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    Peroneal Nerve Palsy Following Acp Treatment

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    LydwiNa Jc
    acupunture causes peroneal nerve palsy if not right

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    Peroneal Nerve Palsy Following Acp Treatment

    Uploaded by

    LydwiNa Jc
    62 views3 pages
    acupunture causes peroneal nerve palsy if not right

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    acupunture causes peroneal nerve palsy if not right

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    © All Rights Reserved
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    Download as pdf or txt
    62 views3 pages

    Peroneal Nerve Palsy Following Acp Treatment

    Uploaded by

    LydwiNa Jc
    acupunture causes peroneal nerve palsy if not right

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    COPYRIGHT 2003

    BY

    THE JOURNAL

    OF

    BONE

    AND JOINT

    SURGERY, INCORPORATED

    Peroneal Nerve Palsy Following


    Acupuncture Treatment
    A CASE REPORT
    BY MASAKI SATO, MD, HIROMU KATSUMOTO, MD, KOUI KAWAMURA, MD,
    HIROSHI SUGIYAMA, MD, AND TSUTOMU TAKAHASHI, MD
    Investigation performed at the Department of Orthopaedic Surgery, Asahi General Hospital, Asahi-City, Chiba, Japan

    cupuncture is an increasingly popular treatment method


    used to relieve pain. Adverse events related to acupuncture have been reported1-3 rarely. The purpose of this
    report is to describe what we believe to be the first case of peroneal nerve palsy caused by penetration and breakage of an
    acupuncture needle. Our patient was informed that data concerning the case would be submitted for publication.
    Case Report
    sixty-two-year-old woman was admitted to our hospital
    with a left dropfoot and anterior pain and numbness in
    the left leg. There was no history of spinal disorder or diabetes mellitus. Initially, the patient had a spontaneous onset of
    acute posterior pain in the left leg. Her general practitioner
    diagnosed sciatica and prescribed bed rest. One week later,
    because of persistent symptoms, she received the first of a series of acupuncture treatments, and the pain decreased after
    several treatments. During the sixth treatment, she felt a sudden radiating pain in the anterior part of the left leg when the
    acupuncture needle was inserted. A burning sensation and
    numbness in the anterior part of the left leg occurred immediately after this treatment. When the patient was stepping
    out of the bathtub on the following night, she noticed a left
    dropfoot for the first time, and she experienced difficulty
    with walking. The pain, burning sensation, numbness, and
    weakness in the left leg persisted. After receiving additional
    acupuncture treatments, she consulted a neurologist, who diagnosed an L5 radiculopathy and referred her to the orthopaedic department.
    On physical examination in our department, sensation
    was diminished on the dorsum and lateral side of the left
    great toe and on the dorsal aspect of the web space between
    the great and second toes but was otherwise normal. The
    strength of the tibialis anterior and extensor hallucis longus
    muscles was graded 1 of 5, but the strength of the peroneus
    longus and flexor hallucis longus muscles was graded 5 of 5.
    The Tinel sign was positive just posterior to the fibular head.
    A small brown discoloration was noted in this area, which, according to the patient, was where an acupuncture needle had
    been inserted. Radiographs showed a metallic needle-like object, approximately 1 cm in length, lying near the fibular head

    (Fig. 1), and magnetic resonance imaging demonstrated metallic artifact in the same area. Examination of the lumbosacral spine revealed normal findings. Compound muscle action
    potentials of the peroneal nerve in the left leg showed a remarkable decrease in amplitude distal to the level of the fibular head (Fig. 2).
    Surgery was performed two weeks after the presumed

    Fig. 1

    Lateral radiograph showing a fractured acupuncture needle (arrow)


    near the fibular head.


    THE JOUR NAL

    OF BONE & JOINT SURGER Y JBJS.ORG


    VO L U M E 85-A N U M B E R 5 M AY 2003

    P E RO N E A L N E R VE P A L S Y F O L L OW I N G
    A C U P U N C T U RE TRE A T M E N T

    peroneal nerve was identified and was traced distally. No foreign body was visible at first, but something firm could be palpated within the nerve. On reflection of the nerve, a broken
    needle was found just proximal to the point of division of the
    deep and superficial peroneal nerves (Fig. 3). No scar tissue or
    sign of infection was identified about the nerve. The needle
    fragment, which was 12 mm in length and had penetrated the
    nerve by approximately 5 mm, was removed without difficulty.
    On the day after the surgery, sensation and strength remained
    unchanged, but the pain and numbness had disappeared. The
    patient was provided with a dorsiflexion assist ankle-foot
    orthosis. Four months after the operation, the strength of the
    tibialis anterior muscle was graded 4 of 5, and that of the extensor hallucis longus muscle was graded 2 of 5. The hyperesthesias remained unchanged. The gait had become normal, and
    use of the orthosis was discontinued. Ten months after the operation, the tibialis anterior and extensor hallucis longus muscles had improved in strength and were graded 5 of 5 and 4 of
    5, respectively, but the hyperesthesias remained unchanged.
    Discussion
    cupuncture points are cutaneous areas containing relatively high concentrations of free nerve endings, nerve
    bundles, and nerve plexuses4, but no major peripheral nerves.
    The acupuncture point most commonly used for sciatic pain
    relief 5 is located at point 34 on the gallbladder meridian,
    which is on the anterior side of the fibular head. The Japanese
    call this point yoryosen (Fig. 4), and the World Health Organization defines it as Yanglingquan. We speculate that the
    acupuncture needle was inserted incorrectly in our patient,
    posterior to the fibular head and close to the peroneal nerve,
    which is where the skin discoloration was found. The acu-

