Introduction
Acupuncture is commonly used for musculoskeletal pain. Acupuncture seems as low-risk alternative modality, but there are some complications. Spondylitis with spinal epidural abscess after acupuncture is a rare major complication, and recurrence rate of spondylitis is as low as 10%. In this report, we present a case of recurrent thoracic spondylitis with epidural abscess after acupuncture.
Case Report
An 82-year-old man visited the outpatient department of neurosurgery because of thoracic back pain. About 3 months ago, he fell down on the thoracic back and received acupuncture for thoracic back pain. Exact acupuncture date and procedure were unknown. He had tenderness on the thoracic paraspinal region without neurological abnormalities. A blood test showed elevated C-reactive protein (CRP) as 17.43 mg/dL. Thoracic spine magnetic resonance imaging (MRI) revealed T6/7 and T8/9 spondylitis. Methicillin-sensitive Staphylococcus aureus (MSSA) was cultured on the blood and surgical biopsy. Intravenous (IV) ceftriaxone was administered for 4 weeks, but MSSA was re-cultured with breakthrough fever. T6 laminectomy was performed. After 4 weeks of IV nafcillin treatment, the patient could walk with holding a cane and was discharged. Two weeks later, the patient re-visited the hospital because of paraplegia. On neurologic examination, both lower extremity weakness was Medical Research Council (MRC) grade 2, and was accompanied by the impairment of pinprick and light touch sensation below T5 dermatome. On a blood test, CRP was 24.17 mg/dL, and MSSA was re-cultured. Thoracic spine MRI showed the aggravation of T6/7 and T8/9 spondylitis with epidural abscess. Removal of epidural abscess and T7 subtotal laminectomy were done. IV vancomycin was administered for 4 weeks, and then oral cefixime continued. The patient was transferred to the department of rehabilitation medicine. After 1 week, CRP was elevated to 3.34 mg/dL. IV vancomycin with oral rifampin was administered for 6 weeks due to continued CRP elevation. He was undergone lower extremity strengthening, proprioceptive stimulation, gait training, and physical modalities for thoracic back and lower extremity pain. After 2 months of rehabilitation, both lower extremity weakness was improved as MRC grade 4, but sensory impairment of pinprick and light touch below T5 dermatome was unchanged. The patient was able to walk for 50 meters with holding a high walker without assistance.
Conclusion
Acupuncture is a common therapeutic intervention for back pain. Major complications of acupuncture on the back are spondylitis, pneumothorax, and neurovascular injury, and so on. Although there were some cases of spinal epidural abscess after acupuncture, these cases were treated successfully by an extended course of antibiotics with laminectomy. This case is the first reported case of recurrence of thoracic spondylitis with spinal abscess after acupuncture despite antibiotic and surgical treatment. |
