Abstract
Background Spinal epidural abscess is a rare but potentially devastating infection that may cause irreversible neurological injury. Although acupuncture is generally considered safe, serious infectious complications have been reported.
Case A previously healthy 54-year-old woman developed neck pain, diffuse paresthesia, and urinary retention 10 days after acupuncture. Magnetic resonance imaging revealed a posterior epidural abscess from C5 to T2 with severe spinal cord compression, together with paravertebral and retropharyngeal abscesses. Within 36 hours, her neurological status deteriorated, progressing to quadriparesis with minimal motor function in all 4 limbs. An urgent decompression and abscess evacuation was performed. Blood and intraoperative cultures grew penicillin-sensitive Staphylococcus aureus. Repeat imaging showed an anterior epidural abscess with C5 to C6 discitis-osteomyelitis, requiring a second anterior decompression and fixation.
Literature Review A review of the published literature revealed 22 reported cases of spinal epidural abscess following acupuncture. Patients ranged from 12 to 89 years old; symptoms typically developed within 2 weeks. S aureus was the predominant pathogen, and 59.1% required surgery.
Conclusion Although acupuncture is generally safe, in rare cases, it may lead to severe spinal infection. Early diagnosis and prompt treatment are essential to prevent neurological sequelae.
Introduction
Spinal epidural abscess (SEA) is a rare but potentially devastating pyogenic infection of the spinal canal. Delayed diagnosis may lead to irreversible neurological impairment, sepsis, or death. The recent estimated incidence is 5.1 to 8.0 infections per 10,000 hospital admissions,1 with most abscesses occurring in the posterior epidural space due to its adipose tissue and venous plexus, unlike the ventral dura, which is tightly adherent to the vertebral body and intervertebral disc.2 SEA typically affects adults around the sixth decade of life, most commonly associated with intravenous drug use and diabetes mellitus.3
Early diagnosis remains challenging because the initial presentation is often nonspecific. Back or neck pain is the most common presenting symptom, whereas the classic triad of pain, fever, and neurological deficit, although highly specific, lacks sensitivity.3,4 Contrast-enhanced magnetic resonance imaging (MRI) is the diagnostic modality of choice.2 Management generally includes urgent surgical decompression and targeted antibiotic therapy in patients with neurological impairment. Whereas selected neurologically intact patients may be treated nonoperatively under close monitoring, though with a notable risk of treatment failure.2
Acupuncture is widely used for musculoskeletal pain and is generally considered safe.5,6 However, rare but serious infectious complications, including SEA, have been reported. Reported cases include cervical, thoracic, lumbar, and even multilevel abscesses, occasionally accompanied by osteomyelitis, discitis, facet joint infection, or paravertebral and psoas abscesses leading to severe neurological impairment.7–9 Staphylococcus aureus is the most frequently isolated pathogen, although other microorganisms have also been identified.5,6,10,11
SEA secondary to acupuncture remains poorly defined, and clinical awareness of this complication is limited. Here, we describe a case of cervical SEA in a previously healthy 54-year-old woman who developed symptoms 10 days after acupuncture. We also present our findings from a literature review of published cases over the past 28 years. These cases highlight that even seemingly minor procedures may lead to deep spinal infection. Any intervention, ranging from a blood draw to major surgery, must be evaluated in terms of its associated risks and benefits, and acupuncture is no exception.
Case Presentation
A previously healthy 54-year-old woman presented to the emergency department with neck pain, diffuse paresthesia involving all 4 limbs in a nonspecific distribution, and urinary retention 10 days after acupuncture. She denied any history of trauma or fever. Neurological examination revealed decreased strength graded 4/5 in the right C6 to C7 myotomes, sensory dysesthesia on the right side, and hyperreflexia of the triceps reflex on both sides. The postvoid residual urine volume was 780 mL. Laboratory evaluation revealed a white blood cell (WBC) count of 11.6 × 10⁹/L and a C-reactive protein (CRP) level of 22.96 mg/dL, and blood cultures were obtained.
Contrast-enhanced MRI performed 1 day after admission demonstrated a large posterior epidural abscess extending from C5 to T2, causing severe spinal cord compression, most pronounced at C7 to T2, with associated bilateral paravertebral and longus colli abscesses (Figure 1). Thirty-six hours after admission, the patient’s neurological status deteriorated, progressing to quadriparesis with minimal motor function in all 4 limbs. Urgent decompressive laminectomy from C5 to T2 with evacuation of the epidural abscess was performed. Intraoperatively, a large amount of pus was encountered within the epidural space across these levels (Figure 2).