    Fig. 2

    Compound muscle action potentials of the left peroneal nerve, recorded from the extensor digitorum brevis, showed a remarkable decrease in amplitude. The sites of stimulation included the ankle (a) and
    the region distal to the fibular head (b).

    nerve injury. A skin incision was extended from the medial side
    of the biceps tendon to the posterior aspect of the fibula. The

    Fig. 3

    Anatomical view. The base of the


    fractured acupuncture needle is
    held by the forceps. The tip of the
    needle is penetrating the common
    peroneal nerve. The distal aspect
    of the wound is to the left in the
    photograph.


    THE JOUR NAL

    OF BONE & JOINT SURGER Y JBJS.ORG


    VO L U M E 85-A N U M B E R 5 M AY 2003

    P E RO N E A L N E R VE P A L S Y F O L L OW I N G
    A C U P U N C T U RE TRE A T M E N T

    nally 40 mm in length. Even a disposable needle can break.


    Acupuncture needles rarely break7, but they may damage a
    spinal nerve root8,9 or a peripheral nerve10. We are aware of two
    case reports of peripheral nerve injuries caused by acupuncture in the literature10,11, but peroneal nerve palsy caused by the
    breakage of an acupuncture needle in the nerve has not been
    previously described, to our knowledge. However, with the increasing use and growing popularity of acupuncture as a therapeutic intervention, the number of adverse events will likely
    also increase.
    Although the facts of our case do not allow us to state
    whether nerve injury can result simply from penetration of the
    acupuncture needle without breakage, our case does demonstrate that the breakage of even a fine acupuncture needle can
    cause injury to a peripheral nerve. Compound muscle action
    potentials of the peroneal nerve in our patient showed a remarkable decrease in amplitude, indicating probable axonopathy and wallerian degeneration of the nerve12, conditions that
    require a lengthy recovery period. Clinicians should be aware of
    the potential for this complication following acupuncture treatments. In addition, we believe that acupuncturists should always check used needles as they are removed from a patient to
    be certain that the needle has been removed in its entirety. 

    Fig. 4

    Location of yoryosen and the scar where the acupuncture needle


    was inserted.

    puncture needle penetrated the peroneal nerve and broke with


    the tip remaining in the nerve. Although we do not know how
    the needle actually broke, it may have been broken as a result
    of muscular contraction due to sudden radiating pain during
    treatment6.
    Acupuncture needles are typically left in acupuncture
    points such as yoryosen for ten minutes without manipulation. In our patient, the acupuncture needle was disposable,
    made of stainless steel, and 0.16 mm in diameter and origi-

    Masaki Sato, MD
    Hiromu Katsumoto, MD
    Koui Kawamura, MD
    Hiroshi Sugiyama, MD
    Tsutomu Takahashi, MD
    Department of Orthopaedic Surgery, Asahi General Hospital, I-1326,
    Asahi-City, Chiba 289-2511, Japan
    The authors did not receive grants or outside funding in support of their
    research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such
    benefits from a commercial entity. No commercial entity paid or
    directed, or agreed to pay or direct, any benefits to any research fund,
    foundation, educational institution, or other charitable or nonprofit
    organization with which the authors are affiliated or associated.

    References
    1. Ernst E, White A. Life-threatening adverse reactions after acupuncture?
    A systematic review. Pain. 1997;71:123-6.

    7. Umlauf R. Analysis of the main results of the activity of the acupuncture


    department of faculty hospital. Acupunct Med. 1988;5:16-8.

    2. Norheim AJ, Fonnebo V. Adverse effects of acupuncture. Lancet. 1995;


    345:1576.

    8. Isu T, Iwasaki Y, Sasaki H, Abe H. Spinal cord and root injuries due to glass
    fragments and acupuncture needles. Surg Neurol. 1985;23:255-60.

    3. Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ.


    1999;319:973-6.

    9. Kondo A, Koyama T, Ishikawa J, Yamasaki T. Injury to the spinal cord produced by acupuncture needle. Surg Neurol. 1979;11:155-6.

    4. Kendall DE. A scientific model for acupuncture: Part I. Am J Acupunct. 1989;


    17:251-68.

    10. Southworth SR, Hartwig RH. Foreign body in the median nerve: a complication of acupuncture. J Hand Surg [Br]. 1990;15:111-2.

    5. Gellman H. Acupuncture treatment for musculoskeletal pain: a textbook for


    orthopaedics, anesthesia, and rehabilitation. 1st ed. New York: Taylor and
    Francis; 2002. p 137.

    11. Sobel E, Huang EY, Wieting CB. Drop foot as a complication of acupuncture injury and intragluteal injection. J Am Podiatr Med Assoc. 1997;87:
    52-9.

    6. Rogers PAM. Serious complications of acupuncture: or acupuncture


    abuses? Am J Acupunct. 1981;9:347-51.

    12. Oh SJ. Clinical electromyography: nerve conduction studies. 2nd ed. Baltimore: Lippincott Williams and Wilkins; 1993. p 479-95.

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