[Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]

Updated perspectives on neurogenic thoracic outlet syndrome

Pain represents a foremost feature of neurogenic thoracic outlet syndrome (NTOS). Similar to other persistent pain conditions, the physical discomfort associated with NTOS can cause severe and often debilitating symptoms. In fact, those suffering from the syndrome report a quality of life impacted as significantly as those with chronic heart failure. This evidence-based literature review focuses on the classification, etiology, clinical presentation, diagnostic measures, and surgical treatment of NTOS, with a focus on nonoperative therapies such as physical modalities, pharmacological therapies, and more contemporary minimally invasive intramuscular treatments with botulinum toxin.

Single CT-guided chemodenervation of the anterior scalene muscle with botulinum toxin for neurogenic thoracic outlet syndrome

OBJECTIVE

To examine pain relief in patients with neurogenic thoracic outlet syndrome (NTOS) after a single, low dose injection of botulinum toxin A (Botox) into the anterior scalene muscle (ASM) under computed tomographic (CT) guidance.

DESIGN

Prospective longitudinal study.

SETTING

Academic medical institution.

PATIENTS

Patients 18 years of age and older were evaluated for potential scalenectomy and first rib resection using the transaxillary approach at the study institution between 2005 and 2008. All patients had failed physical therapy. A total of 29 procedures on 27 participants were studied.

INTERVENTIONS

A single, 20-unit injection of Botox into the ASM under CT-guidance.

OUTCOME MEASURES

Short-form McGill Pain Questionnaire (SF-MPQ) prior to and at 1, 2, and 3 months post-Botox toxin injection.

RESULTS

There was a decline in pain during the 3 months subsequent to Botox injection as noted by the following components of the SF-MPQ: sensory (P = 0.02), total (P = 0.05), visual analog scale (VAS [P = 0.04]), and present pain intensity (PPI) score (P = 0.06). The proportion of patients reporting more intense pain scores did not return to the pre-intervention level at 3 months post-Botox injection.

CONCLUSION

Patients experienced substantial pain relief in months 1 and 2 following a single Botox injection into the ASM under CT guidance. Significant pain reduction was noted for 3 months after Botox injection with respect to both sensory and VAS scores, and the total and PPI scores approximated statistical significance. After 3 months, patients experienced a 29% decrease in the sensory component of their pain as well as an approximate 15% reduction in their VAS score. A single, CT-guided Botox injection into the ASM may offer an effective, minimally invasive treatment for NTOS.

Soft tissue determinants of low back pain

Low back pain is one of the complaints most commonly seen in the clinical setting. Correctly or incorrectly, these patients are often given the diagnosis of fibromyalgia, myofascial pain syndrome, disk herniation, or some other label. It is important to recognize the soft tissue causes of low back pain and understand how they can be most appropriately diagnosed and managed. Nonligamentous disorders of the low back region may occur in isolation or in combination with underlying discogenic, ligamentous, and facet-mediated causes of pain. Therefore, in order to fully evaluate and treat a patient with low back pain, it is necessary to consider and address these soft tissue conditions. This paper reviews soft tissue causes of low back pain and discusses how they are most appropriately diagnosed and managed.

Botulinumtoxin zur Behandlung des gustatorischen Schwitzens

BACKGROUND

Botulinum toxin A has meanwhile become a proven method for treatment of gustatory sweating (focal hyperhidrosis, Frey's syndrome). Clear-cut recommendations regarding dosage of botulinum toxin A in Frey's syndrome are currently not available. The aim of this prospective randomized study therefore was to investigate botulinum toxin A with respect to its efficacy in Frey's syndrome, the ideal dose yielding maximal duration of the effect, and patient contentedness as well as unwanted side effects in patients of the Clinic of OMF Surgery at the Ruhr-University of Bochum.

PATIENTS AND METHOD

Twenty patients suffering from severe Frey's syndrome as a result of operations of the parotid gland were examined with the starch iodine test according to Minor. The gustatory skin areas were re-examined after intracutaneous injection of botulinum toxin A for up to 1 year. The patients ( n=20) were randomly assigned to two different treatment groups (group I: 2 MU/cm(2), n=10; group II: 3 MU/cm(2), n=10).

RESULTS

Mean sweating skin areas in the two treatment groups ranged between 39+/-9 and 32+/-12 cm(2), respectively. A single injection of 3 MU botulinum toxin A resulted in a nearly complete blockade of gustatory sweating for the observation period of 1 year. In the group treated with 2 MU botulinum toxin A, 44% of the total gustatory skin areas were still sweating, thus necessitating a second injection of botulinum toxin A in these patients.

CONCLUSION

Intracutaneous injection of botulinum toxin A represents a highly effective and minimally invasive procedure for the treatment of Frey's syndrome. This study shows for the first time that a dosage of 3 MU/cm(2) of botulinum toxin A achieves a complete and reliable blockade of gustatory sweating lasting for at least 12 months. This dose may therefore be recommended for treatment of this syndrome.

The Therapeutic Potential of Botulinum Toxin

BACKGROUND

Botulinum toxin type A (BTX-A; commercial preparation BOTOX) is most well known for its effect on muscle contraction because of the BTX binding to the presynaptic nerve terminal, inhibiting the release of acetylcholine (ACH). The therapeutic benefit of BTX-A, however, can also be isolated to pain relief alone, suggesting that BTX-A also works through additional modes of action.

OBJECTIVE

This article provides insight by an experienced physician into four different case reports. Each case demonstrates the therapeutic potential of BTX-A and the possibility of a different mechanism of action for BTX other than the inhibition of ACH release.

RESULTS

Four patients, each with different symptoms such as relapsing-remitting multiple sclerosis, postherpetic neuralgia, peripheral neuropathy, and severe tingling caused by herniation of cervical vertebrae at the level of C8, were treated with BOTOX, and their symptoms were alleviated.

CONCLUSIONS

The BTX-A mechanism providing pain relief is hypothesized to be something other than muscle relaxation by inhibiting the release of ACH at the neuromuscular juncture, such as inhibition of the release of substance P or the blocking of autonomic pathways, etc. This article is intended to continue to keep physicians using this substance for dermatologic indications aware of the potential unsuspected effects.

Botulinum toxin: application into acupuncture points for migraine

BACKGROUND

: Botulinum toxin has been employed in orthopedics, physiatrics, gastroenterology, gynecology, neurology, pediatrics, general surgery, plastic surgery, and several other specialties. We have applied this drug to treat hyperhidrosis and wrinkles in dermatology; it offers also a secondary benefit: relief for headaches.

OBJECTIVE

: We have performed studies based on acupuncture principles in order to develop new botulinum toxin application sites for the treatment of migraine. These additional sites are helpful when patients expect results for both their illness and their wrinkles; whereas some patients will show improvement with the classic treatment for wrinkles, additional sites may be required.

METHODS

: Ten patients suffering from migraine, as diagnosed through the criteria proposed by the Headache Classification Committee of the International Headache Society, were selected. We used easily recognizable acupuncture sites for the injection of botulinum toxin.

RESULTS

: There was significant improvement in patients with acupuncture site-guided botulinum toxin injection. It showed to be a safe and effective therapy for migraine.

CONCLUSION

: There are alternative sites besides those used for the treatment of expression lines, which bring forth an improvement of migraine.

Cervical myofascial pain and headache

Myofascial pain is a common cause of regional chronic pain. Myofascial trigger points can refer pain to the head and face in the cervical region, thus contributing to cervicogenic headache. When identified properly, cervical myofascial pain is a treatable component of headache management. This article reviews current literature on the pathophysiology, diagnosis, and management of cervical myofascial pain.