Chronic Joint & Tendon Pain Embolization (MSKE)
Chronic Joint and Tendon Pain is characterised by the in-growth of abnormal tiny blood vessels and pain nerve fibres at the site of injury, these perpetuate the cycle of long term pain.
Musculo-Skeletal Embolization (MSKE) blocks the tiny blood vessels and kills off the abnormal nerve fibres, reducing pain and improving joint function. MSKE is a low-risk minimally invasive procedure pioneered in Japan since 2009 where 1000s of patient have been treated to relieve chronic joint and tendon pain
Conditions treated: early knee osteoarthritis • anterior knee pain • jumpers knee • tennis elbow • golfers elbow • frozen shoulder • plantar fasciitis • Achilles tendinitis • high hamstring tendinopathy • persistent pain post knee joint replacement
MSKE QUICK SUMMARY
- It's just not getting better?
- Pain killers not enough?
- Steroid injections no longer working?
- Pain re-occurred after other treatments?
- Surgery too invasive?
- Too young for joint replacement?
- Sick of being out of action?
- Minimally invasive image-guided procedure
- Identifies and treats the exact location of pain
- Blocks off the tiny abnormal blood vessel perpetuating the pain
- Performed under twilight sedation, no general anaesthetic needed
- Symptom improvement within 2-14 days
- Day case procedure - go home after 3 hours
- Low risk , quick recovery
- Suitable as a first treatment or where other treatments have not succeeded.
MSKE: The Full Story
Chronic Joint and Tendon Pain
'Chronic' is a medical term used to describe a health problem that is not getting better for a long time, generally more than 3 months, potentially lasting for years and the rest of your life.
Chronic joint and tendon pain is a very common condition affecting many parts of the body in people of all ages.
Typical problems are:
- anterior knee pain
- jumpers knee
- tennis elbow
- golfers elbow
- frozen shoulder
- plantar fasciitis
- Achilles tendinitis
- high hamstring tendinopathy
- knee osteoarthritis
- persistent pain post knee joint replacement
Frequently these joint and tendon problems arise from an injury or over-use playing sports or in the work place. In many cases, with early rest and treatment, the pain will settle and not persist in the long-term. However all too frequently the pain does not settle or keeps coming back.
Studies have shown this chronic pain is associated with the in-growth of tiny new and abnormal blood vessels at the site of pain. This is part of the body's response to the on-going injury, unfortunately this response does not help to cure the problem. In fact, it makes things worse, as tiny abnormal pain nerve fibres grow with the new blood vessels too. Together these blood vessels and nerve fibres perpetuate an on-going cycle of recurrent pain and disability.
Resting the problem area may relieve the pain, but as soon as normal activities are resumed the pain comes back. This is because the abnormal blood vessels and pain nerve fibres are still there to perpetuate the cycle of pain.
The growth of these new and abnormal blood vessel and nerve fibres is well recognised as the underlying problem and is the target of numerous treatments, such as hydrodistention for frozen shoulder, ultrasound guided needling for tennis elbow and stripping for Achilles tendonitis. The aim is to disrupt the blood vessels and break the cycle of inflammation and pain.
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What is Musculo-Skeletal Embolization(MSKE)?
'Musculoskeletal' is medical term encompassing anything to do with muscles, bones, joints, and tendons.
'Embolization' is a minimally invasive way of blocking blood vessels in the body that has been established for over 50 years in the treatment of a wide range of conditions such as uterine fibroids, bleeding after trauma, some cancers and prostate enlargement.
MSKE uses the embolization technique to block the tiny abnormal blood vessels causing joint and tendon pain, also killing off the tiny pain nerve fibres. This treats the body's abnormal reaction to injury and breaks the cycle of recurrent pain.
The MSKE technique has been pioneered since 2009 by Dr Yuji Okuno in Tokyo, Japan. Since 2014 over 3000 MSKE procedures have been performed in Dr Okuno's clinics, the technique has also been taken up in centres in Australia, North America, Korea, France, UK, Spain and The Netherlands.
MSKE is performed under local anaesthetic and twilight sedation, so a general anaesthetic is not needed.
The whole procedure is performed through a tiny 2mm nick in the skin overlying the groin or wrist. Ultrasound and high resolution low-dose real-time X-ray imaging are used to accurately guide the embolization.
During the MSKE, a tiny tube called a microcatheter is manipulated from the skin entry point to the arteries supplying the joint or tendon. A dye that shows up on X-rays is injected to identify all the areas of abnormal blood vessel which are causing the pain.
