The dangers of alternative medicine: An unusual cause of winging of the scapula. A case report and review of the literature

P.A.Banaszkiewicz, K.Szalai W.M.Ledingham

Department of Orthopaedic Surgery, Woodend Hospital, Eday Road, Aberdeen, AB15 6ZQ,U.K.

Correspondence to pbanaszkiewicz@hotmail.com

SMJ 2006 51(2): 54

Abstract

This is a case report of a 30-year-old man who presented with winging of his scapula secondary to acupuncture treatment for chronic neck pain. This complication has never previously been described and would be classified as a major adverse event following acupuncture use. 

Keywords: Acupuncture, Winging Scapula

Case Report

A thirty-year-old right-handed military fireman presented to the orthopaedic clinic with a six-week history of left shoulder weakness. He described waking up one morning with his “left arm suddenly dead and difficulty moving his shoulder”.

He had sustained a minor neck injury several weeks previously, which had been slow to resolve. A formal course of physiotherapy had provided only marginal benefit. The day prior to the onset of shoulder weakness he underwent his first acupuncture session to his painful neck. This consisted of inserting needles into various acupuncture points along his cervical spine, posterior scapula area and scapula spine.

On examination he was a well-built young man who favoured his right arm whilst undressing. His neck and shoulder contours were normal. Whilst there were no scars or obvious muscle wasting present various colourful body tattoos were visible. Palpation revealed mild tenderness of his lower cervical spine, left trapezius muscle and spine of the scapula.

Forward flexion of his left shoulder was limited actively to 100° completing an arc of 170° passively. Similarly abduction was again limited to 100° but could be completed passively to 170°. He had no pain on movement of his shoulder.

On pushing his hands against a wall at various heights above and below the shoulder gross winging of the scapula was demonstrated. The scapula rotated upwards and outwards suggesting weakness of the serratus anterior muscle (Figures 1 and 2).

Motor power of other muscle groups around the shoulder was otherwise normal. There were no other features of note on examination.

A provisional diagnosis of winging of the left scapula was made. It was thought most likely that the winging would resolve spontaneously given time. A course of physiotherapy was arranged. Nerve conduction and electromyography studies were initially considered but then discounted on the basis that they would be difficult to perform, merely confirm a diagnosis that was evident clinically and contribute little to his overall management. He was kept under regular orthopaedic review and at his final clinic visit seven months later he had made a complete recovery. He had regained complete full range of movement and power of his left shoulder.

Whilst it is possible the winging may have occurred spontaneously and be unrelated to acupuncture we believe its sudden onset following acupuncture was too co-incidental for this to be the case. The acupuncturist involved in the patients care was a fully qualified licensed practitioner. Disposable needles and a clean needle technique were used.

Review of the literature

Classical winging of the scapula is due to paralysis of the serratus anterior muscle, which is supplied by the long thoracic nerve. The long thoracic nerve may be injured by blunt trauma or surgery such as radical mastectomy, axillary lymph node dissection and first rib resection. Weakness of serratus anterior will cause the scapula to rotate upwards and outwards with the inferior angle rotating medially.

Winging of the scapula may also be caused by weakness of either the trapezius or rhomboid muscles. Weakness of trapezius leads to winging in which the scapula moves downwards and inwards with the inferior angle of the scapula rotating laterally. Winging secondary due to rhomboid muscle weakness is extremely rare and is similar to that seen with trapezius winging.

In our case report winging occurred secondary to long thoracic nerve injury. The acupuncture needles must have been inserted in an unusual and/or deep manner although we cannot exclude anatomical variations of the nerve. The long thoracic nerve was most probably injured by localised compression from either bleeding or an acute inflammatory reaction. Less likely but still possible would be direct damage to the nerve.

