Open access peer-reviewed chapter

Needling Therapies in the Outpatient Care: Adverse Effects

Written By

Inés Llamas-Ramos and Rocío Llamas-Ramos

Submitted: October 17th, 2020 Reviewed: October 27th, 2020 Published: November 23rd, 2020

DOI: 10.5772/intechopen.94774

Chapter metrics overview

322 Chapter Downloads

View Full Metrics


The invasive techniques have been used for many years. There is a lot of literature on the advances that have been made, as well as the adverse effects or possible complications that have occurred during the performance of these treatments. Acupuncture and injections (saline, anesthetics, corticosteroids or botulinum toxin) have reported several cases of complications. Dry needling is also beginning to have several publications of this type. The objective of this chapter is to summarize the articles published in relation to adverse effects of needling therapies to promote a good practice and knowledge. Original articles in form of randomized controlled trials, case reports and reviews relating adverse effects and possible complications due to invasive/needling techniques: acupuncture, injections and dry needling have been included. 102 articles met the inclusion criteria between January 2000 and January 2020. The first limitation found in the literature was the huge variety of cases, therapists and incidents to generalize. As a conclusion we can stated the importance of a good knowledge of the anatomy and its variants, the correct application of these techniques and a continuous training of these therapists must be essential.


  • dry needling
  • acupuncture
  • injection
  • adverse effect
  • safety

1. Introduction

Muscular pain is a very common pathology in the physiotherapy treatment of outpatient care. The invasive techniques for treating these patients have aroused great interest, there are many reviews made in recent years about its effectiveness but none with conclusive results [1, 2, 3, 4, 5, 6]. Articles about post-needling pain [7, 8] and adverse side effects that may occur due to dry needling are being published until this day.

Dry needling is a minimally invasive technique into the most hypersensitive area/point of a tense band in a skeletal muscle (called myofascial trigger point), without the addition of any drug (Figure 1). It can be classified as deep or superficial [9]. There is not much evidence about which of the two options is better, it seems that deep dry needling has shown greater effectiveness due to penetrating the myofascial trigger point while the superficial dry needling penetrates the skin and the subcutaneous cellular tissue [10, 11]. In the same way, the appearance of local twitch response would guarantee its effectiveness [12, 13].

Figure 1.

Myofascial trigger point.

These myofascial trigger points present a high equivalence with the ashi points of acupuncture, corresponding to approximately 71% as Melzack introduced [14]. Acupuncture is based on a traditional and invasive Chinese technique of thousand years of age based on metaphysical concepts of "Ch'i" (Qi), the body energy flows through channels called "meridians" that has hypersensitive areas called ashi points (Figure 2). Its treatment also consists in the insertion of a needle in these points without any type of drugs [15].

Figure 2.

Acupuncture Meridians.

On the other hand, injections have also been the subject of many reviews, [16, 17] they have combined the effects of needling with the effect of local anesthetics. However, in 1943 Lewit [18] demonstrated that the true effectiveness of the infiltrations was due to the mechanical effect generated by the insertion of the needle itself and not the anesthetic.

The objective of this study is to summarize the articles published in relation to adverse effects of needling therapies to promote a good practice and knowledge.


2. Method

2.1 Data sources and searches

A review of the literature was carried out in Pubmed, Web of Science, Medline and PEDro databases. The search was limited to studies on adverse effects and possible complications due to invasive/needling techniques: acupuncture, injections and dry needling in English and Spanish.

The keywords in English first introduced separately were: "acupuncture", "injection", "dry needling" and "adverse effect/event". In a second time, in order to limit the article sample, 12 searches were added: 1–3: “acupuncture/dry needling/injection” AND "complication"; 4–6: “acupuncture/dry needling/injection” AND "iatrogenic"; 7–9: “acupuncture/dry needling/injection” AND "safe practice" and 10–12: “acupuncture/dry needling/injection” AND "academic training". A manual search of the references of pre-selected articles was also carried out.

The search fields were title/abstract of the keywords of the studies publishes by the journals indexed in Pubmed during the period between 2000 (January) AND 2020 (January). In Web of Science the search fields were TS (theme)/TI (title). In Medline search field was TI (title) and in PEDro a simple search was done. The manuscripts selected for this systematic review met the following inclusion criteria: (i) articles that report the adverse effects and/or complications of invasive/needling techniques; (ii) reviews of such complications; (iii) articles in English and Spanish and (iv) articles with protocols or recommendations on the safe practice of these techniques. We excluded theoretical articles on the application of these techniques and articles that were not published in English or Spanish.

2.2 Study selection and data extraction

Type of articles:randomized clinical trials, case reports and reviews were included in this review. Letters to editor, commentaries to other articles and practical application of these techniques were excluded.

Type of participants:participants of all ages/nationalities/sex/gender/education level/socioeconomic status which has been treated with needling therapies.

Type of interventions and outcomes:articles which have reported adverse effects (mild-severe) due to acupuncture, dry needling and injection were selected.

Type of publications:full text articles published in English or Spanish. Once the articles were found, randomized clinical trials, case reports and reviews were selected. Once duplicates were removed, 2 reviewers analyzed the abstracts in a first screening and then carried out an exhaustive reading of the preselected ones until obtaining the final sample of articles reviewed and included in this study. If there was disagreement among the independent reviewers, a third reviewer decided. The data were extracted independently by the reviewers.

Data extraction: tables summarize the different adverse effects in chronological order classified in relation of the type of intervention.

Quality assessment: both authors selected, reviewed and assessed the quality of studies included in this review. Discrepancies were resolved by consensus.

2.3 Data synthesis and analysis

A summary of the findings of the included studies was performed, structured in the incidence/frequency of adverse effects, most prevalent adverse effects, type of intervention, type of population and other associated diseases which could influence the results (Tables 13). Each article was named by the author and date; they have a brief description of the intervention, the type of the adverse effect and the conclusion/resolution of the inconvenience.


3. Results

3.1 Selection of the studies

The initial search provided 4.034 potential reports, after applying the inclusion and exclusion criteria, the sample consisted of 2.169 articles from Pubmed, 814 articles from Web of Science, 781 articles from Medline, 270 from PEDro and 9 found manually through preselected references from the Google Scholar database (Figure 3). After duplicated were excluded, 1.881 articles were selected. Both reviewers screened abstracts in a first time. In a second time, articles selected had a more detailed evaluation and 46 articles were excluded by the language, being letters to the editor or comments on other articles. Finally, 102 articles considered valid (93 from the initial search and 9 found manually). Detailed characteristics of the included studies are described in Tables 13 in relation to acupuncture, injection or dry needling respectively.

Figure 3.

Flow chart for different stages of the review.

