A significant proportion of chronic pain is of musculoskeletal origin. Botulinum toxin (BTX) has been successfully used in the treatment of spasmodic torticollis, limb dystonia, and spasticity. Investigators have, thus, become interested in its potential use in treating many chronic pain conditions. Practitioners have used BTX, outside the product license, in the treatment of refractory myofascial pain syndrome and neck and low back pain (LBP). This article reviews the current evidence relating to chronic pain practice. There is evidence supporting the use of both BTX type A and type B in the treatment of cervical dystonias. The weight of evidence is in favor of BTX type A as a treatment in: pelvic pain, plantar fasciitis, temporomandibular joint dysfunction associated facial pain, chronic LBP, carpal tunnel syndrome, joint pain, and in complex regional pain syndrome and selected neuropathic pain syndromes. The weight of evidence is also in favor of BTX type A and type B in piriformis syndrome. There is conflicting evidence relating to the use of BTX in the treatment whiplash, myofascial pain, and myogenous jaw pain. It does appear that BTX is useful in selected patients, and its duration of action may exceed that of conventional treatments. This seems a promising treatment that must be further evaluated.
Horner's syndrome is a well-recognised complication of regional analgesia in the neck and shoulder region but it is not often encountered as a complication of blocks performed elsewhere. This is a report of the details of two patients who developed Horner's syndrome after lumbar epidural blocks. Case historiesCase 1 A 25-year-old mother, weight 69 kg and height 152 cm, had a lumbar epidural block performed 2 hours after labour had been induced by amniotomy and the intravenous infusion of oxytocin. The epidural block was performed between the second and third lumbar spinous processes, with the patient lying on her left side. A cannula (Portex) was passed via a Tuohy needle 3 cm into the epidural space. Eight ml of 0.5% bupivacaine, without adrenaline, was given through the cannula and produced virtually complete analgesia; some pain persisted and was felt suprapubically on the right side. Cutaneous sensory loss to pin prick was present on the left side only and extended from L3 to T6.Twenty-five minutes after the first injection a second injection of 4 ml of 0.5% bupivacaine was made with the patient lying on her right side. Complete analgesia was produced and cutaneous sensory loss extended from L3 to T6 on the left side and from Ll to T11 on the right side. A further two doses of 4 ml and 5 ml were given l+ and 3 hours later; the fourth dose was given with the patient sitting up since cervical dilatation had reached 9 cm. Cutaneous sensory loss extended from L3 to T7 on both sides after the fourth injection.The foetal head persisted in the occipito-posterior position in the second stage of labour and maternal effort produced poor progress. After 30 minutes in the second stage the patient was placed in the lithotomy position and prepared for a manual rotation and forceps delivery. It became apparent during the preparation of the patient
Spine published the results of a randomized clinical trial entitled "Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy." 1 Certain medical assessment groups have interpreted this study as evidence that all radiofrequency neurotomy for the treatment of chronic low back pain is ineffective. While we consider that the Leclaire et al. study was conducted in a sound, scientific manner, we want to be certain that the results have not been improperly interpreted and extrapolated by certain medical assessment groups.By this open letter to the authors, we would request an explanation on precisely what medical assessment groups should interpret from the results of the study. How did the study methodology differ from other randomized controlled trials that have endorsed radiofrequency neurotomy for the treatment of chronic lumbar facet pain?We would also appreciate the authors' comments as to how the methodology performed in their study differed from other approaches for both the selection of patients and for the technical performance of the radiofrequency neurotomy procedure?
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