Adverse events of miniscalpel-needle treatment in Korea: A systematic review

Delphi study for developing a checklist of adverse events associated with acupotomy

BACKGROUND

Acupotomy, a more invasive procedure than acupuncture, involves the use of a thicker needle with an integrated knife at the tip, necessitating safety research. We aimed to define relevant adverse events (AEs) and create a standardized form of the ACUPOtomy-related AEs CHECKlist (ACUPOCHECK).

METHODS

Before conducting the Delphi process, a systematic review and pilot prospective study were conducted to gather information on previously reported AEs. Using these data, pilot versions of the ACUPOCHECK and Delphi questionnaires were developed. The Delphi questionnaire involved selecting types of AE for inclusion, establishing separate criteria for acupotomy-related AEs, and achieving a consensus on AE assessment. Thirteen Korean doctors with experience in acupotomy or AE research were recruited to participate in each Delphi round. Consensus was considered to have been reached if the critical value for the content validity ratio met or exceeded 0.538.

RESULTS

The final ACUPOCHECK was developed using four rounds of the Delphi method and one face-to-face consensus meeting. It included 12 local AEs (pain, hemorrhage, bruise, hematoma, edema, pruritus, rash, infection, nerve damage, dysesthesia, movement impairment, and pneumothorax) and 14 systemic AEs (disease aggravation, needle fatigue, sleepiness, procedural nausea, procedural vomiting, procedural headache, procedural dizziness, sweating, procedural shock, syncope, dyspnea, procedural pain, sleep disorder, and postprocedural infection). Separate criteria were established for pain, hemorrhage and bruising: pain was defined as pain that occurrs during daily activities and persists for longer than 72 h, hemorrhage as bleeding that continues for ≥ 3 min despite pressure application, and bruising as having a bruise with a diameter of ≥ 3 cm. Open-ended descriptions were allowed for AEs not covered by the checklist, and severity and causality were assessed using the Common Terminology Criteria for Adverse Events and modified World Health Organization-Uppsala Monitoring Center criteria.

CONCLUSION

ACUPOCHECK provides a standardization framework that can help research on traditional practices as well as new tools and techniques that are more invasive and may cause more severe AEs. Subsequent studies will use ACUPOCHECK to develop rational safety guidelines for acupotomy techniques. Please cite this article as: Jun H, Lee H, Yoon SH, Kwon CY, Jeon D, Lee JH, Leem J. Delphi study for developing a checklist of adverse events associated with acupotomy. J Integr Med. 2024; 22(5): 579-587.

Acupotomy in Korean Medicine Doctors: A Preliminary Survey on Experiences, Perceptions, and Clinical Usage Status

Acupotomy is a widely used medical intervention in traditional East Asian medicine, and efforts are being made to improve its effectiveness and safety. As a first step toward establishing more standardized procedural guidelines, a survey was conducted to explore the current clinical practice status and perceived adverse events (AEs) by Korean Medicine (KM) practitioners. The survey was developed via expert consensus and included information on clinical usage, perception, and the AEs experienced. The largest acupotomy society in Korea, which consists of 185 KM doctors, participated in an online survey conducted in September 2021. Of the 185 KM doctors, 107 (57.8%) responded. Musculoskeletal and connective tissue diseases accounted for 80.8% of suggested indications by KM doctors. Regarding the detailed procedure, there were considerable discrepancies between KM doctors. The most frequent acupotomy-related AEs observed by KM practitioners were bruises (77.3%), fatigue (57.7%), pain (51.8%), and hematoma (51.8%). Only 1.8% of the respondents answered that they had experienced severe AEs. Survey respondents answered that the use of imaging devices during acupotomy and the development of clinical practice guidelines are the most necessary policy requirements for promoting the use and ensuring the safety of acupotomy. To the best of our knowledge, this study marks the initial exploration into the KM physicians' clinical usage status, AEs experienced, and their requests for standardized guidelines and expanded health insurance coverage concerning acupotomy. Further research should include qualitative studies to assess patient experience and prospective observational studies to examine the effects of operator skills and treatment modalities on AEs and adherence.

Safety of acupotomy in a real-world setting: A prospective pilot and feasibility study

OBJECTIVE

Acupotomy is a modern acupuncture method that includes modern surgical methods. Since acupotomy is relatively more invasive than filiform acupuncture treatment, it is important to establish the safety profile of this practice. To justify further large-scale prospective observational studies, this preliminary study was performed to assess the feasibility of the approach and investigate the safety profile and factors potentially associated with adverse events (AEs).

METHODS

This was a prospective pilot study that assessed the feasibility of a large-scale forthcoming safety study on acupotomy treatment in a real-world setting. The feasibility (call response rate, drop-out rate, response rate for each variable and recruitment per month) and safety profile (incidence, type, severity and causality of AEs, and factors potentially associated with AEs) were measured.

