Koyama T, Ishikawa Y, Yamasaki T: Injury to the spinal cord produced by acupuncture needle. Surg Neurol 11: 155-156, 1979 Maruoka N, Kinoshita K, Wakisaka S: Spinal cord injury by a broken acupuncture needle. A case report. No Shinkei Geka 14: 785-787, 1986 (in Japanese) Miyazaki Y, Inaba K: Transfixion of cervical cord by a glass fragment. Report of a case. No Shinkei Geka 4: 799-803, 1976 (in Japanese) Noumi T, Yamauchi Y, Kamimura K, Kuba Y, Satoh N, Muraoka Y, Saitoh Y: A broken acupuncture nee dle migrated into the spinal canal. Nippon Iji Shinpo 3131: 32-34, 1984 Sasaki H, Abe H, Iwasaki Y, Tsuru M, Itoh T: Direct spinal cord and root injury caused by acupuncture. Report of two cases. No Shinkei Geka 12: 1219-1223, 1984 (in Japanese) Shiraishi S, Gotoh I, Kuroiwa Y, Nishio S, Kinoshita K: Spinal cord injury as a complication of an acu puncture. Neurology (Minneap) 29: 1180-1182, 1979 Spring M: The practical medical aspects of acupunc ture. Bull NY Acad Med 51: 914-921, 1975

18)

Stack BHR: Pneumothorax associated ture. Br Med J 1: 96, 1975

with acupunc

19) Ueyama S, Kajihara M, Tada A, Fukushima T, Ikeda R: Sesshin. Tokyo, Ido No Nippon, 1974, pp 1-128 (in Japanese)

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