Medulla oblongata injury caused by an acupuncture needle; warning for serious complications due to a common method of alternative medicine

Abstract

Acupuncture has become popular and an increasing number of procedures are performed worldwide. While acupuncture is generally considered safe, complications can occur due to its nature of insertion of sharp needles into the skin. Neurological complications are rare but reports have included peripheral nerve injury and spinal cord injuries [1–6]. Because of protection by the cranium, complications involving the brain are rare, and only a few cases have been reported [1, 7–9]. We report here a rare case of injury to the medulla oblongata due to migration of an acupuncture needle. A 44-year-old man presented with abnormal sensation 6 days after acupuncture treatment for stiff neck. He had felt dull pain on his left cheek and left back teeth after the course of the treatment. However, there was no dental problem on examination by a dentist. On admission, he had dysesthesia and pain in his left leg, and pain in the left V1 and V2 area of the face when he turned his neck. Computed tomography showed an acupuncture needle sticking the medulla oblongata (Fig. 1a), and the tip of the needle was located near the left vertebral artery (Fig. 1b). As there was risk of further injury to medulla oblongata and vertebral artery, emergent surgery was performed under general anesthesia. Extreme care was taken not to move the needle around the procedure to expose the needle. After removal of the needle the surface of the medulla oblongata was observed through a small craniotomy to rule out active bleeding (Fig. 1d). After the operation, facial pain persisted and an abnormal sensation of heat and pain appeared in the right leg. T2-weighted MRI showed a high intensity lesion in the area that had been pricked by the needle (Fig. 1e). His symptoms were gradually relieved, and he was discharged with dysesthesia in the left face and left leg. Although acupuncture is generally considered safe, complications can occur and sometimes result in a serious outcome [10, 11]. Among complications of the central nervous system, there have been reports of spinal cord injuries [2–6]. Brain injury is extremely rare, but can happen in the cases in which the needle is placed near the cervico-cranial junction, by migration of the needle through the foramen magnum [1, 7–9]. In our case, neurological symptoms appeared several days after the acupuncture session, and showed a progressive course. The broken needle had been overlooked and was left in the suboccipital muscle layer. As the tip of the needle remained sharp and the other end was dull, it might have gradually advanced inward piercing the dura mater and becoming lodged to the medulla oblongata. There are several case reports describing the delayed appearance of the symptoms [2, 9] due to similar mechanisms. The needle should be removed emergently to prevent further injury of nervous system and vasculature. First, the neck must be immobilized using a hard collar to prevent the needle from progressing further. At the introduction of general anesthesia, the patient was intubated with the help of an endoscope to prevent moving the needle by retroflexion of the cervix. Radiological diagnosis requires special attention. Although regular disposable acupuncture needles are made S. Fukaya T. Kimura (&) A. Morita Department of Neurosurgery and Stroke Unit, NTT Medical Center Tokyo, 5-9-22 Higashigotannda, Shinagawa-ku, Tokyo 141-8625, Japan e-mail: tkim-tky@umin.ac.jp