Tandon, S. (1998) [19]48-year-old male suffering from bronchial asthma. Pneumothorax following acupuncture with electrical stimulation in the third and fourth intercostal spaces.
Peuker, ET. (1999) [20]To review the traumatic injuries after acupuncture and discuss how to avoid these adverse effects.
Kirchgatterer, A. (2000) [21]83-year-old female. Syncope and cardiogenic shock after acupuncture into the sternum.
Lao, L. (2003) [22]1965-1999 review: 202 incidents in 98 papers from 22 countries.
Ha, KY. (2003) [23]68-year-old female. Low back pain and sciatica aggravated by acupuncture. Chronic inflammatory granuloma with compression of the lumbar fourth nerve and dural sac.
Chang, SA. (2004) [24]68-year-old male. Death for massive hematemesis resulting from aortoduodenal fistula caused by acupuncture.
Saw, A.(2004) [25]55-year-old female, diabetic. Necrotising fasciitis due to acupuncture in a knee osteoarthritis.
Lee, WM. (2005) [26]36-year-old female. Bilateral pneumothorax after acupuncture.
Ryu, HJ. (2005) [27]Clinical manifestations and treatment for Mycobacterium abscessus due to acupuncture.
Kung, YY. (2005) [28]2 elderly patients: 72-year-old male and 63-year-old female. Between 2000 and 2002: syncope after acupuncture.
Chauffe, RJ. (2006) [29]Since 1985: 9 pneumothorax cases after acupuncture. 27-year-old student seeking acupuncture at levator scapular.
Su, J. (2007) [30]52-year-old female with chronic coughing. Acupuncture at BL131: paravertebral point at the level of the spinous process of the third vertebra: bilateral pneumothorax.
Lee, S. (2008) [31]79-year-old male (hypertension and diabetes). Bacterial aortitis with pseudoaneurysm formation after acupuncture.
Hwang, JK. (2008) [32]25-year-old female: Pneumoretroperitoneumen after acupuncture in right psoas muscle.
Juss, JK. (2008) [33]50-year-old female. Pneumothorax by acupuncture at scapulothoracic region.
Jindal, V. (2008) [34]Acupuncture to prevent postoperative nausea in children and to inhibit chemotherapy vomiting in adults.
Tsukazaki, Y. (2008) [35]32-year-old female (recurrent headache). Subarachnoid hemorrhage following acupuncture.
Witt, CM. (2009) [36]Review of acupuncture for osteoarthritis knee or hip, low back pain, neck pain or headache, asthma, rinitis or dysmenorrhoea. 229.230 patients: 19.726 suffered at least one adverse effect.
Kim, JH. (2009) [37]55-year-old female. Hemopericardium after acupuncture.
Kuo, HF. (2010) [38]39-year-old female with paresthesia and soreness at popliteal fossa. Fistula arteriovenous: vascular complication after acupuncture.
Ernst, E. (2010) [39]Systematic review of cardiac tamponade due to acupuncture. 5 Databases, no restrictions in time or language. 26 cases (14 fatal consequences).
Nam, KH. (2010) [40]4 cases of epidural hematomas after facet block, acupuncture and epidural injections.
Inayama, M. (2011) [41]37-year-old female. Pneumothorax and pleural fluid collection after acupuncture on neck and upper back.
Hsieh, RL. (2011) [42]44-year-old female (aplastic anemia). Staphylococcus infection after acupuncture at right calf.
He, W. (2012) [43]Chinese review of 167 papers: 1.038 cases (35 deaths).
Xu, S. (2012) [44]Frequency and severity of adverse events of acupuncture, moxibustion and cupping between 2000-11: 117 reports with 308 adverse effects from 25 countries.
Lee, JH. (2012) [45]47-year-old female: epidural abscess at C1-C3 after acupuncture and cupping.
Tagami, R. (2013) [46]69-year-old male: bilateral pneumothorax after acupuncture at upper back.
Stenger, M. (2013) [47]64-year-old male: pneumothorax after acupuncture for lumbar pain and sciatica.
82-year-old female: pneumothorax after acupuncture for herpes zoster.
Lee, SW. (2014) [48]47-year-old female with abdominal pain after acupuncture. Endoscopy: needle in the posterior wall of the antrum.
Hamptom, DA. (2014) [49]43-year-old female with chronic neck pain. Pneumothorax after acupuncture.
Peuker, E. (2014) [50]38-year-old female. Pneumothorax after acupuncture at subacromial region (BL13), paravertebral point at the spinous process of the third thoracic vertebrae.
Chun, KJ. (2014) [51]48-year-old female, (breast cancer 7 years before). Cardiac tamponade after acupuncture at fourth intercostal space.
Peuker, E. (2014) [52]Review of traumatic lesions after acupuncture.
Wu, J. (2014) [53]Chinese review of adverse effects between 1980 and 2013. 3 databases: 182 incidents in 133 relevant papers.
Ji, GY. (2014) [54]54-year-old female; 38-year-old female and 60-year-old male: 3 cases of hemiplegia after cervical paraespinal needling (intramuscular stimulation, acupuncture or lidocaine) in 2002-2013 in Korea.
Schar, ML. (2015) [55]39-year-old female with peripheral neuropathy history. Pneumothorax and broken needle in her chest.
Karavis, MY. (2015) [56]37-year-old female. Haemothorax after acupuncture for neck and right upper back pain.
Callan, AK. (2015) [57]15-year-old female with scoliosis. Periscapular abscess after acupuncture due to instrumentation.
White, A (2015) [58]715 adverse effects: 90 trauma (186 secondary reports); 204 infections (91 reports); 144 miscellaneous (12 deaths).
Brogan, RJ. (2015) [59]66-year-old male. Left pneumothorax after acupuncture (paraespinal, infrascapular and axillary regions bilaterally) for low back pain secondary to arthritis.
Wigger, O. (2015) [60]51-year-old female with breast pain and dyspnea. Cardiac perforation due to acupuncture.
Yao, Y. (2015) [61]54-year-old male. Epidural abscess at C4-T2 due to acupuncture.
Huisma, F. (2015) [62]53-year-old female. Pneumothorax after acupuncture at posterior left hemithorax medial to the scapula.
Kim, JS. (2016) [63]Review between 2011 and 2015: 17 pneumothoraxes (1 bilateral and 16 unilateral).
Ehgbal, K. (2016) [64]74-year-old female. Quadriparesis and sensory deficit due to cervical subdural hematoma at C4-C6 after acupuncture at neck and shoulder.
Li, X. (2017) [65]Meta-analysis of 33 randomized controlled trials about dry needling and manual acupuncture until February 2016. 33 trials with 1.692 patients.
Kim, D. (2017) [66]55-year-old female. She died by acute peritonitis three days after acupuncture.
Domenicucci, M. (2017) [67]64-year-old male. Hematoma epidural spinal C2-T12 (hemiparesis and paresthesias) after acupuncture for lumbosciatic pain.
Lee, HJ. (2017) [68]Retrospective observational study (2010-2014): 10 pneumothorax and 2 pneumoperitoneum.
Sia, CH. (2018) [69]50-year-old women. Pneumothorax after acupuncture for neck pain.
Lin, SK. (2019) [70]Pneumothorax incidence after acupuncture in Taiwan (1997-2012) 411.734 patients, 5.407.378 treatments.
Lee, H. (2019) [71]80-year-old male. Retroperitoneal abscess after lumbar acupuncture.
Lin, SK. (2019) [72]Cellulitis after acupuncture incidence in Taiwan (1997-2012). 407.80 patients, 6.207.378 treatments.
Liu, ZH. (2019) [73]42-year-old male. Broken needle in retroperitoneum after acupuncture treatments 2 years ago.
Tucciarone, M. (2019) [74]36-year-old male. Abscess in prevertebral muscles after acupuncture.
Ullah, W. (2019) [75]Old man. Pericarditis secondary to acupuncture after Staphilococus aureus infection.
Priola, SM. (2019) [76]47-year-old female. Epidural intracraneal abscess after acupuncture.
Ullah, W. (2019) [77]Systematic review about cardiac complications after acupuncture. 30 articles: 8 infections, 22 cardiac tamponades.
Corado, SC. (2019) [78]79-year-old female. Pneumothorax 2 days after interscapular acupuncture.

Table 1.

Detail of articles included about acupuncture.

