Spinal cord injury (SCI) encompasses damage to any part of the spinal cord or the nerves at the end of the spinal canal.¹ Depending on the location and severity of the injury, symptoms may vary and commonly include muscle weakness, altered sensation, loss of bowel or bladder control, changes in sexual function, and, in cases above the thoracic cord, breathing difficulties. The leading global causes of SCI are transport accidents, falls, violence, and sports-related incidents. Notably, iatrogenic SCI accounts for 18% of cases, with surgery or infection being the primary causes.² Although SCI occurs relatively infrequently, its profound impact on the affected individual’s quality of life and the substantial lifelong healthcare expenses associated with the injury warrant diligent efforts to reduce the occurrence of iatrogenic SCI through comprehensive case reporting and causative analyses.^2,3 Therefore, efforts to reduce the prevalence of iatrogenic SCI cases through active case reports and cause analysis are essential. In this case report, we present a unique case of cervical SCI following acupuncture, wherein direct needle injury was inflicted on the spinal cord.

A 27-year-old woman (height: 167 cm; weight: 65 kg) presented at our Rehabilitation Outpatient Department with paresthesia and a tingling sensation all over her left arm region. One month prior to this visit, she received acupuncture treatment around the neck at a local oriental clinic due to left posterior neck pain without any radiologic evaluation. According to her statement, during the procedure, she assumed a prone position with a pillow supporting her chest and her neck slightly flexed. A needle (length: 60 mm; gauge: 0.40 mm) (Fig. 1) was inserted perpendicular to the skin from the left side of her neck, targeting the EX-B2 acupoint, which is the left C3−4 interlaminar space.⁴ Although the depth of needle insertion was unclear, as the needle entered the left side of her neck, she experienced an abrupt, intense surge of pain that persisted for several minutes. Subsequently, she reported worsening pain accompanied by tingling paresthesia in her left upper limb. One month later, she sought consultation at our clinic. She had no medical history of any diseases or prior surgeries; however, a cervical X-ray taken before the incident revealed cervical kyphosis (Fig. 2). There was no personal or family medical history. Neurologic examination revealed no motor weakness or bladder or bowel issues, but she complained of persistent paresthesia with an intensity of 8 on the numeric rating scale (NRS) over the entire left arm for 20 seconds every 30 minutes each day. Pinprick and light touch tests showed that the left C4–7 dermatome had decreased to 1. Her elbow, knee, and ankle reflexes were intact. On cervical MRI taken a month after the symptom onset, a prominent cystic lesion (syringomyelia) was observed in the left central cord of C3–4, accompanied by peripheral swelling but no degenerative lesions (Fig. 3-A and 3-B). Examination of median somatosensory evoked potentials (SEPs) indicated ambiguous and significantly reduced amplitudes of P13 and N19 on the left side compared with the right side (Table 1). Other electrodiagnostic findings were normal. Finally, acute cervical SCI, which mainly involved sensory areas, was diagnosed. Conservative treatment was chosen rather than surgery. First, gabapentin 100 mg three times a day was prescribed to alleviate left arm numbness and pain for 2 weeks, but there was no significant effect and the patient complained of drowsiness and refused to increase the dose. We thought that acupuncture may have caused damage not only to the spinal cord but also to surrounding structures such as the ligaments, so we decided to try cervical intervention for inflammation. Afterward, ultrasound-guided selective nerve root blocks (SNRBs) at left C5 and C6 with lidocaine were performed for diagnostic purposes with the patient lying on the right lateral decubitus using the in-plane technique. When evaluating the pain 5 days later, the patient reported that the frequency of the pain decreased to 6∼7 times a day, lasting every 20 seconds, and that compared to before, the pain disappeared from the shoulder to the elbow and was limited to the hand. Then, left C7 SNRB with steroid was performed. Upon evaluation 1 month later, both frequency and pain intensity decreased, with a frequency of 1∼2 times per day and an intensity of 4 on the NRS. Since then, cervical prolotherapy and chronic pain education have been performed once a month. At the follow-up after 4 months from the onset, another MRI was taken, revealing the disappearance of peripheral swelling around the syringomyelia (Fig. 3-C and 3-D). The patient reported a 50% reduction in pain frequency and intensity. At the follow-up after 6 months, the patient reported that hand pain persisted without worsening. Pinprick and light touch follow up tests around the left C4–7 dermatome showed an improvement of 2, almost the same as on the right side.

Figure 1. Acupuncture needle.

Figure 2. Lateral view of the cervical X-ray taken before the incident. The cervical spine’s lordosis has progressed to kyphosis.

Figure 3. Cervical spine MRI performed 1 month and 4 months after the onset of symptoms. (A) Sagittal MRI performed a month after the onset of symptoms displayed a cystic lesion in the spinal cord of C3–4. (B) Sagittal MRI performed 4 months after the onset of symptoms. (C) Axial MRI at the C3–4 level revealed syringomyelia in the left central cord of C3–4, accompanied by peripheral swelling. (D) At follow-up, axial MRI at the C3–4 level revealed the disappearance of swelling around the syringomyelia. The linear distance from the syringomyelia to the injection site was approximately 51 mm.

Table 1 . Median Somatosensory Evoked Potentials (SEPs).

Median nerve	P13 latency			N19 latency			P13N19 amplitude
	Right	Left		Right	Left		Right	Left
	14.2	13.4		17.6	17.8		1.22	0.06

On examination, the left median SEP showed greater ambiguity and decreased amplitude at P13 and N19 compared with right median SEP..