In its most traditional form acupuncture involves the insertion through the skin of solid needles ranging from 15-50mm in length.1  Depth of insertion varies from a few millimetres to several centimetres. The tip of the needle often lies in a muscle but many acupuncture points may overlie other structures such as the pleura and peripheral nerves.2  These needles are usually manually stimulated to correct disruptions in harmony.

Although disputed by some authors at least 7 deaths may have occurred following acupuncture use ranging from acute hepatitis to cardiac tamponade and pneumothorax. 3, 4, 5

Worldwide the most frequent major complication of acupuncture treatment is acute hepatitis. A recent systematic review of published case reports documented 94 cases of hepatitis associated with acupuncture use between 1974 and 1988.6  Unsterile techniques were used in all cases including testing the sharpness of needles both before and after use with a bare hand and the mixing of sterile and unsterile needles. Stringent infection control, universal precautions and the introduction of disposable needles have all but eliminated this major complication in recent years.

Other cases of infection reported include auricular infections, spinal infections, chronic osteomylitis, subacute bacterial endocarditis, staphylococcal septicaemia and glenohumeral septic arthritis.7  HIV infection may also be a problem with at least three cases of infection reported following acupuncture use. These cases occurred in patients at high risk for HIV infection and therefore a causal relation has not been established beyond reasonable doubt. 8, 9

At least 90 cases of pneumothorax including 2 reported fatalities have occurred following acupuncture use. Needle perforation of the lung can lead to bilateral as well as unilateral pneumothorax as two recent case reports have highlighted. 10, 11

At least 6 cases of cardiac tamponade have been reported following acupuncture use, two of which were fatal.12  One of the fatal cases was caused by lack of awareness of the sternal foramen, a common congential anomaly caused by incomplete fusion of the sternal plates. In the other case the acupuncture was self-administered.

Other miscellaneous major complications reported include spinal cord injury, peripheral nerve injury, retained or broken needles, retroperitoneal haematoma, false aneurysm of the popliteal artery and compartment syndrome.

Minor adverse events include pain at the site of needling, tiredness, contact dermatitis, minor haemorrhage, ecchymosis, haematoma, hypotension, syncope, dizziness, prolonged paraesthesia, increase in pain, nausea, vomiting and sweating. (Table 1) 13

Table 1

Reported adverse events associated with acupuncture

Recent published research suggests minor complications may be more common than previous appreciated but the risk of a serious adverse event occurring is extremely rare.14

A recent prospective study in the U.K involving 574 professional acupuncturists (members of the British Medical Acupuncture Society) reported on adverse events and treatment reactions associated with 34 407 treatments.15  No serious adverse events were reported although 43 minor adverse events were reported as “significant”, a rate of 1.3 per 1000 treatments. The most common events were severe nausea and fainting (28%), severe prolonged aggravation of existing symptoms (16%) and prolonged unacceptable pain and bruising (12%). Three avoidable events were reported, two patients had needles left in, and one patient had moxibustion burns to the skin.

In reality it is very difficult to draw any firm conclusions regarding the frequency of minor adverse effects following acupuncture. Figures vary substantially between studies. A systematic review on the safety of acupuncture showed a wide range of figures for common adverse effects such as needle pain (1% to 45%), bleeding (0.03% to 38%) and tiredness (2%to 41%). 14 This wide variation is due to many reasons such as no universal definition of a minor adverse event, under or over reporting from practitioners, no long term follow –up of patients, whether the acupuncturist was professionally trained and the type of acupuncture practiced.

The style of acupuncture differs between cultures. China, Japan and Korea have each developed their own distinctive version of acupuncture. Korean acupuncture is based on hand micromeridians with the use of ¼ inch needles and skin penetration of only 1 mm.  Chinese-style acupuncturists tend to insert needles deeply into muscles and to stimulate them manually. In contrast with Japanese-style acupuncture, needles are usually inserted only into subcutaneous tissues and are not stimulated. Despite the suggestion that the risk of adverse events is less with Japanese style acupuncture for complex reasons more adverse events seem to occur in Japan than in most other countries.