Antoni, RO. (1961) [79]Review of 226 cases between 1955 and 1959: 71 iatrogenic pneumothoraxes.
Shafer, N. (1970) [80]29-year-old female with severe neck pain with radiation into her right arm and limitation of motion. Pneumothorax after injection.
Cheng, J. (2007) [81]Review from 1966 to November 2006: 35 papers. Infections, nerve injury, pneumothorax, embolism.
Usman, F. (2011) [82]37-year-old female, 20 weeks pregnant. Retrosternal abscess after injection at sternoclavicular joint.
Ahiskalioglu, EO. (2016) [83]25-year-old female. Pneumothorax after 4ml injection of lidocaine at thoracic region for neck and low back pain.
Soriano, PK. (2017) [84]39-year-old male. Hipokalemic paralisis after injection guided by ultrasound in iliopsoas.
Choe, JY. (2017) [85]70-year-old male (diabetic and cardiac history). Descending necrotizing mediastinitis after lidocaine injection at upper trapezius. Death by septic shock.
Lee, DG. (2018) [86]38-year-old male. Scapular neuropathy after 1% lidocaine injection and 6ml of saline.
De la Torre-Canales, G. (2019) [87]Systematic review about adverse effects of botulinum toxin A for masticatory muscles. 16 articles.
Camões-Barbosa, A. (2019) [88]33-year-old female. Weakness after botulinum toxin A injection for spasticity.
Mozafari, N. (2019) [89]55-year-old male. Cutaneous necrotic lesion after interferon beta 1-b injection.
Yurük, D. (2019) [90]Rhabdomyolysis after epidural steroid injection.
Marcus, F. (2019) [91]4 cases of Nicolau Syndrome: rare complication after intramuscular injections.
Kang, HY. (2019) [92]Systemic toxicity after cervical epidural steroid injection guided (February 2016-October 2017) 11 patients.
Park, HB. (2019) [93]Possible association between injections and calcification in lateral epicondylitis.
Al-Omari, AA. (2019) [94]78-year-old male. Avascular necrosis after one intra-articular injection.
Lobaton, GO. (2019) [95]62-year-old male. Vertebral osteomyelitis after epidural steroid injection. Permanent neurological injury.
Quincer, E. (2019) [96]5-year-old male. Nicolau Syndrome after intramuscular injection in deltoid muscle.
Anderson, SE. (2019) [97]Adverse effects after intra-articular corticosteroid injections (2000-2016), 1.708 patients, 104 adverse effects.
Kim, BR. (2019) [98]Review of adverse events of intra-articular facet joint injections. (2007-2017). 11.980 procedures, 101 adverse events in 99 patients.
Wang, RN. (2019) [99]61-year-old female. Oculo-motor nerve palsy after epidural lumbar injection.
Petrin, Z. (2019) [100]87-year-old female. Paralysis without hematoma after lumbar epidural steroid injection.
Rensma, HG. (2019) [101]33-year-old male. Nicolau syndrome after elbow injection.
Hu, Y. (2019) [102]Optic perineuritis after hyaluronic acid injections.
Lee, JH. (2019) [103]81-year-old female. Osteonecrosis after intra-articular corticosteroid injection.
Ali, D. (2019) [104]72-year-old female. Ischaemic stroke after cervical transforaminal injection.
Rouientan, A. (2019) [105]22-year-old male. Complication after botulinum toxin A.
Jani, P. (2019) [106]Iatrogenic adrenal suppression after facet joint injection.
Desai, K. (2019) [107]Review of 354 cases about iatrogenic peripheral nerve injuries.
Park, CW. (2019) [108]68-year-old male. Iatrogenic injury of sciatic nerve after intramuscular injections.
Ali, SS. (2019) [109]Iatrogenic spinal epidural hematoma and intracranial hypotension after thoracic epidural injection.
Sencan, S. (2019) [110]3 males treated with transsacral blocks. Neuropatic sciatic after gluteal injection.

Table 2.

Detail of articles included about injections.

Lee, JH. (2011) [111]58-year-old female with neck and upper extremity pain. Acute cervical epidural hematoma (C3-T1) after dry needling.
McCutcheon, L. (2011) [112]Techniques modifications to avoid pleura and lung. Understanding anatomy and its variants. Safe technique for training physiotherapists.
Brady, S. (2014) [113]2 questionnaires for 10 months. 39 physiotherapists and 1463 adverse effects. Safe technique.
Halle, JS. (2016) [114]To evaluate benefits/risks of these techniques to minimize them.
Halle, JS. (2016) [115]Adequate training and education: safe and effective technique. To inform patients via informed consent.
McManus, R. (2018) [116]27-year-old female, secretary. Neurapraxia of radial nerve after dry needling.
Berrigan, WA. (2018) [117]62-year-old female. Epidural hematoma and broken needle after dry needling.
Uzar, T. (2018) [118]36-year-old male. Pneumothorax after dry needling for pain in back muscles.
Kim, DC. (2018) [119]16-year-old male. Local abscess after dry needling at the thigh for pain after a knee injury.
McDowell, JM. (2018) [120]Safety of acupuncture and dry needling in pregnant women. 124 responses: only 60 needle pregnant women and a 60% of them feel safety.

Table 3.

Detail of articles included about dry needling.

3.2 Characteristics of the reviewed articles

102 articles met the inclusion criteria of the research in the period between 2000 (January) and 2020 (January) in form of original articles, case reports and reviews.

From these 102 articles selected, 23 refer to pneumothorax including more than 120 cases (19 of acupuncture, 3 of injection and 2 of dry needling); 4 articles refer to cardiac tamponade with more than 25 cases (both of acupuncture), 21 in relation to infections, abscesses or hemorrhages (14 of acupuncture, 6 of injection and 1 of dry needling) and other 7 articles refer to adverse effects such as syncope and cardiogenic shock (acupuncture), 3 pneumoperitoneo (acupuncture), 9 hematoma (6 of acupuncture, 1 of injection, 2 of dry needling), hemiplegia (acupuncture), cardiac perforation (acupuncture), hypokalemic paralysis (injection), 6 neuropathies (injection), 1 neuroapraxia (dry needling) and 12 cutaneous lesions/Nicolau syndrome/necrosis (3 of acupuncture, 9 of injection). In 11 articles there already was an existing disease, in other 4 the needle was broken and unfortunately in 4 articles the consequences were fatal. It has also collected 21 review articles of these needling therapies (more than 21.000 adverse effects described). Finally, 6 articles have synthetized information about benefits, risks, perception of security and even modifications of the application of these techniques (Figure 4).

Figure 4.

Prevalence of most common adverse events.


4. Discussion

Considering the outpatient care treatment, adverse effects are possible complications that can occur during or even after the application of these techniques. In more cases there has little importance such as pain, a slight bleeding or a small bruise that disappears quickly. However, other adverse effects without a clear cause can suppose a serious risk for the patient.

These risks have always been present, but in recent years publications have increased considerably. There is no consensus about the classification of these adverse effects. Some authors [111] categorized them into four groups: delayed or missed diagnosis, adverse effects during treatment, bacterial or viral infections, or tissue or organ trauma.

4.1 Incidence/frequency of adverse effects

The incidence/frequency of these adverse effects is not clear. Acupuncture seems to have an incidence of 2/125.000 cases [30]; White et al. [58] estimated the risk of a serious adverse event with acupuncture at 0.05 per 10.000 treatments, and 0.55 per 10.000 individual patients, Lin et al. [70] reported a pneumothorax incidence of 0.87 per 1.000.000 acupuncture treatments and 1.75 per 1.000.000 in anatomical risk areas; these authors also showed a cellulitis incidence [72] about 64.4 per 100.000 treatments.

In relation to injections, Anderson et al. [97] explained an incidence of 5.8% of adverse effects. Kim et al. [93] introduced the incidence separately in relation with the case: 0.84% and 1.63% in relation to the patient; on the other hand, the procedure had an incidence of 0.07% and the administrated drug 0.15%. Finally, the unknown etiology had a 0.63% for this author [93] and for other authors it is unknown [121].

Data about incidence of dry needling procedures has not been found.

The most reviewed articles refer isolated cases and not a periodicity, but other authors have published several reviews that try to synthesize this information. Considering these 3 needling techniques, acupuncture leaves a clear superiority in relation to the number of publications with adverse effects.

