Spinal epidural abscess is a rare clinical encounter accounting for 0.005% of hospital admissions.[10] Case report literature review showed that radiation related cervical osteomyelitis and epidural abscess for a patient with hypopharyngeal wall carcinoma was reported by Ueki et al [11]. In their case, it was suggested that post-radiation necrosis of posterior pharyngeal wall could develop into cervical spine osteomyelitis [11]. A systematic review by Turner et al. discusses cervical spinal epidural abscesses [12]. This review attributes the most common risk factor for spinal epidural abscesses to drug use [12]. Iatrogenic risk factors which were less common included prior surgery, neck radiation, deep paravertebral injections of the neck and peridural injections [12]. Vertebral osteomyelitis and spinal epidural abscess as a result of acupuncture is rare and not widely reported especially in cervical spine. One case reported [13] of an uncommon complication of acupuncture and wet cupping with another middle-aged man having neck pain and fever and subsequent diagnosis of cervical spine epidural abscess at C4 to T2 by MRI scan. The focal neurological symptoms and signs resolved partially after treatment with antibiotics. The case [13] concluded that acupuncture and wet-cupping therapy should be considered as a cause of spinal epidural abscesses in patients with relevant history. Education with guidelines regarding hygienic measures should be provided to acupuncture and wet-cupping practitioners. This case [13] did not report the bacteria responsible for the cervical spine epidural abscess, while our case reported the acupuncture-introduced Staphylococcal aureus being responsible for C5-T2 spinal abscess and C7-T1 osteomyelitis.

In review of case report literature with spinal abscess formation following acupuncture, seven cases including our case have reported the responsible bacteria [14,15,16,17,18]. Six of seven cases were treated successfully with an extended course of antibiotics and serial MRIs with one case requiring decompression laminectomy. The most common causative pathogen was Staphylococcus aureus, responsible for five of these cases, the others being Serratia marcescens and Escherichia coli. It is to be noted that unlike our patient, none of the cases in literature had profound neurological deficits before treatment. Our case has highlighted a rare but potentially severe complication of acupuncture, which only had an incidence of 0.55 per 10000 patients based on one study [19], even rarer cause would be myelitis following acupuncture. Common complications of acupuncture include acupuncture site infection and rarer complications of neurovascular damage and pneumothorax have been reported [19].

A unique learning point in our case is to stress the importance of identifying red-flag history of recent acupuncture usage, particularly the home-based acupuncture with recycled needles of inappropriate sterilisation, which can lead to an early diagnosis and prompt treatment in order to minimize permanent neurological deficit and prevent the potentially fatal outcome of acute myelitis secondary to paravertebral and epidural abscess.

Authorship Criteria:

Dan Xu and Ding bang Chen concepted and designed the initial draft of the case. Dennis Nixon and Li Feng drafted the initial manuscript of the case. All authors reviewed and edited the revised and final manuscript of the case for important intellectual content. All authors have approved the submitted manuscript of the case and take the responsibility for the integrity of the work.

Conflicts of Interest/ Competing Interests:

All authors have no conflict of interests to declare.

Grant Information:

All authors received no specific funding for this work.

Acknowledgements:

Staff at Curtin Medical School of Curtin University and First Affiliated Hospital of Sun Yat-Sen University