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| |  ESRA: Botulinum Toxin A Highly Beneficial for Sciatica and Lower Back Pain By Cameron Johnston Special to DG News
WARSAW, POLAND -- September 20, 2001 -- Botox (botulinum toxin A), which has gained a reputation for removing wrinkles and frown-lines, might have a role to play in treating sciatica and lower back pain. In a presentation today at the annual meeting of the European Society for Regional Anaesthesia, Dr. Magdy Aglan of the department of anaesthesia at Macclesfield General Hospital in Macclesfield, England, reported the findings of a small study in which people with chronic sciatica and lower back pain were treated with the high-cost toxin. As Dr. Aglan explained, other forms of therapy, such as injecting the iliopsoas/piriformis muscle with local anesthetics and steroids, has been useful in some people with sciatica. However, the effect seems to wear off before there can be adequate rehabilitation and what he referred to a "change of muscle memory". Botox A, on the other hand, can last four to six months - roughly the same length of time it is effective when used to treat other conditions, such as blephorospasm, or spastic toritcolis. Botulinum works by blocking the release of acetylcholine at the neurotransmitter junction, thus blocking muscle contraction, Dr. Aglan explained. Progressive relaxation of the affected muscle may decompress any entrapped nerves to relieve pain. In Dr. Aglan’s study, 12 patients, six men and six women all of whom had major sciatica and/or lower back pain for a period of at least six months, and who had failed all other therapies (one subject had had three surgeries) were treated with 100 mg of botulinum toxin, in 4 mL of normal saline and 6 mL of bupivacaine 0.25% (Carbostesin, AstraZeneca). The injection was guided by computed tomography to ensure that the drug was delivered “absolutely in the bed of the muscle”, and to avoid any risk of nerve damage, Dr. Aglan explained. There was also post-injection physiotherapy consisting of passive traction of the leg, and active rehabilitation through home exercises. Outcome measures included a visual analogue scale (VAS 0-100), sleep and daily work activities, as well as objective measurements such as hip extension, hip internal rotation and amount of medication needed to control the pain. There were significant reductions in VAS scores, sleep disturbances, and disturbances to activities of daily living. Pre-test, the mean VAS score was 75, sleep disturbances were reported in 57 percent of patients, and disturbances in activities of daily living were reported by 84 percent of subjects. Four months after the Botox injections, the VAS scores were 24; sleep disturbances were seen in 3.5 percent of patients, and disturbances to activities of daily living reported in 25 percent. Objective measurements were just as encouraging. Hip extensions increased from 8.1 to 16.6, while internal hip rotation increased from 2.5 degrees to 32 degrees post-injection. Half of the patients reported that they had stopped using all analgesics, while five of the original 12 showed a 50 percent improvement in daily activities, and a greater than 50 percent reduction in the medications they were taking. One patient of the 12 showed no improvement in the activities of daily living, nor any reduction in the amount of medications he was taking. Overall, there were no side effects associated with the use of Botox. For patients who are refractory to other forms of therapy, and when used as part of an overall physiotherapy regimen, Botox A might prove to be a safe and highly useful adjunct to treatments that are currently available for sciatica and chronic, non-specific lower back pain, Dr. Aglan said. Despite its cost of 140 £ per injection, he said this expense is more than justified by the reduction in drugs that the patients are taking, and fewer visits to pain specialists, to their general practitioners and to physiotherapists. "The cost of morphine, and other drugs that the patients had been taking before they came to our clinic, was more than 200 £ a year," he said.
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