Peuker et al. [20] investigated the traumatic wounds caused by acupuncture and discuss how these complications could be avoided. Lao et al. [22] reviewed 98 publications (1965–1999) and they found 202 complications (infections, tissue/organ damage and nerve injury). Cutaneous disorders, hypotension, fainting and vomiting were some adverse effects described. Chauffe et al. [29] found 9 cases of pneumothorax since 1985. Witt et al. [36] reviewed acupuncture studies in chronic osteoarthritis pain of the knee or hip, lumbar, cervical, head, allergic rhinitis, dysmenorrhea and asthma. Out of 229.230, 19.726 reported at least 1 adverse effect (bleeding, pain, vegetative symptoms). The longest duration of these adverse effects was 180 days (nerve injury). Ernst et al. [39] conducted a review of cardiac tamponade after acupuncture: 26 cases were found and 14 with fatal complications. He et al. [43] reviewed 167 articles with 1.038 cases (35 deaths) from Chinese literature. 468 cases were syncope, 307 pneumothorax, and 64 subarachnoid hemorrhage. Xu et al. [44] checked the frequency and severity of these effects (2000–2011): 117 articles with 308 adverse effects in 25 countries (294 for acupuncture, 4 moxibustion and 10 cupping). Peuker et al. [52] reviewed the traumatic lesions after acupuncture. Wu et al. [53] performed a review in China (1980–2013), finding 182 incidents in 133 papers (internal organ, tissue and nerve injury are the major complications). The adverse effects included were syncope, infection, hemorrhage, allergy, burn, aphonia, hysteria, cough, thirst, fever, somnolence and broken needles. White et al. [58] found 715 incidents in their review: 90 reports of trauma and 12 reports of death. In Taiwan, Lin et al. [70, 72] published 2 reviews (1997–2012) about pneumothorax and cellulitis incidence respectively. They evaluated 411.734 patients with 5.407.378 treatments of acupuncture [70] and 407.802 patients with 6.207.378 acupuncture treatments [72]. In both articles the authors emphasized the importance of the previous medical history. Ullah et al. [77] reviewed 133 articles and selected 30 cases with relevant cardiac complications: 8 were infective complications and 22 cardiac tamponades.

Regarding injections, 8 articles have been found. Antoni Ro et al. [79] reviewed 226 cases (1955–1959), finding 71 cases of pneumothorax and Cheng et al. [81] performed a review (1966–2006) explaining the complications of this technique: “infections, spinal cord injury and peripheral nerve injuries, pneumothorax, air embolism, pain or swelling at the site of injection, chemical meningism, granulomatous inflammation of the synovium, aseptic acute arthritis, embolia cutis medicamentosa, skeletal muscle toxicity, and tendon and fascial ruptures”. De la Torre et al. [87] introduced a review about the adverse effects caused by botulinum toxin A in masticatory muscles. They used 436 citations and concluded with 16:7 were myofascial pain and 9 were trigeminal neuralgia. The most frequent adverse effects were “temporary regional weakness, tenderness over the injection sites and minor discomfort during chewing”. Most of them had a spontaneous resolution. Marcus et al. [91] found a very rare complication due to injections (diclofenac, dexamethasone and benzathine penicilin): Nicolau Syndrome. They found 4 cases (2016–2018). Park et al. [93] investigates an association between steroid injection and calcification in lateral epicondylitis. They evaluated 110 patients (February 2016-October 2018) and concluded that the injections history and the number of them has a significative association with soft tissue calcifications. A review (January 2000-April 2016) about adverse events due to intra-articular corticosteroid injections was made by Anderson et al. [97] 1.708 patients from 3 regional hospital participated: 99 patients had 104 adverse effects within 90 days post-injection. The most prevalent symptom was flare (78 patients) and 10 patients had skin reactions. There were no infections. Years before, Kim et al. [98] had reviewed 11.980 injections in 6.066 patients (January 2007-December 2017). There were 101 facet-joint injections and 99 patients developed adverse effects. 7 patients had an infectious spondylitis, 1 patient died of an uncontrolled infection and 2 patients had partial recovery of their neurological condition. Finally, Desai et al. [107] published a review of 17 years where reflected the iatrogenic peripheral nerve injuries due to injections. They included “intramuscular injections, brachial nerves procedures, subclavian and jugular venous cannulation and routine intravenous injections”. The most frequents symptoms were pain, paresthesia and sensory-motor deficits. 190 patients needed surgical intervention, 164 had any sequel or no recovery and 9 had neurological deterioration with weakness.

There is not standard data on the incidence of these events. Unfortunately, the huge diversity of pathologies, interventions, therapists… makes difficult a generalization.

4.2 Most prevalent adverse effects

There is no consensus about the most frequent adverse effect in the literature. Some of them are pneumothorax, cardiac tamponade, air embolism, spinal epidural haematoma/abscess, abdominal visceral injury, median and fibular nerve injury and infection [20, 36, 75, 77, 81, 87, 111].

Some authors reflected that pneumothorax is the most cited adverse effect, [50, 63] while for others is infection [44]. White et al. [58] agree with both theories being the most common complication pneumothorax and injury to the central nervous system and infection will be in second place. Ullah et al. [77] concluded that cardiac tamponade is the most frequent complication.

It seems that invasive techniques on the thorax are related to a high incidence of pneumothorax [118]. There are some investigations in different countries (United Kingdom, Japan, Czechoslovakia, Switzerland, Germany, Japan and Taiwan) about it. The incidence of these cases is low, less than 1/10.000. However, there have been more than 100 cases reporting iatrogenic pneumothorax due to acupuncture and dry needling, including cases of death [112]. Lin et al. [70] showed an incidence of 0.84/1.000.000 and 1,75/1.000.000 at risk anatomical areas. Most iatrogenic pneumothorax used to be unilateral, but there are bilateral cases too [26, 30]. In this article there are 23 articles related to pneumothorax [19, 26, 29, 30, 33, 46, 47, 49, 50, 55, 56, 59, 62, 63, 68, 69, 70, 78, 79, 80, 83, 112, 118].

Other incidents (less frequent) reported in the literature but not less important are cardiac tamponade [21, 39, 51, 75, 77], granulomas [23], fistulas [24, 38], necrosis [25, 42, 85], infections [27, 57, 119], abscesses [27, 45, 61, 71, 74, 76], pneumoretroperitoneum [32], hemorrhages [35], hemopericardium [37], haematomas [40, 64, 67, 109, 111, 117], chilotorax [41], organ perforation [48, 60], needle rupture [53, 55, 117], hemiplegia [54], hemothorax [56], peritonitis [66], cellulitis [72], hypokalemic paralysis [84], nerve injury [86, 99, 102, 107, 108, 110, 116], weakness [88], necrosis [89, 90, 94, 103], Nicolau Sydrome [91, 96, 101], toxicity…[92] Almost all had a complete resolution of the symptoms. However, publications with fatal and irreversible consequences have also been found [24, 37, 98].

4.3 Special considerations

There are several aspects must be considered when carrying out these techniques in the treatment of muscular pain in outpatients. These incidents, even taking caution may occur; therefore, it is important to obtain a complete clinical history highlighting possible underlying pathologies [70, 71, 72]. Several articles have found patients with asthma [19], diabetes [25, 85], anemia [42], herpes zoster [47], cancer [51], miastenia gravis [55] and scoliosis [57] and sclerosis [89]. These pathologies could influence the appearance or greater probability of developing a complication.

4.4 Type of population

The age of the patients is other aspect to discuss. A review performed in children (acupuncture to prevent postoperative nausea) has been published without conclusion about its effectiveness [34]. Quincer et al. [96] showed the case of a 5-year-old boy who developed a Nicolau Syndrome after an intramuscular injection in deltoid. Besides, cases of elderly people who have suffered syncope’s due to acupuncture have also been described [28]. These patients (the most prevalent population in the outpatient) may be more debilitated and suffer more adverse effects even taking precautions.

There are some types of population could be considered “at risk” when using these needling techniques, like pregnant women. We have found an article that exposes a retrosternal abscess due to sternoclavicular joint injection with resolution [82]. McDowell et al. have developed a review on the safety of acupuncture and dry needling in pregnant women in New Zealand. They conclude that of 124 responses obtained, only 60 therapists needle pregnant women and only 66% of them express safety. More training is needed in this field, particularly on dry needling [120].

In relation to sex, only one article showed major incidence in men than in woman [70].

