MD, PhD, FMedSci, FSB, FRCP, FRCPEd

An article with this title was published recently by a team from Israel; essentially, it reports two interesting case histories:

Case 1

A 59-year-old male underwent a course of acupuncture for chronic low back pain, by a 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 his family doctor diagnosed cellulitis and prescribed oral amoxicillin with clavulanic acid. 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. At that stage, 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).

Figure 1.
Figure 1.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. 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.

Case 2

A 27-year-old male with chronic cervical and back pain without any previous medical treatment or imaging was referred to a tertiary medical facility. 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 an emergency room with symptoms of progressive weakness in all four extremities and weakness. No additional symptoms were seen. Immediate MRI demonstrated an epidural hematoma at the C3-4 level (Figure 2).

Figure 2.
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 literature includes several reports of SSPE immediately following a chiropractic manipulation that was considered the cause of this event. The authors of this case report concluded 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.

On this blog, I have repeatedly warned that not all alternative treatments are free of risks. These two cases are impressive reminders of this undeniable fact.

I am sure that most proponents of alternative medicine will try to claim that

  • such complications are true rarities,
  • I am alarmist to keep alerting my readers to such events,
  • conventional medicine is dimensions more harmful,
  • the above cases are caused by poor practice.

However, I feel compelled to stress that there are no adequate post-marketing surveillance systems in alternative medicine and that the true frequencies of such events are therefore unknown. It seems therefore imperative (and not alarmist) to publicize such risks as widely as possible – in the hope that alternative practitioners, one day, might do the ethically and morally correct thing and implement proper surveillance of their practices.

6 Responses to The Perils of Complementary Alternative Medicine

  • I searched Youtube to find something demonstrative on “dry needling”, which is presumably the term for what the poor sod in the first clinical case got his infection from. It entails sticking the needles deep into affected muscles in an attempt to promote recovery. It seems also to be called “Myofascial Pain Therapy” by some, presumably because it sounds several degrees more professional than “dry needling”.

    Lo and behold!! The first hit was a short theatrical demonstration of how to introduce random bugs deep into the musculature of the trunc, in this case the lumbar area. The video even demonstrates with clarity his dirt-infested fingernails in a close up shot. One cannot but wonder what the man was scratching before he started his self-satisfied show.

    I was actually looking for a video I had recently seen, showing a frequent commentator on the SBM blog using himself as pin-cushion. His particular fancy seems to be this kind of “trigger point/MPT/acupuncture mix”. His promotional videos are quite demonstrative in many ways, like how he talks so his patients are happy they survived the dangerous quackery of other doctors and came to this master of miracles.

    Apropos adverse effects, another videoof his shows him making several attempts at puncturing the pulmonary apex, which may easily result in a pneumothorax. This complication can have serious consequences such as death and infection Pneumothorax is apparently not so uncommon after acupuncture. I wonder if he is saving on gloves as he only wears one on the palpating hand but is obviously handling and stroking the needle itself with the ungloved fingers!

  • The bias of Prof Ernst when given several references.
    I suppose you didn’t see these.
    “A 59-year-old man presented to the emergency department (ED) the day after a minor motor vehicle crash for evaluation of bilateral shoulder pain. He underwent ED evaluation for his back pain two more times before it was found that he had a spontaneous spinal epidural hematoma (SSEH).”e patient was successfully treated with cervical hemilaminectomy

    A young man presented with quadriparesis and spinal shock because of a spontaneous cervical spinal epidural haematoma was reported. Immediate MRI diagnosis followed by emergency decompression with six hours of presentation resulted in complete recovery.

    A case of spontaneous spinal epidural hematoma is reported. The 56-year-old man was hospitalized with neck pain followed by right sided Brown-Sequard syndrome at the level of C5-6 with a light rectovesical insufficiency and cervical sympathetic symptomatology. CT scan revealed right sided extradural high density mass. Following emergency operation removing the epidural hematoma ensured good recovery from the illness.

    Spinal epidural hematoma is a rare complication after chiropractic manipulation. In the literature, only three cases have been reported, which all necessitated surgical treatment.

    Chiropractic manipulation and spinal epidural hematoma–what came first?]

  • Thank you, prof. Ernst, for including four claims that invalidate your article on the perils of complementary alternative medicine. Since you didn’t undertake any effort to disprove these claims, I have to assume you agree they are correct.

    The reason you wanted to present the provided case histories anyway was, in your own words, ‘the hope that one day alternative practitioners will implement proper surveillance of their practices.’ That might be sound advice, but it is in no way an argument for presenting these sad cases, quite simply because they don’t add or prove anything. Your fellow skeptics fully agree with me on this point: http://www.skepticreport.com/sr/?p=423.
    If I would, for whatever good reason write an article entitled The Blessings of Alternative Medicine or The Perils of Conventional Medicine, presenting mere case histories without a trace of proof, the skeptic community would rightfully be on my case.

    If the need for better surveillance would truly be the main topic of your article, your alarming and stigmatizing title misses the point completely, more so as you state that it is unknown how often serious adverse effects occur. It gets even worse, I have to add, as there is well-documented proof that acupuncture treatments have a very low rate of – mostly minor – adverse effects. One large study concludes that acupuncture, in the hands of qualified practitioners, is an inherently safe therapy. I can only guess why this significant information is missing in your article.
    http://www.who.int/bulletin/volumes/88/12/10-076737/en/
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3616356/

    The only possible conclusion is that your article is highly biased on so many points that it is inexcusable.

    • pleasure! no need to thank me.
      the title, by the way, was not mine but the title of the original article – and so were the details of the two cases.
      I fail to see what is “inexcusable” about commenting on newly published evidence, particularly if it has the potential to make the world a safer place – but I am not a TCM-practitioner like you.

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