Two patients suffering from complications of alternative medicine were treated in our hospital: one patient developed necrotizing fasciitis after acupuncture, and the second developed an epidural hematoma after chiropractic manipulation.
The first case is that of a 59-year-old male, who underwent a course of acupuncture for chronic low back pain, by a young female acupuncturist. During the therapy the patient noted swelling at the point of puncture, but his therapist dismissed the claim. The region continued to swell, and three days later the patient presented to his family doctor, who diagnosed cellulitis and prescribed oral amoxicillin with clavulanic acid (Augmentin; GlaxoSmithKline plc, Brentford, UK). The following day the patient’s condition worsened—he started to suffer from chills and more intense pain, so he went to the emergency room.
Upon examination, the patient had a fever of 37.9°C, a pulse of 119, and a blood pressure of 199/87. Edema was noted over the patient’s entire right flank (Figure 1A). Laboratory results were notable for a level of glucose of 298 mg/dL, sodium of 128 mmol/L, and white blood count (WBC) of 26,500 cells/μL with left shift. An emergency CT revealed an abscess of the abdominal wall involving the muscles, but no intra-abdominal pathology (Figure 1B).
Photo and CT Scan of the Patient’s Right Flank.
The patient received broad-spectrum antibiotics and was taken to the operating room for debridement. Upon incision there was subcutaneous edema with no puss, gangrene of the entire external oblique muscle, and an abscess between the external and internal oblique muscles. The muscles were debrided back to healthy, bleeding tissue and the wound copiously irrigated with saline. The wound was left open, with gauze and iodine as a cover. Gram stains and cultures returned group B streptococcus (GBS) sensitive to penicillin, and antibiotic coverage was adjusted accordingly. The patient returned to the operating room for serial debridement until the wound developed healthy granulation tissue, as is well advocated in the medical literature.1–6 The patient received four units of blood and required 13 days of hospitalization. To date, he suffers from a disfiguring wound of his abdominal wall.
Considering the fact that group B streptococci live primarily in the female vagina, and that the acupuncturist was a young female, it is possible to assume that the cause for this grave illness was due to improper hygiene while treating our patient with acupuncture. Although rare, this tragic consequence of acupuncture has been seen previously by other researchers.7 Research has also shown that GBS has been transmitted via person-to-person direct contact; thus, an association between GBS colonization and hand-washing in the general population seems likely. The crude association of tampon use with GBS (OR, 5.7) was statistically significant, which also strengthens our suspicion of transmission from the female acupuncturist.8
The second case involved a 27-year-old male with chronic cervical pain, without any previous medical treatment or imaging, who was referred to our tertiary medical facility. The patient suffered from back pain. To manage his pain, the patient used the services of a chiropractor who used cervical manipulation. Immediately after such a manipulation, the patient felt a severe cervical pain; 30 minutes after manipulation the patient started feeling paresthesia in his hands and legs. The patient was admitted to our emergency room with symptoms of progressive weakness in all four extremities and weakness that was measured as 3/5. No additional symptoms were seen. Immediate MRI demonstrated an epidural hematoma at the C3-4 level (Figure 2
The patient underwent immediate surgery to evacuate the hematoma via an anterior approach and C3-4 cage placement. The day after surgery the patient showed a remission of symptoms. At 6 months follow-up his remission was complete.
The incidence of spontaneous spinous epidural hematoma (SSPE) is considered to be very low. Kuker et al. reported that SSPEs most frequently occur at the thoracic or lumbar spine, with incidences in the cervical region being quite rare—only 1 out of 7 reported cases.9 The hematoma can be epidural or subdural. The presenting symptoms of SSPE may be shoulder pain,10 interscapular pain,11 associated with radicular radiation into the upper extremities, neck pain,12 hemiparesis like in cases of Brown–Sequard syndrome,10,11,13,14 progressive weakness,12 or even spinal shock.15 Symptoms of neck and upper extremity pain with bilateral signs of myelopathy with a sensory level should lead to the suspicion of acute cervical cord compression.16 A few case reports have shown that SSPE can follow minor traumatic injury as in a motor vehicle accident.17 To our knowledge, the literature includes only three reports of SSPE immediately following a chiropractic manipulation that was considered the cause of this event.17–19 We conclude from the current case that chiropractic procedures can be dangerous when performed by practitioners who might be only partially trained, who might tend to perform an insufficient patient examination before the procedure, and thus endanger their patients. In the current case, an acute epidural hematoma diagnosed by immediate MRI followed by emergency decompression within six hours of presentation resulted in complete recovery. We believe that the standard treatment in these cases is a prompt surgical evacuation of the hematoma, after MRI as the imaging modality, as had been done in the current case.