Current Pain and Headache Reports

, Volume 11, Issue 5, pp 352–358 | Cite as

Treatment of chronic low back pain with botulinum neurotoxins



In a double-blind, randomized, placebo-controlled study, administration of botulinum toxin A (Botox; Allergan Inc., Irvine, CA) into paraspinal muscles using a novel technique produced significant pain relief in 60% of patients with chronic, refractory low back pain. A similar yield of 53% was noted in a prospective, randomized, open-label study of 75 patients, with 14 months of follow-up. In this study, an early response predicted later responsiveness, with 91% of the responders continuing to respond to repeat injections. The technique of treatment for both studies included covering the whole length of the lumbar erector spinae with one injection given at each lumbar level regardless of pain, tenderness, or trigger point location(s). The dose per injection site was 50 U (Botox), with the total dose per session not to exceed 500 U. Side effects were uncommon and consisted of a transient, mild flu-like reaction in 5% of the patients. Botulinum treatment of paraspinal muscles can reduce pain in a substantial number of patients with refractory chronic low back pain and is safe in the recommended doses.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Anderson GB, Pope MH, Fromyer JW, Snook SH: Epidemiology and cost. In Occupational Low Back Pain: Assessment, Treatment and Prevention. Edited by Pope MH, Anderson GB, Frymoyer JW, Chaffin DB. St. Louis: Mosby Yearbook; 1991:107–146.Google Scholar
  2. 2.
    Krousel-Wod MA, Mc Cune TW, Abdoh A, et al.: Predicting work status for patients with an occupational medicine setting who report back pain. Arch Fam Med 1994, 3:349–355.CrossRefGoogle Scholar
  3. 3.
    Spengler AM, Bogos SA, Martin NA, et al.: Back injuries in industry. Overview and cost analysis. Spine 1986, 11241–11245.Google Scholar
  4. 4.
    Frymoyer JW, Cats-Baril WL: An overview of incidences and costs of low back pain. Orthop Clin North Am 1991, 22:263–271.PubMedGoogle Scholar
  5. 5.
    Van Tulder MW, Koes B, Malmivaara A: Outcome of noninvasive treatment modalities on back pain: an evidence-based review. Eur Spine J 2006, 15(Suppl 1):S64–S81.PubMedCrossRefGoogle Scholar
  6. 6.
    Liuke M, Solovieva S, Lamminen A, et al.: Disc degeneration of the lumbar spine in relation to overweight. Int J Obes (Lond) 2005, 29:903–908.CrossRefGoogle Scholar
  7. 7.
    Battie MC, Videman T, Levalahati E, et al.: Heritability of low back pain and the role of disc degeneration. Pain 2007, In Press.Google Scholar
  8. 8.
    Gray’s Anatomy. Edited by Bannister LH et al. Edinborough: Churchill Livingston; 1995.Google Scholar
  9. 9.
    Harrington JF, Messier AA, Bereiter D, et al.: Herniated lumbar disc material as a source of free glutamate available to affect signals through the dorsal root ganglion. Spine 2000, 25:929–936.PubMedCrossRefGoogle Scholar
  10. 10.
    McLachlan EM, Janig W, Devor M, et al.: Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 1993, 363:543–546.PubMedCrossRefGoogle Scholar
  11. 11.
    Peng B, Wu W, Hou S, et al.: The pathogenesis of discogenic low back pain. J Bone Joint Surg Br 2005, 87:62–67.PubMedGoogle Scholar
  12. 12.
    Gillette R, Kramis R, Roberts W: Sympathetic activation of cat spinal neurons responsive to noxious stimulation of deep tissues in the low back. Pain 1994, 56:31–42.PubMedCrossRefGoogle Scholar
  13. 13.