Preoperative magnetic resonance imaging of the cervical spine. Sagittal T1-weighted (left) and T2-weighted (right) images show a posterior lesion extending from C5 to T2, hypointense with peripheral rim enhancement on T1-weighted imaging (green arrow) and hyperintense on T2-weighted imaging (blue arrow).
Intraoperative photograph following posterior decompression from C5 to T2, revealing purulent material within the epidural space.
Blood and intraoperative cultures isolated penicillin-sensitive S aureus, and intravenous cefazolin was initiated. On postoperative day 4, the patient demonstrated only mild neurological improvement, which was less than expected despite a reduction in inflammatory markers, with CRP decreasing to 15.08 mg/dL and WBC to 14.1 × 10⁹/L. Owing to the limited clinical response, a repeat contrast-enhanced cervical MRI was obtained and revealed an anterior epidural abscess posterior to the C5 to C6 vertebral bodies, causing compression of the thecal sac, together with C5 to C6 discitis-osteomyelitis (Figure 3). An urgent second surgery was performed via an anterior approach, including C5 to C6 and C6 to C7 discectomy, partial corpectomy of the inferior C5 vertebral body, and fixation with a locking plate.
Postoperative cervical spine magnetic resonance imaging after C5–T2 laminectomy showing contrast-enhanced sagittal T1-weighted images (left) and sagittal T2-weighted images (right). A hyperintense lesion anterior to the dural sac (green arrow) and marrow edema with enhancement of the C5 and C6 vertebral bodies (yellow arrow) on T1-weighted images. Hyperintense on T2-weighted imaging (blue arrow).
After 25 days of hospitalization, the patient showed neurological improvement and further laboratory normalization, with CRP decreasing to 0.79 mg/dL and WBC to 9.6 × 10⁹/L.
At 3-month follow-up, the patient showed marked clinical and radiological improvement, although residual urinary incontinence and gait disturbance persisted. Follow-up MRI demonstrated adequate decompression without significant residual cord compression (Figure 4).
Three-month postoperative magnetic resonance imaging of the cervical spine. Sagittal T1-weighted (left) and T2-weighted (right) images show adequate decompression and no significant residual cord compression. Focal intramedullary T2 hyperintensity extending from C3 to C6, compatible with myelomalacia.
Literature Review
A literature review was performed to identify published reports of SEA following acupuncture. Three major electronic databases—Scopus, Web of Science, and MEDLINE (via PubMed)—were searched for articles published up to April 2026 using the following search terms: (“spinal epidural abscess” OR “epidural abscess” OR “spinal abscess” OR “epidural empyema”) AND (“acupuncture” OR “dry needling” OR “acupotomy” OR “needle-knife”; Figure 5).
The search results and selection processes for literature review of spinal epidural abscess following acupuncture.
Eligible studies were English-language case reports or case series describing SEA following acupuncture, with diagnosis confirmed by MRI (Table).
Summary of the lecture review.
In the updated literature review, 22 cases of SEA following acupuncture were identified. Patients ranged in age from 12 to 89 years (median age 54.5 years), and sex distribution was equal (11 males and 11 females). A total of 12 patients (54.5%) had no reported comorbidities, whereas type 2 diabetes mellitus was the most common underlying condition, present in 6 cases (27.3%). Symptoms typically developed within days to 2 weeks after acupuncture, with a median time to presentation of approximately 12 days. The lumbar spine was the most frequently involved region, followed by the cervical and thoracic regions; several cases also demonstrated multilevel involvement. S aureus was the predominant causative organism. A total of 13 patients (59.1%) required surgical intervention in addition to antibiotic therapy, while 9 (40.9%) were treated with antibiotics alone. Favorable outcomes were reported in 14 cases (63.6%; Table).
Discussion
SEA following acupuncture remains a rare but serious complication. Since the first documented case in 1998,12 only a limited number of cases have been reported. The clinical course is often rapid, with symptoms typically developing within approximately 2 weeks. Staphylococcus species are the most common pathogens. Despite treatment, outcomes are frequently incomplete, emphasizing the importance of early diagnosis.