Syringomyelia is a fluid-filled cyst within the spinal cord, classified into three types: congenital, complication as a trauma, infection, or tumor; and idiopathic. Above all, the mechanism of trauma-induced syringomyelia involves primary and secondary injuries. Primary injuries encompass impact with persistent compression, impact alone with transient compression, and ion/transection.⁵ Subsequently, these primary injuries trigger secondary injuries, leading to further chemical and mechanical damage to spinal tissues, resulting in neuronal excitotoxicity characterized by elevated intracellular calcium levels, increased concentrations of reactive oxygen species, and glutamate. This chemical and mechanical damage leads to necrotic cell injury from neuronal excitotoxicity, followed by axon demyelination and Wallerian degeneration, ultimately forming glial scars and cystic formations.^5,6

In this particular case, SCI and acupuncture procedures may be intertwined for several reasons. First, the patient experienced electric shock-like pain for minutes following the injection, and subsequently reported abnormal sensations, such as paresthesia, in her left arm. Second, MRI revealed edema around the syringomyelia, performed due to persisting neck and arm pain after the procedure, indicating an acute phase. Third, the patient was a young woman with no history of spinal degenerative lesions or prior medical conditions. Fourth, the patient’s muscle strength remained normal, but abnormal sensations persisted. This is consistent with the fact that the syringomyelia’s location was confined to the left central region, involving part of the dorsal column and spinothalamic tract, whereas the corticospinal tract was rarely affected. In this case, it is possible that the needle used in acupuncture passed through the paraspinal muscles, entered the interlaminar space widened by cervical flexion in the presence of kyphosis, damaging surrounding structures, and finally, the spinal cord.

To gain insight into existing English case reports on acupuncture-associated spinal cord injuries between 2006 and 2023, we conducted a thorough PubMed search. Our search (terms used: “acupuncture, acupuncture anesthesia, acupuncture analgesia” combined with “spinal cord injury, myelopathy, epidural hematoma, epidural abscess”) revealed 11 reported cases.^7-17 Among these cases, five patients complained of neck pain/stiffness, one of headache, four of back pain, and one of neck and back pain prior to the incident. The injuries in four cases were due to epidural or subdural hematomas, four cases were infections, and three cases were direct injuries caused by broken needles. The practitioners included four oriental doctors, four acupuncturists, two nonmedical practitioners, and two cases lacked description (Table 2). Notably, in all three cases resulting from direct needle injury, cord injuries occurred several months to years later, as the broken needles migrated.^7,10,11 However, in our case, direct damage occurred instantaneously upon needle insertion, an exceptionally rare occurrence, as we have found no prior cases with a similar mechanism.

Table 2 . Case Reports of Spinal Cord Injury Following Acupuncture.

First author/year (reference)	Age/sex	Disease treated	Punctured site	Complication	Practitioner
Murata et al. 19907	33/F	Post neck pain	C1–2	Direct injury-broken needle	Acupuncturist
Bang and Lim 20068	64/M	Back pain	Lower back	Epidural abscess and spondylitis	Oriental doctor
Chen et al. 20069	30/M	Back pain	C7–T3	Epidural hematoma	Acupuncturist
Liou et al. 200710	29/M	Neck stiffness	Epidural space at the C2 level	Direct injury: broken needle	Nonmedical practitioner
Miyamoto et al. 201011	47/M	Neck stiffness	Cervical region	Direct injury: broken needle	Self-acupuncture (nonmedical practitioner)
Lee et al. 201212	47/F	headache	C1–3	Epidural abscess	Oriental doctor
Yu et al. 201313	80/F	Neck and back pain	C3–7, L3–5, and L5–S1	Multiple epidural abscess	Oriental doctor
Park et al. 201314	69/M	Neck pain	Cervical region	Subdural hematoma	Oriental doctor
Callan et al. 201615	15/F	Back and shoulder pain	Periscapular region	Deep spine infection	Not specified
Domenicucci et al. 201716	64/M	Back pain	T9–L3 paraspinal regions	Epidural hematoma	Acupuncturist
Chen et al. 202017	52/M	Neck pain	Bilateral neck and upper back	Epidural hematoma	Not specified

In the context of cervical epidural steroid injections, several recommendations have been proposed to ensure safe procedures.^18,19 Notably, Bicket et al.¹⁸ advised avoiding routine heavy sedation, using a blunt-tip needle instead of a sharp needle and performing a standard preprocedural evaluation of cervical imaging to ensure optimal C-arm positioning and secure needle placement. Rathmell et al.¹⁹ recommended image guidance for all cervical interlaminar injections, emphasizing that performing injections at C7–T1 is safer than higher levels due to the cervical epidural space’s narrowness at other segmental levels, making the dural sac and spinal cord more susceptible to penetration and injury.

There is a dearth of literature providing clear safety protocols for acupuncture.²⁰ Prior case reports lacked standardized treatment methods and involved practitioners with varied backgrounds, including nonspecialists, oriental doctors, and acupuncturists, resulting in insufficient evaluation of patients at the treatment site. For instance, in this case, the patient’s preincident cervical spine X-ray revealed a kyphotic curve, rendering the epidural space more vulnerable. Caution should have been exercised when approaching the area, employing imaging techniques, such as ultrasound, to account for anatomical variations.

Direct SCI by a needle represents an extraordinary and scarcely documented accident. Accessing the upper cervical region is challenging and perilous, and performing a blind needle injection in this area was highly reckless. Although the aforementioned recommendations are not obligatory, treating without adequate knowledge can lead to catastrophic accidents. Practitioners must prioritize the awareness of consequences and acquire sufficient knowledge before performing such procedures.