Botulinum Toxin in Back Pain

Back pain is probably the commonest affliction affecting the population of the developed world. Almost everyone will experience acute back pain at least once in their lifetime. The majority of acute episodes result in spontaneous recovery but a small proportion of cases become chronic.

Traditional advice to those with acute back pain has until recently been centred around rest and inactivity but this is now thought to be the wrong approach, predisposing to long term problems. Current thinking is that those with acute backache should continue to carry on as normal as much as is reasonably possible. With pain-killers if necessary, patients should in effect "soldier on", in order to minimise the risk of developing a long term problem.

Nonetheless a proportion of patients will develop a long term problem and end up in orthopaedic and pain clinics where they will receive X-rays and scans to try and identify an underlying cause. It is important to realise that X-ray findings correlate poorly with symptoms. Many patients with genuine debilitating pain may turn out to have perfectly normal X-rays, but it is not uncommon to see marked arthritic change on X-rays in individuals who have no symptoms whatsoever. Also, as age progresses arthritis of the spine, so called spondylosis, becomes so common that it can hardly be considered a disease, but a natural degeneration, which eventually affects almost everyone, some of whom, though by no means all, will have symptoms.

Back pain is often associated with sciatica, a nerve pain usually radiating into the leg, arising from pressure on the nerve roots within the spine. The classical cause for this is the so called "slipped disc", but again, often no cause can be found to account for undoubted pain.

Treatment options in chronic back pain often have disappointing results. Surgery is not often considered a useful option except in some cases of slipped disc, or narrowing of the spinal canal. Orthopaedic surgeons today are far more selective about the circumstances under which they will offer or advise operative treatment and the great majority of patients will be told that surgery is not an option.

Injection of steroids into the epidural space has for a long time been a very popular treatment, but with very little justification. The definitive review of all the evidence into this treatment reveals the following:

What success this treatment has is confined to those with sciatica, and for simple back pain it is a totally ineffective treatment.
If one aims for 75% pain relief from sciatica, the success rate for short term relief (up to 60 days) is only 1 in 7, and for pain relief lasting longer than this the success rate drops to 1 in 13. If one accepts a lower level of pain relief, 50%, the success rate in the short term is better at 1 in 3, but is no better in the long term. Further, even in those who have a good response repeated steroid injection is not advisable due to long term side effects.

There are other treatments for back pain which have varying levels of success though none has a consistently high success rate. Botulinum toxin has been used in a few places for back pain for only about five years or so. Until recently there has been no evidence to support this treatment option. However this has now changed, and a recent paper in an American journal, "Neurology," in May 2001, has provided interesting results. In this study patients with one-sided simple back pain, without sciatica, were given the toxin by a simple injection to the muscles of the affected side. Significant pain relief lasting for several months occurred in 75% of patients. Unlike steroid, botulinum toxin is not known to have long-term side effects and injections can be repeated at intervals for as long as they prove useful. Those who have no benefit with this technique can sometimes obtain pain relief from injection of toxin into the deeper muscles of the back under X-ray guidance.

Finally, some patients with sciatica have no cause identified within the spine. In some of these the problem may be pressure on the sciatic nerve from a muscle deep within the buttock, called the piriformis. Some of these patients can obtain pain relief from injection of toxin into this muscle again using X-ray guidance.

In summary therefore it seems likely that botulinum toxin will occupy an increasingly important place in the treatment of back pain in the future.

M K Kocan. 03/07/2004.


	Botulinum Toxin in Back Pain Back pain is probably the commonest affliction affecting the population of the developed world. Almost everyone will experience acute back pain at least once in their lifetime. The majority of acute episodes result in spontaneous recovery but a small proportion of cases become chronic. Traditional advice to those with acute back pain has until recently been centred around rest and inactivity but this is now thought to be the wrong approach, predisposing to long term problems. Current thinking is that those with acute backache should continue to carry on as normal as much as is reasonably possible. With pain-killers if necessary, patients should in effect "soldier on", in order to minimise the risk of developing a long term problem. Nonetheless a proportion of patients will develop a long term problem and end up in orthopaedic and pain clinics where they will receive X-rays and scans to try and identify an underlying cause. It is important to realise that X-ray findings correlate poorly with symptoms. Many patients with genuine debilitating pain may turn out to have perfectly normal X-rays, but it is not uncommon to see marked arthritic change on X-rays in individuals who have no symptoms whatsoever. Also, as age progresses arthritis of the spine, so called spondylosis, becomes so common that it can hardly be considered a disease, but a natural degeneration, which eventually affects almost everyone, some of whom, though by no means all, will have symptoms. Back pain is often associated with sciatica, a nerve pain usually radiating into the leg, arising from pressure on the nerve roots within the spine. The classical cause for this is the so called "slipped disc", but again, often no cause can be found to account for undoubted pain. Treatment options in chronic back pain often have disappointing results. Surgery is not often considered a useful option except in some cases of slipped disc, or narrowing of the spinal canal. Orthopaedic surgeons today are far more selective about the circumstances under which they will offer or advise operative treatment and the great majority of patients will be told that surgery is not an option. Injection of steroids into the epidural space has for a long time been a very popular treatment, but with very little justification. The definitive review of all the evidence into this treatment reveals the following: What success this treatment has is confined to those with sciatica, and for simple back pain it is a totally ineffective treatment. If one aims for 75% pain relief from sciatica, the success rate for short term relief (up to 60 days) is only 1 in 7, and for pain relief lasting longer than this the success rate drops to 1 in 13. If one accepts a lower level of pain relief, 50%, the success rate in the short term is better at 1 in 3, but is no better in the long term. Further, even in those who have a good response repeated steroid injection is not advisable due to long term side effects. There are other treatments for back pain which have varying levels of success though none has a consistently high success rate. Botulinum toxin has been used in a few places for back pain for only about five years or so. Until recently there has been no evidence to support this treatment option. However this has now changed, and a recent paper in an American journal, "Neurology," in May 2001, has provided interesting results. In this study patients with one-sided simple back pain, without sciatica, were given the toxin by a simple injection to the muscles of the affected side. Significant pain relief lasting for several months occurred in 75% of patients. Unlike steroid, botulinum toxin is not known to have long-term side effects and injections can be repeated at intervals for as long as they prove useful. Those who have no benefit with this technique can sometimes obtain pain relief from injection of toxin into the deeper muscles of the back under X-ray guidance. Finally, some patients with sciatica have no cause identified within the spine. In some of these the problem may be pressure on the sciatic nerve from a muscle deep within the buttock, called the piriformis. Some of these patients can obtain pain relief from injection of toxin into this muscle again using X-ray guidance. In summary therefore it seems likely that botulinum toxin will occupy an increasingly important place in the treatment of back pain in the future. M K Kocan. 03/07/2004.
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