4.5 Other applications of needling therapies

It seems that the most frequent application of these techniques is analgesia, including analgesic blocks [40], but there are other applications such hyaluronic acid in eyebrow [102], botulinum toxin A for axilar hiperhidrosis [105] and aesthetics for rejuvenation have also presented adverse effects [122, 123].

4.6 Reviews about safety

Among all reviews a meta-analysis of 33 randomized controlled trials was found. The authors conclude that acupuncture and dry needling are effective techniques, but more research on the safety of them is needed [65]. McCutcheon et al. [112] also reviewed the safety of acupuncture and dry needling, suggesting modifications of these techniques to avoid pleura and the lung. However, there are no conclusive results.

Considering the severity of these techniques, Brady et al. [113] conducted a study to check the adverse effects of dry needling. They filled in 2 questionnaires for 10 months to 39 physiotherapists and regrouped 1.463 adverse effects (common/less common/rare). They showed that it was a safe technique. Similarly, Halle et al. have published 2 articles [114, 115]. They assessed the risk/benefit of these techniques to minimize them, proposed an adequate education, knowledge of anatomy, training and to inform the patient via informed consent.

Guided techniques should be an interesting option to reduce these complications, but several articles do not support this affirmation [92, 110]. More investigation in this line is needed. On the other side, if dry needling seems to be safe, maybe it would be chosen instead injections to avoid the possible events effects derivate to the administered drugs like Kim et al. [93] exposed.

4.7 Limitations

Language was the first limitation, several articles have been found in France [124, 125], Portugal [126], Russia [127], Germany [128], Italy [129], Denmark [130], and Iceland [131] that have not been included in the revision due to its original language. 3 reviews in Chinese [132], German [128] and Danish [133] respectively were excluded for the same reason. The first two expose a synthesis or classification of adverse effects and the third, is a review on acupuncture in children in Denmark. Letters and comments were also excluded; however, we highlight the case of acupuncture in the disease of behgets [134]; a letter to editor where they expose a case of pneumothorax during a demonstration of dry needling in the thoracic iliocostal [135] and a needle broken as a complication of acupuncture [136]. Neither has been taken into account articles on practical applications, effectiveness of such techniques or superiority of some over others.

4.8 Future investigations

Acupuncture seems to have the most adverse effects reported throughout the literature, while injections and dry needling are increasing their publications, probably due to the increase in popularity especially of the second [114, 115]. Nowadays adverse effects seem to be common, but complications are rare. All authors of these articles agree in some tips to take in consideration:

  • The anatomy of the area to treat should be familiar to the healthcare professionals before undertaking the procedure.

  • Communication with the patient via informed consent is needed.

  • Aseptic conditions during the procedure are necessary.

  • The appropriate time to apply the treatments correctly becomes essential for a good practice and an adequate achievement of the results.

  • A correct training and continuous formation of healthcare practitioners are necessary.


5. Conclusion

This is a brief summary of the adverse effects found in the literature. There is no clear consensus about incidence, the most prevalent adverse effect, the intervention protocols, or experience of the therapist… As a conclusion, needling therapies are usual techniques in the outpatient care and complications are possible even considering all the precautions. Therapists have to know how to react, recognize the adverse effects and correct them as far as possible or refer the patient to the corresponding service, being always updated to new advances and familiar to the normal and variants of anatomy of the patients to avoid complications as much as possible. Caring the aseptic conditions and the communication with the patient to inform them about all the parts of the treatment with needling therapies are essential.


Conflict of interest

None declared.