Following this, the tiny particles are carefully infused through the microcatheter. The particles flow with the blood down the artery and block the tiny abnormal tiny vessels.
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What are the advantages of MSKE?
Minimally invasive procedure performed under ultrasound and low-dose real-time X-ray imaging
- Day-case procedure under local anaesthetic and sedation
- Go home the same day
- No general anaesthetic required
- Very low complication rate
- Quick recovery - between 2 days and 2 weeks.
- Visualizes and treats all areas causing the joint or tendon pain
- Can be the initial treatment or where other treatments have not worked
- Treats knee osteoarthritis pain in patients not ready for joint replacement surgery
- Persistent pain after joint replacement can be treated by MSKE
Who is suitable for MSKE?
If you have a joint or tendon problem that has been going on for more than 3 months you are potentially suitable for MSKE.
Early knee osteoarthritis (KL grades 1 & 2) has exactly the same in growth of abnormal blood vessels and pain fibres. When pain killers are no longer working, but the patient is too young for joint replacement, MSKE is good treatment to reduce pain and postpone joint replacement surgery.
MSKE for the knee osteoarthritis is also known as 'Geniculate Artery Embolization (GAE)'
After total knee replacement surgery, some patients have persistent pain. As the joint capsule is not completely removed during the surgery, the tiny abnormal blood vessels may still be present and causing pain. Once possible infection or joint loosening have been excluded by your orthopaedic surgeon, MSKE can improve this persistent pain.
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What tests are needed?
We need to image the affected area to see exactly what the problem is, either with ultrasound, MRI or X-rays.
We will also ask you to complete some questionnaires that score the severity of your pain.
In preparation for the MSKE you will have some routine blood test done (clotting, full blood count, urea and electrolytes).
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Who will be doing the MSKE?
MSKE is performed by an Interventional Radiologist (IR).
IRs are trained and certified in minimally invasive image-guided techniques such as embolization. They are also certified in the interpretation of the MRI, ultrasound, and X-ray imaging needed to diagnose joint and tendon problems.
Your MSKE will be performed by Dr Nick Burfitt, Interventional Radiology Consultant.
Dr Burfitt became a consultant in 2007 at Imperial College NHS Healthcare Trust, specialising in embolization & IR techniques throughout the body.
In 2016 Dr Burfitt went to Tokyo, Japan to train with the pioneer of MSKE Dr Yuji Okuno. He was first the IR to perform MSKE in the UK and has been treating both NHS and private patients since 2017.
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Where will the MSKE take place?
In the Interventional Radiology Department via The Lindo Wing at St Mary's Hospital in Paddington.
MSKE is performed in a dedicated image-guided operating theatre. Whilst Dr Burfitt is performing the MSKE, you will be carefully monitored and cared for by the specially trained IR nursing staff.
A Radiographer will also be present to control the imaging equipment.
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How do I prepare for my MSKE?
Do not eat for 6 hours beforehand, it is ok to drink clear liquids (water, squash, tea and coffee without milk) up to 2 hours before the procedure.
If you are taking blood thinners, please let us know well in advance of the MSKE, otherwise please take your regular medications as normal with a sip of water.
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What actually happens during MSKE?
We will get you comfortable lying on the image-guided operating table.
The nurse looking after you will give you an intravenous sedative to help you feel relaxed. Your blood pressure, heart rate and oxygen levels will be monitored closely throughout the procedure. Depending on the artery access point, the skin over the groin or wrist will be cleaned and sterile drapes placed over you.
Local anaesthetic will be injected through a fine needle under the skin and down to the artery, this will sting a little for about a minute and then go numb.
A small access tube (less than 2.5mm in diameter) will be carefully inserted into the artery under ultrasound guidance, once this is in position you will not really be aware of what is happening inside the arteries.
A very tiny tube called a microcatheter (0.7mm in diameter) is then manipulated under real-time low-dose X-ray into the arteries supplying the joint or tendon.
The abnormal blood vessels are visualized by the injection of a dye that shows up on X-ray. Your pain will briefly be felt more strongly with the dye injection, this helps us to know we are in the right place also. In this way we are able to identify all the problem areas.
Following this, tiny particles are carefully infused through the microcatheter. The particles flow with the blood down the artery and block the tiny abnormal vessels by effectively silting them up.
At the end of the MSKE all tubes are removed. In the groin a very small collagen plug is placed at the artery access site to help stop any bleeding, your body absorbs the plug over the next few months. At the wrist pressure is applied for about 20 minutes to the artery access site to stop any bleeding.