A causal relationship between acupuncture and SEA cannot be proven from the published literature, which consists mainly of case reports. However, the temporal association cannot be denied, and in the absence of another plausible source, acupuncture is the most likely port of entry. Several features strengthen this claim: the short latency to symptom onset, the close anatomical proximity of the needling site to the posterior paraspinal soft tissues, and isolation of typical skin flora such as methicillin-susceptible S aureus or methicillin-resistant S aureus. In our patient, positive blood and intraoperative cultures further suggest a true invasive infection with possible hematogenous spread from the initial entry site.
An important clinical message from our case and the broader SEA literature is that diagnosis is often delayed because early symptoms are nonspecific. The classic triad of spinal pain, fever, and neurological deficit is not sensitive enough for early detection, and contrast-enhanced MRI remains the diagnostic modality of choice. David et al4 found that diagnostic delay occurred in 75% of SEA patients, which was associated with a higher rate of residual motor weakness at discharge.
Management in this setting should follow the same principles as SEA in general. Patients with neurological compromise generally require urgent decompression and targeted antibiotics, whereas carefully selected neurologically intact patients may be treated nonoperatively under close observation. Nevertheless, medical management alone carries a substantial risk of failure. In a review by Epstein et al,27 failure rates of 41% to 42.5% and mortality rates of up to 25% were reported for nonoperative therapy. Also, Kim et al28 found conservative treatment to be more likely to fail in lesions above the conus medullaris. Risk factors for failure include acute neurological deficit, diabetes mellitus, older age, methicillin-resistant S aureus infection, and elevated inflammatory markers.
Conclusion
These cases should remind clinicians that even procedures perceived as low risk are not entirely without risk. Although acupuncture is widely regarded as safe, it may rarely lead to serious complications such as SEA. Strict aseptic techniques, careful patient selection, and a high index of suspicion for rare complications are essential to ensure patient safety.
Acknowledgments
We thank Romy Schindler for editorial assistance.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Patient Consent for Publication Written informed consent was obtained from the patient for publication of this case report and accompanying image.
Ethics Approval Institutional review board approval was not required for this single-patient case report in accordance with institutional policy.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
References
- 1.↵Tande AJ , Currier BL , Osmon DR . Spinal epidural abscess. N Engl J Med. 2026;394(16):1621–1633. 10.1056/NEJMra2412728
- 2.↵Suppiah S , Meng Y , Fehlings MG , Massicotte EM , Yee A , Shamji MF . How best to manage the spinal epidural abscess? A current systematic review. World Neurosurg. 2016;93:20–28. 10.1016/j.wneu.2016.05.074
- 3.↵Prabahkar D , Qazi I , Devi S , Eldahtoury S , Janjua AW . Spinal epidural abscess: raising the index of suspicion. Cureus. 2025;17(6):e85465. 10.7759/cureus.85465
- 4.↵Davis DP , Wold RM , Patel RJ , et al . The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26(3):285–291. 10.1016/j.jemermed.2003.11.013
- 5.↵Cong T , Han Z , Liu Y . Rapidly progressive spinal epidural abscess with purulent meningitis following acupuncture: a case report. Acupunct Med. 2026;44(3):180–182. 10.1177/09645284261421948
- 6.↵Song YW , Yang PS , Cheng IC , Hung CH . Cervical spinal epidural abscess secondary to acupuncture: a case report and literature review. Acta Neurol Belg. 2023;123(6):2419–2421. 10.1007/s13760-023-02244-8
- 7.↵Godhania V . Lumbar spine osteomyelitis and epidural abscess formation secondary to acupuncture. J Surg Case Rep. 2016;2016(3):rjw035. 10.1093/jscr/rjw035