  1. 1. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug;19(4):252-265
  2. 2. Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions a systematic review. J Man Manip Ther. 2015 Dec;23(5):276-293
  3. 3. Fogelman Y, Kent J. Efficacy of dry needling for treatment of myofascial pain syndrome. J Back Musculoskelet Rehabil. 2015;28(1):173-179
  4. 4. Rodríguez-Mansilla J, González-Sánchez B, De Toro GÁ, Valera-Donoso E, Garrido-Ardila EM, Jiménez-Palomares M, et al. Effectiveness of dry needling on reducing pain intensity in patients with myofascial pain syndrome a Meta-analysis. J Tradit Chin Med. 2016 Feb;36(1):1-13
  5. 5. Espejo-Antúnez L, Tejeda JF, Albornoz-Cabello M, Rodríguez-Mansilla J, de la Cruz-Torres B, Ribeiro F, et al. Dry needling in the management of myofascial trigger points. A systematic review of randomized controlled trials. Complement Ther Med. 2017 Aug;33:46-57
  6. 6. Gattie E, Cleland JA, Snodgrass S. The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017 Mar;47(3):133-149
  7. 7. Martín-Pintado-Zugasti A, Mayoral Del Moral O, Gerwin RD, Fernández-Carnero J. Post-needling soreness after myofascial trigger point dry needling. Current status and future research. J Bodyw Mov Ther. 2018 Oct;22(4):941-946
  8. 8. Martín-Pintado-Zugasti A, Fernández-Carnero J, León-Hernández JV, Calvo-Lobo C, Beltran-Alacreu H, Alguacil-Diego I, Gallego-Izquierdo T, Pecos-Martin D. Postneedling soreness and tenderness after different dosages of dry needling of an active myofascial trigger point in patients with neck pain. A randomized controlled trial. PM R. 2018 May 29. pii: S1934-1482(18)30287-9
  9. 9. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Vol. 1. Baltmore, MD: Williams & Wilkins; 1983
  10. 10. Baldry P. Superficial versus deep dry needling. Acupunct Med. 2002 Aug;20(2-3):78-81
  11. 11. Sedighi A, Nakhostin Ansari N, Naghdi S. Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. J Bodyw Mov Ther. 2017 Oct;21(4):810-814
  12. 12. Perreault T, Dunning J, Butts R. The local twitch response during trigger point dry needling Is it necessary for successful outcomes? J Bodyw Mov Ther. 2017 Oct;21(4):940-947
  13. 13. Fernández-Carnero J, Gilarranz-de-Frutos L, León-Hernández JV, Pecos-Martin D, Alguacil-Diego I, Gallego-Izquierdo T, et al. Effectiveness of different deep dry needling dosages in the treatment of patients with cervical myofascial pain. A pilot RCT. Am J Phys Med Rehabil. 2017 Oct;96(10):726-733
  14. 14. Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain. 1977;3(1):3-23
  15. 15. Ulett GA, Han S, Han JS. Electroacupuncture: mechanism and clinical application. Biological psychiatry. 1998;44(2):129-138
  16. 16. Cox J, Varatharajan S, Côté P. Optima Collaboration. Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities A Systematic Review. J Orthop Sports Phys Ther. 2016 Jun;46(6):409-429
  17. 17. Li X, Wang R, Xing X, Shi X, Tian J, Zhang J, et al. Acupuncture for Myofascial Pain Syndrome A Network Meta-Analysis of 33 Randomized Controlled Trials. Pain Physician. 2017 Sep;20(6):E883-E902
  18. 18. Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6(1):83-90
  19. 19. Tandon S, Gupta KB. Acupuncture induced pneumothorax – a case report. Medical Journal of Indonesia. May 1998;7(2):111
  20. 20. Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture. Therapists need to know human anatomy. Arch Fam Med. 1999 Nov-Dec;8(6):553-558
  21. 21. Kirchgatterer A, Schwarz CD, Höller E, Punzengruber C, Hartl P, Eber B. Cardiac tamponade following acupuncture. Chest. 2000 May;117(5):1510-1511
  22. 22. Lao L, Hamilton GR, Fu J, Berman BM. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med. 2003 Jan-Feb;9(1):72-83
  23. 23. Ha KY, Kim YH. Chronic inflammatory granuloma mimics clinical manifestations of lumbar spinal stenosis after acupuncture: a case report. Spine (Phila Pa 1976). 2003 Jun 1;28(11):E217-E220
  24. 24. Chang SA, Kim YJ, Sohn DW, Park YB, Choi YS. Aortoduodenal fistula complicated by acupuncture. Int J Cardiol. 2005 Sep 30;104(2):241-242
  25. 25. Saw A, Kwan MK, Sengupta S. Necrotising fasciitis: a life-threatening complication of acupuncture in a patient with diabetes mellitus. Singapore Med J. 2004 Apr;45(4):180-182
  26. 26. Lee WM, Leung HB, Wong WC. Iatrogenic bilateral pneumothorax arising from acupuncture: a case report. J Orthop Sur (Hong Kong). 2005 Dec;13(3):300-302
  27. 27. Ryu HJ, Kim WJ, Oh CH, Song HJ. Iatrogenic Mycobacterium abscessus infection associated with acupuncture: clinical manifestations and its treatment. Int J Dermatol. 2005 Oct;44(10):846-850
  28. 28. Kung YY, Chen FP, Hwang SJ, Hsieh JC, Lin YY. Convulsive syncope: an unusual complication of acupuncture treatment in older patients. J Altern Complement Med. 2005 Jun;11(3):535-537
  29. 29. Chauffe RJ, Duskin AL. Pneumothorax secondary to acupuncture therapy. South Med J. 2006 Nov;99(11):1297-1299
  30. 30. Su JW, Lim CH, Chua YL. Bilateral pneumothorax as a complication of acupuncture. Singapore Med J. 2007 Jan;48(1):e32-e33
  31. 31. Lee S, Lim SH, Kim DK, Joo HC. Acupuncture induced necrotizing aortitis with infected pseudoaneurysm formation. Yonsei Med J. 2008 Apr 30;49(2):322-324
  32. 32. Hwang JK, Kim J, Lee BJ, Park JJ, Kim JS, Bak YT. Pneumoretroperitoneum following acupuncture. J Altern Complement Med. 2008 Dec;14(10):1299-1301
  33. 33. Juss JK, Speed CA, Warrington J, Mahadeva R. Acupuncture induced pneumothorax – a case report. Acupunct Med. 2008 Sep;26(3):193-196
  34. 34. Jindal V, Ge A, Mansky PJ. Safety and efficacy of acupuncture in children: a review of the evidence. J Pediatr Hematol Oncol. 2008 Jun;30(6):431-442
  35. 35. Tsukazaki Y, Inagaki T, Yamanouchi Y, Kawamoto K, Oka N. Traumatic subarachnoid hemorrhage associated with acupuncture. Headache. 2008 Sep;48(8):1240-1241
  36. 36. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of acupuncture: results of a prospective observational study with 229.230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-97
  37. 37. Kim JH, Kim S, Lee YJ, Ahn R, Hong ES. Hemopericardium following acupuncture. Yonsei Med J. 2011 Jan;52(1):207-209. DOI: 10.3349/ymj.2011.52.1.207
  38. 38. Kuo HF, Shih MC, Kao WP, Su HM, Lin TH, Voon WC, et al. Acupuncture induced popliteal arteriovenous fistula successfully treated with percutaneous endovascular intervention. Kaohsiung J Med Sci. 2010 Mar;26(3):158-162
  39. 39. Ernst E, Zhang J. Cardiac tamponade caused by acupuncture: a review of the literature. Int J Cardiol. 2011 Jun 16;149(3):287-289
  40. 40. Nam KH, Choi CH, Yang MS, Kang DW. Spinal epidural hematoma after pain control procedure. J Korean Neurosurg Soc. 2010 Sep;48(3):281-284
  41. 41. Inayama M, Shinohara T, Hino H, Yoshida M, Ogushi F. Chylothorax caused by acupuncture. Intern Med. 2011;50(20):2375-2377
  42. 42. Hsieh RL, Huang CH, Uen WC. Necrotizing fasciitis after acupuncture in a patient with aplastic anemia. J Altern Complement Med. 2011 Sep;17(9):871-874
  43. 43. He W, Zhao X, Li Y, Xi Q, Guo Y. Adverse events following acupuncture: a systematic review of the Chinese literature for the years 1956-2010. J Altern Complement Med. 2012 Oct;18(10):892-901
  44. 44. Xu S, Wang L, Cooper E, Zhang M, Manheimer E, Berman B, et al. Adverse events of acupuncture: a systematic review of case reports. Evid Based Complement Alternat Med. 2013;2013:581203
  45. 45. Lee JH, Cho JH, Jo DJ. Cervical epidural abscess after cupping and acupuncture. Complement Ther Med. 2012 Aug;20(4):228-231
  46. 46. Tagami R, Moriya T, Kinoshita K, Tanjoh K. Bilateral tension pneumothorax related to acupuncture. Acupunct Med. 2013 Jun;31(2):242-244