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How long does the MSKE take?
Most MSKEs take about 60-70 minutes of actual procedure time, sometimes longer - up to 90-100 minutes, usually when there is are number of areas to treat, or the angles of the arteries are a bit tricky.
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Does MSKE hurt?
The local anaesthetic injected into the skin at the beginning of the procedure stings a bit for around 60 seconds, before the area goes numb.
When the dye and particles are injected into the problem area, this will make you feel your joint or tendon pain a bit more. We will give you intravenous sedation and painkillers to keep you comfortable during the MSKE.
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What happens after the MSKE?
Once the MSKE is completed, you will be transferred back to your private room on the ward for bed rest and observation for 4 hours. You can eat drink normally immediately after the procedure.
Before you go home, we ensure there is no bleeding from the artery access site.
You will have our contact details if there are problems or you want to ask any questions.
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The expected side effects after MSKE
Some patient experience a worsening of their pain after the MSKE, returning back to normal by two weeks and then a gradual improvement over the next two months. Other patients get a significant improvement immediately after the procedure or in the first few days. The majority fall somewhere between these two outcomes.
If you have some pain, ibuprofen and paracetamol are usually adequate to control this.
Following the MSKE we recommend you take one to two days off work, and avoid exercise or strenuous work for at least one week.
After one to two weeks you can re-commence any rehabilitation programmes you were involved in before the embolization.
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Follow up after the MSKE
Dr Burfitt will contact you by telephone 2 weeks after the PAE to see how you are doing.
We will also ask you to complete the questionnaires again on-line at 2 weeks, 1 month, 3 months, 6 months and 1 year.
Dr Burfitt will see you in clinic 3 months after the MSKE to assess the outcome of the MSKE. Depending on the area treated, we may request an MRI as part of the assessment.
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The possible complications after MSKE
MSKE is a relatively new procedure, however from the published data it appears to be very safe, but there are some risks and complications that can arise, as with any medical treatment.
There may occasionally be a small bruise, called a haematoma, around the site where the needle has been inserted into the artery. This may be tender for up to two weeks. If this becomes a large bruise, you should get back in contact with us.
Some patients may get some tiny marks on the skin overlying the treated area, these marks are generally not uncomfortable and resolve after two to three weeks.
There is a small risk of the particles injected during the procedure going to areas of other than the area of pain (non-target embolization) this may cause some tingling in the fingers or toes at the time of the procedure. This sensation may persist after the procedure, but resolves within two to three weeks.
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MSKE history and results
The MSKE technique has been pioneered since 2009 by Dr Yuji Okuno in Tokyo, Japan. Since 2014 over a 3000 MSKE procedures have been performed in Dr Okuno's clinics and the technique has also been taken up in centres in Australia, North America, Korea, France, UK, Spain and The Netherlands.
Dr Okuno's team in Japan have published a number of papers outlining their results with 2-3 year follow-up.
In tennis elbow clinical success was 88% persisting to 2 years. For frozen shoulder 84% of patients stopped taking painkiller at three months and 88% of patients were pain free at 1 year.
In patients with grade 1 and 2 knee osteoarthritis, there was 86.3% clinical success at 6 months, which persisted in 79.8% of patients at 2 years.
Similar results are being reported in other centres around the world, in particular with treatment of early knee osteoarthritis.
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References
Midterm Clinical Outcomes and MR Imaging Changes after Transcatheter Arterial Embolization as a Treatment for Mild to Moderate Radiographic Knee Osteoarthritis Resistant to Conservative Treatment. Okuno Y, Korchi AM, Shinjo T, Kato S, Kaneko T. J Vasc Interv Radiol. 2017 Jul;28(7):995-1002
Transcatheter arterial embolization of abnormal vessels as a treatment for lateral epicondylitis refractory to conservative treatment: a pilot study with a 2-year follow-up. Iwamoto W, Okuno Y, Matsumura N, Kaneko T, Ikegami H. J Shoulder Elbow Surg. 2017 Aug;26(8):1335-1341.
Clinical Outcomes of Transcatheter Arterial Embolization for Adhesive Capsulitis Resistant to Conservative Treatment. Okuno Y, Iwamoto W, Matsumura N, Oguro S, Yasumoto T, Kaneko T, Ikegami H. J Vasc Interv Radiol. 2017 Feb;28(2)
Genicular Artery Embolization for the Treatment of Knee Pain Secondary to Osteoarthritis. Bagla S et al. J Vasc Interv Radiol. 2019 Dec 11;S1051-0443(19)30821-8.
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