Kidney Laceration after Acupuncture and Tuina: A Case Report
Ting-Yao Cheng1, Marcelo Chen1,2
Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan1; School of Medicine, MacKay Medical College, New Taipei City, Taiwan2
Kidney is the most commonly injured urologic organ from external trauma. Blunt trauma accounts for the majority of renal injuries and mostly come from motor vehicle accidents and falls. Acupuncture and Tuina are both form of traditional Chinese medicine, which is popular in west pacific area. They are commonly used as complementary treatment to manage clinical symptoms, especially pain.1 Increasing studies are investigating their safety and efficacy. Herein, we present a case with kidney laceration caused by the combination therapy of acupuncture and Tuina.
A 31-year-old woman presented to emergency department with left flank pain and gross hematuria. The discomfort started as dull pain over left abdomen and gradually turned into left flank soreness. No fever, colic pain, nausea, vomiting or dysuria was complained. Her body mass index was 17.9 kg/m2 and she denied any systemic disease. Her vital signs were stable on arrival. Physical examination was unremarkable except for left flank knocking pain. Urine analysis revealed numerous red blood cells and 10 white blood cells per high power field. Laboratory data reported leukocytosis with white blood cells up to 12,000 cells per microliter. Enhanced computed tomography demonstrated large hematoma in left para-renal space with a laceration about 1cm over posterior border and minimal contrast extravasation, confirming a grade III renal laceration (Fig.1 and 2). The patient had visited Chinese medicine clinic for low back pain around 8 hours before hospital visit. She received acupuncture over bilateral flank region followed by Tuina therapy, including massage and stretching. No other potential traumatic episode was mentioned by the patient. An indwelling urinary catheter was inserted and a total bed rest was applied until no gross hematuria. Her vital signs were stable and hemoglobin was above 11 g/dL throughout the course. The patient was discharged after a 72-hour admission.
Blunt trauma accounts for 80% to 90% of renal injuries, and often come from motor vehicle accidents or falls from heights. On the other hand, penetrating trauma accounts for 10% to 20%, and most come from gunshot or stab wounds.2 We highlight a case with kidney laceration caused by a combination of acupuncture and Tuina therapy. In this case, a preexisting penetrating wound was made with the fine needle of acupuncture, and the following Tuina manual therapy transmitted kinetic energy directly to worsen the condition.
Acupuncture is commonly used for pain control throughout the world. Although lack of universal protocol in needling, Shenshu (BL 23) is often one of the selected acupuncture points in terms of low back pain.3 The location of the acupoint Shenshu is 1.5 cun (approximately 5.0 cm) lateral to the spinous process of the second lumbar vertebra. The patient lies in the prone position. Afterward, the therapist places metallic needles perpendicularly into the skin with the depth of 1 to 1.5 cun (approximately 3.3 to 5.0 cm) at the acupoint. 4 In this case, the patient claimed that at least one needle was placed at both side of flank. The CT showed that the rupture point was at posterior border of kidney at the level of second lumbar vertebra, compatible with the location of acupoint Shenshu. In addition, the patient had a slim body shape with skin-to-kidney distance of 3.59 cm at right side, which raised the risk of accidental needle injury to the kidney during acupuncture.
Tuina, also understood as Chinese massage manual, has been applied to treat numerous clinical symptoms such as pain, nausea and vomiting, and constipation. The technique and protocol for the same symptom vary among different therapist, but generally consists of focal massage and stretching over symptomatic region. In the present case, the patient underwent massage over bilateral flank and low back stretching for a total of 30 minutes after acupuncture. No significant discomfort making cease of therapy was reported. Compared to the blunt force from vehicle accidents or falls from heights, the kinetic energy from Tuina is belong to low velocity impact. Unaware preexisting renal abnormality should be suspected when the clinical results are not compatible with the injury mechanism.5
Needle insertion to the renal parenchyma is of common urologic daily practice, such as cystic aspiration or fine needle biopsy. The diameter of the instruments in these procedures can reach 18 Gauze (approximately 1.3mm) or even 24 French (approximately 8 cm) in percutaneous nephrolithotomy. Those are much thicker and more dangerous than the needles used in acupuncture, generally 28 to 32 Gauge (approximately 0.36 to 0.24 mm). However, surgical related extensive kidney laceration is rarely reported.6 This can be attributed to the postoperative care and education. Those patients are requested to stay bedrest for hours after procedure, and told to avoid strenuous activity for 2 to 4 weeks after discharge. In contrast, the patient in our case sustained force impact from Tuina soon after the needle insertion. Nevertheless, her underweight body figure places her at a higher risk for needle penetration and gives her less cushioning effect from adipose tissue against blunt force.
In conclusion, acupuncture and Tuina may be both safe treatments to manage low back pain. However, caution should be taken to avoid kidney laceration when combination therapy was applied, especially in thin patient.
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3. Stux G, P. B.: Acupuncture: Textbook and atlas. New York: Springer, pp. 455–462, 2012
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5. Schmidlin, F. R., Iselin, C. E., Naimi, A. et al.: The higher injury risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol, 32: 388, 1998
6. Lang, E. K.: Renal cyst puncture and aspiration: a survey of complications. AJR Am J Roentgenol, 128: 723, 1977