  47. 47. Stenger M, Bauer NE, Licht PB. Is pneumothorax after acupuncture so uncommon? J Thorac Dis. 2013 Aug;5(4):E144-E146
  48. 48. Lee SW, Ahn JY, Choi WJ, Kim EJ, Bae SH, Choi YS, et al. A needle penetrating the stomach cavity after acupuncture. Clin Endosc. 2014 May;47(3):258-261
  49. 49. Hampton DA, Kaneko RT, Simeon E, Moren A, Rowell S, Watters JM. Acupuncture-Related Pneumothorax. Med Acupunct. 2014 Aug 1;26(4):241-245
  50. 50. Peuker E. Case report of tension pneumothorax related to acupuncture. Acupunct Me. 2004 Mar;22(1):40-43
  51. 51. Chun KJ, Lee SG, Son BS, Kim DH. Life-threatening cardiac tamponade: a rare complication of acupuncture. J Cardiothorac Surg. 2014 Mar 31;9:61
  52. 52. Peuker E, Grönemeyer D. Rare but serious complications of acupuncture: traumatic lesions. Acupunct med. 2001 Dec;19(2):103-108
  53. 53. Wu J, Hu Y, Zhy Y, Yin P, Litscher G, Xu S. Systematic review of adverse effects: a further step towards modernization of acupuncture in China. Evid Based Complement Alternat Med. 2015;2015:432467
  54. 54. Ji GY, Oh CH, Choi WS, Lee JB. Three cases of hemiplegia after cervical paraspinal muscle needling. Spine J. 2015 Mar 1;15(3):e9-e13
  55. 55. Scharf ML, Kommuri A. delayed recognition of an uncommon cause of iatrogenic pneumothorax. J Bronchology Interv Pulmonol. 2015 Apr;22(2):162-164
  56. 56. Karavis MY, Argyra E, Segredos V, Yiallouroy A, Giokas G, Theodosopoulos T. Acupuncture-induced haemothorax: a rare iatrogenic complication of acupuncture. Acupunct Med. 2015 Jun;33(3):237-241
  57. 57. Callan AK, Bauer JM, Martus JE. Deep spine infection after acupuncture in the setting of spinal instrumentation. Spine Deform. 2016 Mar;4(2):156-161
  58. 58. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004 Sep;22(3):122-133
  59. 59. Brogan RJ, Mushtaq F. Acupuncture-induced pneumothorax: the hidden complication. Scott Med J. 2015 May;60(2):e11-e13
  60. 60. Wigger O, Stortecky S, Most H, Englberger L. Cardiac perforation as a rare complication of acupuncture. Eur Heart J. 2016 May 1;37(17):1383
  61. 61. Yao Y, Hong W, Chen H, Guan Q, Yu H, Chang X, et al. Cervical spinal epidural abscess following acupuncture and wet cupping therapy: a case report. Complement Ther Med. 2016 Feb;24:108-110
  62. 62. Huisma F, Konrad G, Thomas S. Pneumothorax after acupuncture. Can Fam Physician. 2015 Dec;61(12):1071-1073
  63. 63. Kim JS, Kim KH, Kim WW. 17 cases of pneumothorax and factors influencing pneumothorax. Acupunct Electrother Res. 2016;41(2):95-105
  64. 64. Eghbal K, Ghaffarpasand F. An acute cervical subdural hematoma as the complication of acupuncture: case report and literature review. World Neurosurg. 2016 Nov;95:616.e11-616.e13
  65. 65. Li X, Wang R, Xing X, Shi X, Tian J, Zhang J, et al. Acupuncture for myofascial pain syndrome: a network Meta-Analysis of 33 randomized controlled trials. Pain Physician. 2017 Sep;20(6):E883-E902
  66. 66. Kim D, Lee S. An autopsy case of fatal acute peritonitis complicated by illegal acupuncture therapy. Forensic Sci Int. 2017 Jul;276:e13-e15
  67. 67. Domenicucci M, Marruzzo D, Pesce A, Raco A, Missori P. Acute spinal epidural hematoma after acupuncture; personal case and literature review. World Neurosurg. 2017 Jun;102:695.e11-695.e14
  68. 68. Lee HJ, Kim YJ, Kim WY. Safety concerns with thoracoabdominal acupuncture: experience at a tertiary-care emergency department. Pain Med. 2017 Dec 1;18(12):2504-2508
  69. 69. Sia CH, Leow AS, Leong BS. Traumatic pneumothorax secondary to acupuncture needling. Cureus. 2018 Aug 23;10(8):e3194
  70. 70. Lin SK, Liu JM, Hsu RJ, Chuang HC, Wang YX, Lin PH. Incidence of iatrogenic pneumothorax following acupuncture treatments in Taiwan. Acupunct Med. 2019 Dec;37(6):332-339
  71. 71. Lee H, Sung K, Cho J. Retroperitoneal abscess with pylephlebitis caused by lumbar acupuncture: a case report. BMC Surg. 2019 Oct 16;19(1):145
  72. 72. Lin SK, Liu JM, Wang PH, Hung SP, Hsu RJ, Chuang HC, Lin PH. Incidence of cellulitis following acupuncture treatments in Taiwan. Int J Environ Res Public Health. 2019 Oct 11;16(20). pii: E3831
  73. 73. Liu ZH, Wang HD, Xu X, Man LB. Removal of a broken acupuncture needle in retroperitoneum by laparoscopy: a case report. BMC Surg. 2019 Aug 6;19(1):102
  74. 74. Tucciarone M, Taliente S, Gómez-Blasi Camacho R, Souviron Encabo R, González-Orús Á-MR. Extensive pyomyositis of prevertebral muscles after acupuncture: Case report. Turk J Emerg Med. 2019 Apr 4;19(3):113-114
  75. 75. Ullah W, Roomi S, Sattar Z, Ahmad A, Ali Z, Sarwar U, et al. Acupuncture related acute purulent pericarditis masquerading uremic pericarditis. J Community Hosp Intern Med Perspect. 2019 Jun 19;9(3):230-234
  76. 76. Priola SM, Moghaddamjou A, Ku JC, Taslimi S, Yang VXD. Acupuncture-induced cranial epidural abscess: case report and review of the literature. World Neurosurg. 2019 May;125:519-526
  77. 77. Ullah W, Ahmad A, Mukhtar M, Virk HUH, Sarwar U, Figueredo V. Acupuncture-related cardiac complications: A systematic review. J Invasive Cardiol. 2019 Apr;31(4):E69-E72
  78. 78. Corado SC, Graça Santos M, Quaresma L, Baltazar JR. Pneumothorax after acupuncture. BMJ Case Rep. 2019 Jun 11;12(6). pii: e228770
  79. 79. Ro A, Ponka JL. The hazard of iatrogenic pneumothorax in certain diagnostic and therapeutic procedures. Surg Gynecol Obstet. 1961 Jul;113:24-32
  80. 80. Shafer N. Pneumothorax following "trigger point" injection. JAMA. 1970 Aug 17;213(7):1193
  81. 81. Cheng J, Abdi S. Complications of joint, tendon and muscle injections. Tech Reg Anesth Pain Manag. 2007 Jul;11(3):141-147
  82. 82. Usman F, Bajwa A, Shujaat A, Cury J. Retrosternal abscess after trigger point injections in a pregnant woman: a case report. J Med Case Rep. 2011 Aug 23;5:403
  83. 83. Ahiskalioglu EO, Alici HA, Dostbil A, Celik M, Ahiskalioglu A, Aksoy M. Pneumothorax after trigger point injection: a case report and review of literature. J Back Musculoskelet Rehabil. 2016 Nov 21;29(4):895-897
  84. 84. Soriano PK, Bhattarai M, Vogler CN, Hudali TH. A case of trigger point injection induced hypokalemic paralysis. Am J Case Rep. 2017 Apr 26;18:454-457
  85. 85. Choe JY, Kim JK, Lee DE, Seo KS, Park JB, Lee MJ, et al. Descending necrotizing mediastinitis after a trigger point injection. Clin Exp Emerg Med. 2017 Sep 30;4(3):182-185
  86. 86. Lee DG, Chang MC. Dorsal scapular nerve injury after trigger point injection into the rhomboid major muscle: a case report. J Back Musculoskelet Rehabil. 2018 Feb 6;31(1):211-214
  87. 87. De la Torre CG, Poluha RL, Lora VM. Araújo Oliveira Ferreira DM, Stuginski-Barbosa J, Bonjardim LR, Cury AADB, Conti PCR. Botulinum toxin type A applications for masticatory myofascial pain and trigeminal neuralgia: what is the evidence regarding adverse effects? Clin Oral Investig. 2019 Sep;23(9):3411-3421
  88. 88. Camões-Barbosa A, Ribeiro IM, Medeiros L. Contralateral upper limb weakness following botulinum toxin A injection for poststroke spasticity. Acta Med Port. 2019 Apr;26:32(13)
  89. 89. Mozafari N, Saffaei A, Alizadeh M, Shabani M. Cutaneous necrotic lesion: A wonderful delay adverse effect of interferon beta-1b injection for multiple sclerosis treatment. J Cosmet Dermatol. 2019 Aug;22
  90. 90. Yürük D, Yılmaz A, Özgencil GE, Aşık İ. Acute rhabdomyolysis following epidural steroid injection: An unusual complication in a patient with low back pain. Agri. 2019 Jul;31(3):150-152
  91. 91. Marcus F, Claude EV, Josephine M, Teyang A. An Exceptional cause of acute limb ischemia: Nicolau Syndrome-single-center experience with 4 Cases. Ann Vasc Surg. 2019 Jul;58:383.e7-383.e11
  92. 92. Kang HY, Kim JE, Kim YJ, Park SW, Kim Y. An unusual delayed onset of systemic toxicity after fluoroscopy-guided cervical epidural steroid injection with levobupivacaine: A case report. Pain Pract. 2019 Sep;19(7):762-766