- 8.↵Alexandre AR , Raimundo P . Epidural, paravertebral and bilateral psoas abscess after lumbar acupuncture. BMJ Case Rep. 2018;11(1):e228047. 10.1136/bcr-2018-228047
- 9.↵Lee JH , Cho JH , Jo DJ . Cervical epidural abscess after cupping and acupuncture. Complement Ther Med. 2012;20(4):228–231. 10.1016/j.ctim.2012.02.009
- 10.↵Yang CW , Hsu SN , Liu JS , Hueng DY . Serratia marcescens spinal epidural abscess formation following acupuncture. Intern Med. 2014;53(15):1665–1668. 10.2169/internalmedicine.53.1620
- 11.↵Ma F , Kang M , Hui Liao Y , et al . Nocardial spinal epidural abscess with lumbar disc herniation a case report and review of literature. Medicine (United States). 2018;97. 10.1097/MD.0000000000013541
- 12.↵Yazawa S , Ohi T , Sugimoto S , Satoh S , Matsukura S . Cervical spinal epidural abscess following acupuncture: successful treatment with antibiotics. Intern Med. 1998;37(2):161–165. 10.2169/internalmedicine.37.161
- 13.↵Ishibe M , Inoue M , Saitou K . Septic arthritis of a lumbar facet joint due to pyonex. Arch Orthop Trauma Surg. 2001;121(1–2):90–92. 10.1007/s004020000150
- 14.↵Lee SY , Chee SP . Group b streptococcus endogenous endophthalmitis: case reports and review of the literature. Ophthalmology. 2002;109(10):1879–1886. 10.1016/s0161-6420(02)01225-3
- 15.↵Bang MS , Lim SH . Paraplegia caused by spinal infection after acupuncture. Spinal Cord. 2006;44(4):258–259. 10.1038/sj.sc.3101819
- 16.↵Lee KW , Han SJ , Kim DJ , Lee M jin . Spinal epidural abscess associated with moxibustion-related infection of the finger. J Spinal Cord Med. 2008;31(3):319–323. 10.1080/10790268.2008.11760732
- 17.↵Yu HJ , Lee KE , Kang HS , Roh SY . Teaching neuroimages: multiple epidural abscesses after acupuncture. Neurology. 2013;80(15):e169. 10.1212/WNL.0b013e31828c2f1d
- 18.↵Chan JJ , Oh JJ . A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture. Int J Emerg Med. 2016;9(1):22. 10.1186/s12245-016-0116-5
- 19.↵Yao Y , Hong W , Chen H , et al . Cervical spinal epidural abscess following acupuncture and wet-cupping therapy: a case report. Complement Ther Med. 2016;24:108–110. 10.1016/j.ctim.2015.12.002
- 20.↵Cupler ZA , Anderson MT , Stancik TJ . Thoracic spondylodiscitis epidural abscess in an afebrile navy veteran: a case report. J Chiropr Med. 2017;16(3):246–251. 10.1016/j.jcm.2017.03.002
- 21.↵Shew W , Bell S . Unusual presentation of spinal epidural abscess and a cautionary tale of acupuncture. N Z Med J. 2019;132(1493):69–72.
- 22.↵Wang G , Xu N , Yang L , et al . Community acquired stenotrophomonas maltophilia discitis: diagnosis aided by shotgun metagenomic sequencing. Int J Infect Dis. 2019;81:1–3. 10.1016/j.ijid.2019.01.032
- 23.↵Maiese A , Volonnino G , Viola RV , et al . A rare case of spinal epidural abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. considerations concerning uncommon risk factor for development of spinal epidural abscess and its prevention. Clin Ter. 2020;170(1):e15–e18. 10.7417/CT.2020.2183
- 24.↵Tsai ST , Huang WS , Jiang SK , Liao HY . Cervical spinal epidural abscess following needle‐knife acupotomy, with an initial presentation that mimicked an acute stroke: a case report. Hong Kong j Emerg Med. 2020;27(2):99–102. 10.1177/1024907918790858
- 25.↵Usman S , Badar F , Collado C , Weber A , Kaell A . Septic shock from pan-spinal epidural abscess attributed to recent acupuncture and trigger point injections for acute lower back pain in a previously undiagnosed diabetic patient: a case report. Cureus. 2023;15(6):e40088. 10.7759/cureus.40088
- 26.↵Yuan J , Goh AGW , Mohamed Shah MTB . Bilateral facet joint septic arthritis induced by acupuncture: a case report highlighting diagnostic challenges and the importance of early intervention. Am J Case Rep. 2024;25:e944596. 10.12659/AJCR.944596
- 27.↵Epstein NE . Timing and prognosis of surgery for spinal epidural abscess: a review. Surg Neurol Int. 2015;6(Suppl 19):S475–86. 10.4103/2152-7806.166887
- 28.↵Soehle M , Wallenfang T . Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery. 2002;51(1):79–85. 10.1097/00006123-200207000-00013