    Roberts WI: A hypothesis on the physiological basis of causalgia and related pains. Pain 1986, 24:297–311.PubMedCrossRefGoogle Scholar
  14. 14.
    Konno S, Kikuchi S, Nagaosa Y: The relationship between intramuscular pressure of the paraspinal muscles and low back pain. Spine 1994, 19:2186–2189.PubMedCrossRefGoogle Scholar
  15. 15.
    Cui M, Khanijou S, Rubino J, Aoki KR: Subcutaneous administration of botulinum toxin A reduces formalin-induced pain. Pain 2004, 107:125–133.PubMedCrossRefGoogle Scholar
  16. 16.
    Aoki KR: Evidence for antinociceptive activity of botulinum toxin type A in pain management. Headache 2003, 43(Suppl 1):S9–S15.PubMedCrossRefGoogle Scholar
  17. 17.
    Welch MJ, Purkiss JR, Foster KA: Sensitivity of embryonic rat dorsal root ganglia neurons to Clostridium botulinum neurotoxins. Toxicon 2000, 38:245–258.PubMedCrossRefGoogle Scholar
  18. 18.
    Ishikawa H, Mitsui Y, Yoshitomi T, et al.: Presynaptic effects of botulinum toxin type A on the neuronally evoked response of albino and pigmented rabbit iris sphincter and dilator muscles. Jpn J Ophthalmol 2000, 44:106–109.PubMedCrossRefGoogle Scholar
  19. 19.
    Rand MJ, Whaler RC: Impairment of sympathetic transmission by botulinum toxin. Nature 1965, 206:588–591.PubMedCrossRefGoogle Scholar
  20. 20.
    Fillipi GM, Errico P, Santarelli R, et al.: Botulinum A toxin effects on rat jaw muscle spindles. Acta Otolaryngol 1993, 113:400–404.Google Scholar
  21. 21.
    Wiegand H, Erdman G, Welhoner HH: 125 I-labeled botulinum toxin A neurotoxin.: pharmacokinetics in cats after intramuscular injection. Arch Pharmacol 1976, 292:161–165.CrossRefGoogle Scholar
  22. 22.
    Tsui JK, Eisen A, Stoessl AJ, et al.: Double-blind study of botulinum toxin in spasmodic torticollis. Lancet 1986, 2:245–247.PubMedCrossRefGoogle Scholar
  23. 23.
    Jankovic J, Schwartz K, Donovan DT: Botulinum toxin injections for cervical dystonia. Neurology 1990, 40:277–280.PubMedCrossRefGoogle Scholar
  24. 24.
    Babcock M, Foster L, Pasquina P, Jabbari B: Treatment of pain attributed to plantar fasciitis with botulinum toxin A: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil 2005, 84:649–654.PubMedCrossRefGoogle Scholar
  25. 25.
    Silberstein S, Mathew N, Saper J, et al.: Botulinum toxin type A as a migraine preventive treatment: for the BOTOX Migraine Clinical Research Group. Headache 2000, 40:445–450.PubMedCrossRefGoogle Scholar
  26. 26.
    Foster L, Clapp L, Erickson M, Jabari B: Botulinum toxin A and chronic low back pain. Neurology 2001, 56:1290–1293.PubMedGoogle Scholar
  27. 27.
    Jabbari B, Ney J, Sichani A, et al.: Treatment of refractory, chronic low back pain with botulinum toxin A: a prospective open label study with 14 months follow up. Pain Med 2006, 7:260–264.PubMedCrossRefGoogle Scholar
  28. 28.
    Lang AM: A pilot study of botulinum toxin type A (BOTOX), administered using novel injection technique for treatment of myofascial pain. Am J Pain Manage 2000, 10:108–112.Google Scholar
  29. 29.
    Royal MA, Guneya I, Bhakta B, et al.: Botulinum toxin type A in the treatment of refractory myofascial pain. Neurology 2001, 56(Suppl 3):A350.Google Scholar
  30. 30.
    Cannard K, Difazio M, Jabbari B: The efficacy of botulinum toxin A for treatment of low back pain caused by trauma and strain injury [abstract]. Neurology 2005, 64(Suppl):151.Google Scholar

Copyright information

© Current Medicine Group LLC 2007

Authors and Affiliations

  1. 1.Department of NeurologyYale University School of MedicineNew HavenUSA

Personalised recommendations