RESULTS

A total of 28 participants joined the study from January to May 2018. A follow-up assessment was achieved in 258 (1185 treatment points) out of 261 sessions (1214 treatment points). The response rate via telephone on the day after treatment was 87.3%. There were 8 systemic AEs in all the sessions (8/258; 3.11%) and 27 local AEs on the total points treated (27/1185; 2.28%). Severe AEs did not occur. Total AE and local AE occurrence were associated with blade width and the number of needle stimulations per treatment point.

CONCLUSION

The findings suggest that it could be feasible to analyze the safety of acupotomy in a real-world setting. Moreover, the primary data on some relevant AEs could be determined. We are planning large-scale prospective studies based on these findings.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS) KCT0002849 (https://cris.nih.go.kr/cris/search/detailSearch.do/11487).

A Systematic Review and Meta-analysis of Acupotomy for Scoliosis

This review investigated the effectiveness and safety of acupotomy treatment for scoliosis. There were 7 online databases used in the search from inception to March 17, 2021, for randomized controlled trials of the use of acupotomy in patients with scoliosis. The Cochrane risk-of-bias tool was used to assess the methodological quality of the studies included (n = 12). A quantitative synthesis of the randomized controlled trials was performed using RevMan Version 5.3. The effect sizes of studies were presented as mean differences for continuous outcomes and risk ratios for dichotomous outcomes, with a 95% confidence interval. As part of combined therapy, acupotomy was reported to significantly improve Cobb’s angle compared with other treatments. Likewise, the Visual Analog Scale score, the Oswestry Disability Index score, and pulmonary function were also reported to be improved following acupotomy combination therapy. Although 5 studies mentioned the criteria for reporting adverse events, only 1 study reported adverse events. In conclusion, acupotomy may be an effective treatment for scoliosis. However, the small number, and heterogeneity of the included studies, as well as the poor methodological quality, indicate that higher-quality studies should be conducted to verify the effectiveness and safety of acupotomy treatment for scoliosis.

Quality Assessment and Implications for Further Study of Acupotomy: Case Reports Using the Case Report Guidelines and the Joanna Briggs Institute Critical Appraisal Checklist

This review aimed to evaluate the quality of case reports where acupotomy was performed according to the CAse REport (CARE) guidelines and the Joanna Briggs Institute (JBI) critical appraisal checklist. Case reports on acupotomy published in Korea from 2013 to October 2020 were included in this review. A total of 28 acupotomy related case reports were selected, and a quality evaluation was verified using the CARE guidelines and JBI critical appraisal checklist. Among the case reports, spinal conditions/diseases were most commonly reported. The overall complete reporting rate for each study was relatively high (median of 63.4% according to the CARE guidelines and 73.4% according to JBI critical appraisal checklist for case reports and 62% for case series). However, low reporting rates were determined in several subcategories namely, “Intervention adherence and tolerability,” “Timeline,” “Diagnostic challenges,” “Patient perspective,” and “Adverse or unanticipated events” for case reports, and “Reporting of the presenting site/clinic,” “Demographic information,” “Statistical analysis,” and “Clear criteria for inclusion” for case series. When reporting cases where acupotomy was performed, it is recommended that the CARE guidelines are followed to improve the quality of research. In addition, new guidelines and tools for the clinical situation of Korean medicine should be developed.

Using magnetic resonance imaging to measure the depth of acupotomy points in the lumbar spine: A retrospective study

Background

The acupotomy is an acupuncture device recently used to stimulate lumbar vertebrae such as transverse processes (TPs) and facet joints (FJs). However, there are many organs, nerves, and blood vessels, which can lead to side effects if the needle misses the treatment target. Therefore, information regarding appropriate insertion depths, which is currently lacking, could facilitate its safe use. We retrospectively investigated the depth from the skin to the TP and FJ of the lumbar vertebrae, using magnetic resonance imaging (MRI).

Methods

This retrospective chart review was conducted at a single medical centre in Korea. From 55,129 patient records, 158 subjects were selected. Perpendicular depth from the skin to the left and right TPs and FJs was measured using T1-weighted sagittal plane MRI. Depth differences between the left and right sides were evaluated using the paired t-test and analysis of covariance (body mass index [BMI] as a covariate). The influence of BMI on depth at each location was evaluated by simple linear regression analysis.

Results

The mean age was 43.2 years and mean BMI was 23.6 kg/m². The depth from skin to the TPs or FJs was unaffected by age, sex, or side. Mean depths (cm) were as follows: (TPs) L1 = 4.5, L2 = 4.9, L3 = 5.3, L4 = 5.7, L5 = 5.9; (FJs) L12 = 3.8, L23 = 4.0, L34 = 4.4, L45 = 4.6, L5S1 = 4.6. Depth was highly correlated with BMI at each location.

Conclusion

The depth of TPs and FJs adjusted for BMI can safely and effectively be used for treatment via various invasive interventions, including acupotomy treatment, in the lumbar region.