  93. 93. Park HB, Kam M, Gwark JY. Association of steroid injection with soft-tissue calcification in lateral epicondylitis. J Shoulder Elbow Surg. 2019 Feb;28(2):304-309
  94. 94. Al-Omari AA, Aleshawi AJ, Marei OA, Younes HMB, Alawneh KZ, ALQuran E, Mohaidat ZM. Avascular necrosis of the femoral head after single steroid intra-articular injection. Eur J Orthop Surg Traumatol. 2020 Feb;30(2):193-197
  95. 95. Lobaton GO, Marrache M, Petrusky O, Cohen DB, Jain A. Devastating vertebral osteomyelitis after epidural steroid injection: a case report. JBJS Case Connect. 2019 Dec;9(4):e0028
  96. 96. Quincer E, Jaggi P. Nicolau Syndrome: A rare complication following intramuscular injection. J Pediatr. 2019 Sep;212:238-238.e2
  97. 97. Anderson SE, Lubberts B, Strong AD, Guss D, Johnson AH, DiGiovanni CW. Adverse events and their risk factors following intra-articular corticosteroid injections of the ankle or subtalar joint. Foot Ankle Int. 2019 Jun;40(6):622-628
  98. 98. Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures. Eur Radiol. 2020 Mar;30(3):1507-1516
  99. 99. Wang RN, Naraghi L. Oculomotor Nerve Palsy in the Emergency Department: A Complication of Epidural Injection. J Emerg Med. 2019 Nov 18. pii: S0736-4679(19)30841-8
  100. 100. Petrin Z, Marino RJ, Oleson CV, Simon JI, McCormick ZL. Paralysis following lumbar interlaminar epidural steroid injection in the absence of hematoma: A case of congestive myelopathy due to spinal dural arteriovenous fistula and a review of the literature. Am J Phys Med Rehabil. 2019 Oct;7
  101. 101. Rensma HG, Van de Kerkhof-Van Bon B. Severe pain and skin discolouration after injection: Nicolau syndrome, a rare complication. Ned Tijdschr Geneeskd. 2019 Oct 17;163. pii: D4001
  102. 102. Hu Y, Wang Y, Tong Y. Optic perineuritis secondary to hyaluronic acid injections: a case report. BMC Ophthalmol. 2019 Nov 27;19(1):241
  103. 103. Lee JH, Wang SI, Noh SJ, Ham DH, Kim KB. Osteonecrosis of the medial tibial plateau after intra-articular corticosteroid injection: A case report. Medicine (Baltimore). 2019 Nov;98(44):e17248
  104. 104. Ali D, El Khoumsi M, Gorur Y, Cardos B, Villalba NL. Rare case of ischaemic stroke following cervical transforaminal injection. Eur J Case Rep Intern Med. 2019 Mar 20;6(3):001082
  105. 105. Rouientan A, Alizadeh Otaghvar H, Mahmoudvand H, Tizmaghz A. Rare complication of botox injection: a case report. World J Plast Surg. 2019 Jan;8(1):116-119
  106. 106. Jani P, Morley HL, Shetty N. Iatrogenic adrenal suppression following caudal epidural and facet joint injection. BMJ Case Rep. 2019 Feb 21;12(2). pii: e225828
  107. 107. Desai K, Warade AC, Jha AK, Pattankar S. Injection-related iatrogenic peripheral nerve injuries: Surgical experience of 354 operated cases. Neurol India. 2019 Jan-Feb;67(Supplement):S82-S91
  108. 108. Park CW, Cho WC, Son BC. Iatrogenic injury to the sciatic nerve due to intramuscular injection: A Case Report. Korean J Neurotrauma. 2019 Apr 8;15(1):61-66
  109. 109. Ali SS, Shaw AE, Oselkin M, Bragin I. Iatrogenic spinal epidural hematoma associated with intracranial hypotension. Cureus. 2019 Mar 4;11(3):e4171
  110. 110. Sencan S, Cüce İ, Gündüz OH. Use of fluoroscopic-guided transsacral block for the treatment of iatrogenic post-injection sciatic neuropathy: Report of three cases. Turk J Phys Med Rehabil. 2019 Nov 22;65(4):406-410
  111. 111. Lee JH, Lee H, Jo DJ. An acute cervical epidural hematoma as a complication of dry needling. Spine (Phila Pa 1976). 2011 Jun;36(13):E891-E893
  112. 112. McCutcheon L, Yelland MJ. Iatrogenic pneumothorax: Safety concerns when using acupuncture or dry needling in the thoracic region. Physical Therapy Reviews 16(2):126-132. April 2011 
  113. 113. Brady S, McEvoy J, Dommerholt J, Doody C. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Man Manip Ther. 2014 Aug;22(3):134-140
  114. 114. Halle JS, Halle RJ. Pertinent dry needling considerations for minimizing adverse effects - Part one. Int J Sports Phys Ther. 2016 Aug;11(4):651-662
  115. 115. Halle JS, Halle RJ. Pertinent dry needling considerations for minimizing adverse effects - Part two. Int J Sports Phys Ther. 2016 Oct;11(5):810-819
  116. 116. McManus R, Cleary M. Radial nerve injury following dry needling. BMJ Case Rep. 2018 Jan 26;2018. pii: bcr-2017-221302
  117. 117. Berrigan WA, Whitehair CL, Zorowitz RD. Acute spinal epidural hematoma as a complication of dry needling: A case report. PM R. 2019 Mar;11(3):313-316
  118. 118. Uzar T, Turkmen I, Menekse EB, Dirican A, Ekaterina P, Ozkaya S. A case with iatrogenic pneumothorax due to deep dry needling. Radiol Case Rep. 2018 Sep 20;13(6):1246-1248
  119. 119. Kim DC, Glenzer S, Johnson A, Nimityongskul P. Deep infection following dry needling in a young athlete: an underreported complication of an increasingly prevalent modality: a case report. J Bone Joint Surg Am. 2018 Jul-Sep;8(3):e73
  120. 120. McDowell JM, Kohu SH, Betts D. Safe acupuncture and dry needling during pregnancy: New Zealand physiotherapists’ opinion and practice. Journal of Integrative Medicine. January 2019;17(1):30-37
  121. 121. Leung JS. Complementary medicine, acupuncture, and pneumothorax. Hong Kong Med J. 2002;8:225
  122. 122. Park KY, Jang WS, Kim IS, Ko EJ, Seo SJ. Hong CK Multiple epidermal cysts as a complication of gold acupuncture. Ann Dermatol. 2014 Jun;26(3):405-406
  123. 123. Bashey S, Lee DS, Kim G. Extensive facial sclerosing lipogranulomatosis as a complication of cosmetic acupuncture. Dermatol Surg. 2015 Apr;41(4):513-516
  124. 124. Henneghien C, Bruart J, Remacle P. A new iatrogenic pathology: pneumothorax after acupuncture. Rev Pneumol Clin. 1984;40(3):197-199
  125. 125. Cantan R, Milesi-Defrance N, Hardenberg K, Vernet M, Messant I, Freysz M. Bilateral pneumothorax and tamponade after acupuncture. Presse Med. 2003 Feb 22;32(7):311-312
  126. 126. Morrone N, Freire JA, Ferreira AK, Dourado AM. Iatrogenic pneumothorax caused by acupuncture. Rev Paul Med. 1990 Jul-Aug;108(4):189-191
  127. 127. Marchuk IK, Kuz'mich VN, Marchuk LI, Ordynskiĭ NL. Iatrogenic pneumothorax. Lik Sprava. 1993 Oct-Dec;(10-12):81-82
  128. 128. De Groot M. Acupuncture complications, contraindications and informed consent. Forsch Komplementarmed Klass Naturheilkd. 2001 Oct;8(5):256-262
  129. 129. Ronconi G, De Giorgio F, Ricci E, Maggi L, Spagnolo AG, Ferrara PE. Pneumothorax following dry needling treatment: legal and ethical aspects. Ig Sanita Pubbl. 2016 Sep-Oct;72(5):505-512
  130. 130. Steentjes K, de Vries LM, Ridwan BU, Wijgman AJ. Infection of a hip prosthesis after dry needling. Ned Tijdschr Geneeskd. 2016;160:A9364
  131. 131. Valgardsson AS, Gudbjartsson T. Bilateral pneumothoraces in a pregnant woman following acupuncture – a case report. Laeknabladid. 2019 Jan;105(1):19-21
  132. 132. Zhao DY, Zhang GL. Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection. Zhongguo Zhen Jiu. 2009 Mar;29(3):239-242
  133. 133. Larsson AS, Jørgensen IM. Acupuncture-induced bilateral pneumothorax in a 16-year-old boy. Ugeskr Laeger. 2018 Feb 26;180(9). pii: V10170804
  134. 134. Murray PI, Aboteen N. Complication of acupuncture in a patient with Behçet's disease. Br J Ophthalmol. 2002 Apr;86(4):476-477
  135. 135. Cummings M, Ross-Marrs R, Gerwin R. Pneumothorax complication of deep dry needling demonstration. Acupunct Med. 2014 Dec;32(6):517-519
  136. 136. Patrick BS. Acupuncture complication--a case report. J Miss State Med Assoc. 2005 Jul;46(7):195-197

Written By

Inés Llamas-Ramos and Rocío Llamas-Ramos

Submitted: October 17th, 2020 Reviewed: October 27th, 2020 Published: November 23rd, 2020