The unique Japanese acupuncture method of Umebari” whereby inserted needles are intentionally broken has been associated with major internal organ injury.16  The needle fragments left in the body are subsequently pressed further and retained permanently. The number of needles embedded can vary from several to hundreds. These embedded needles may twist and migrate to other parts of the body and cause internal organ injuries. Adverse events as a result of unsupervised self-treatment are relatively frequent in Japan. Documented injuries include subarachnoid haemorrhage, myelitis and spinal cord injury. 

Serious adverse effects of acupuncture are thought to be generally associated with poorly trained unlicensed acupuncturists. It has been pointed out that many of the case reports documenting serious injuries associated with acupuncture use could have easily been avoided if practitioners had better anatomical knowledge and applied existing anatomical knowledge better.12

Strict codes of ethics, practice, and professional conduct for accreditation of acupuncturists by the British Acupuncture Accreditation Board has reduced the frequency of adverse effects occurring over time and ensure that its members practise traditional acupuncture safely and competently.

Summary 

Acupuncture treatment is generally safe if a well-trained licensed practitioner performs it properly. Despite this neither acupuncture nor acupuncturists are entirely safe. inoshita K.Spinal cord injury as a complication of an acupuncture. Neurology. 1979 Aug; 29(8): 1188-90.

References

1. Lao L. Safety issues in acupuncture. J Altern Complement Med. 1996; 2:27-31. 

2. Yong D, Lim SH, Zhao CX, Cui SL, Zhang L, Lee TL. Acupuncture treatment at Ang Mo Kio Community Hospital-a report on our initial experience. Singapore Med J. 1999; 40:260-4. 

3. Norheim AJ.Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med. 1996 Summer; 2(2): 291-7. 

4. Ernst E, White A.Life-threatening adverse reactions after acupuncture? A systematic review. Pain. 1997 Jun; 71(2): 123-6 

5. MacPherson H.Fatal and adverse events from acupuncture: allegation, evidence, and the implications. J Altern Complement Med. 1999 Feb; 5(1): 47-56. 

6. Lao L, Hamilton GR, Fu J, Berman BM Is acupuncture safe? A systematic review of case reports. A systematic review of case reports. Altern Ther Health Med. 2003 Jan-Feb; 9(1): 72-83. 

7. Ernst E, White A. Acupuncture: safety first. BMJ 1997; 314: 1362 

8. Vittecoq D, Mettetal JF, Rouzioux C, Bach JF, Bouchon JP Acute HIV infection after acupuncture treatments. N Engl J Med. 1989 Jan 26; 320(4): 250-1. 

9. Castro KG, Lifson AR, White CR, Bush TJ, Chamberland ME, Lekatsas AM, Jaffe HW.Investigations of AIDS patients with no previously identified risk factors. JAMA. 1988 Mar 4; 259(9): 1338-42. 

10. Iwadate K, Ito H, Katsumura S, Matsuyama N, Sato K, Yonemura I, Ito Y.An autopsy case of bilateral tension pneumothorax after acupuncture. Leg Med (Tokyo). 2003 Sep; 5(3): 170-4 

11. Ramnarain D, Braams R.Bilateral pneumothorax in a young woman after acupuncture Ned Tijdschr Geneeskd. 2002 Jan 26; 146(4): 172-5. 

12. Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture. Therapists need to know human anatomy. Arch Fam Med. 1999; 8:553-8.

13. White A, Ernst E. Adverse events associated with acupuncture reported in 2000. Acupunct Med. 2001 Dec; 19(2): 136-7. 

14. Ernst E, White AR. Prospective studies of the safety of acupuncture: a systematic review. Am J Med. 2001 Apr 15; 110(6): 481-5. 

15. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001; 323:486-7. 

16. Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K.Spinal cord injury as a complication of an acupuncture. Neurology. 1979 Aug; 29(8): 1188-90.

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