Embolization for Relief of Chronic Shoulder or Elbow Pain
A recent study from researchers at the Konkuk University School of Medicine in Seoul, Korea have published their findings on embolization for relief of chronic shoulder or elbow pain associated with tendinopathy refractory to conservative treatment. The study included 13 patients (15 procedures) and involved 8 shoulders and 7 elbows. The elbow pain was due to lateral epicondylitis and the shoulder pain was secondary to rotator-cuff tendinopathy (n=6) and calcific tendinitis (n=2). The researchers used microspheres (40-120 micron) in the first 4 cases and imipenem/cilastatin sodium(mixed with lipiodol) in the remaining 11. Technical success was seen in all patients with clinical success in 73% (11 of 15). Among the 12 patients with pain relief, 7 patients (58%) experienced pain relief within 1 week and 9 (75%) experienced pain relief within 1 month. The remaining 3 cases experienced pain relief between 1-4 months post embolization. Authors noted that when a patient had “evident” enhancement, 90% of them had clinical success. However, 60% (3 of 5) had success when there was not evident enhancement. There were no major adverse events. Self-limited forearm erythema was noted in 1 patient that resolved within 1 month. The authors conclude that embolization may be an option for pain relief associated with chronic shoulder and elbow tendinopathy.
Fig 2. Left brachial arteriographic imaging before and after transcatheter arterial embolization with microspheres in a 48-year-old woman (patient 2; Table) with chronic elbow pain (7 mo) as a result of lateral epicondylitis. (a)Preembolization arteriography shows evident enhancement (white arrows) fed by the recurrent radial artery (black arrows) in a region adjacent to the lateral epicondyle. (b) Postembolization arteriography shows disappearance of hyperenhancement adjacent to the lateral epicondyle. At 4-month follow-up, the patient continued the pretreatment medication regimen despite a reduction in VAS score from 5 to 2.
This paper presents a new and innovative treatment approach to chronic shoulder and elbow pain. There has been previous literature suggesting that embolization may be beneficial for adhesive caposulitis and knee osteoarthritis. Tendinopathy is a costly medical condition that has multiple treatment options that are frequently refractory to treatment. As such, an alternative treatment approach may have widespread use and applicability. Neovessels and accompanying nerves have been identified as possible sources of inflammation and pain in this setting. The present study shows promising results in embolization of this neovascularity as a treatment method. As detailed above, identifying “evident” enhancement increased the chances of clinical success. VAS scores in the evident enhancement group were decreased more (P < .05) than those in the group with no evident enhancement. These results suggest that the degree of lesion enhancement on DSA might be a factor to predict the degree of pain relief after embolization. Of note, IPM/CS has been approved by the FDA as an antibiotic. It is slightly soluble in water but will crystallize when mixed with a contrast agent and create 10-70 micron size particles. Previous literature has shown this embolic to be associated with decreased rates of cutaneous erythema. Limitations of this manuscript include the small number of patients, retrospective nature, short follow-up (4 months), lack of standard embolic use, and non-standard post-procedure pain control. However, within these limitations, the future of this therapy appears promising and future trials are warranted. This manuscript further proves that there is no vascular territory that we will not embolize.
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Hwang JH, Park SW, Kim KH, et al. Early Results of Transcatheter Arterial Embolization for Relief of Chronic Shoulder or Elbow Pain Associated with Tendinopathy Refractory to Conservative Treatment. J Vasc Interv Radiol. 2018; 29: 510-517.
Luke R. Wilkins, MD
Department of Radiology and Medical Imaging
Section of Vascular and Interventional Radiology
University of Virginia