Botox Injections

Botox (or Botulinum toxin) injection involves using small injected amounts of a synthesized version of a naturally occurring paralytic toxin for medical treatment, including treatment of certain painful disorders. Correctly injected botox may relieve painful muscle spasms, in a manner akin to trigger point injections. Note: trigger point injections last weeks while muscle relaxation due to botox injections last three to four months. 

One painful condition involving spasmodic muscles is called cervical dystonia.  This disease causes spasms of neck muscles resulting in abnormal posture of the neck and head. Unlike muscle spasm from overuse or inappropriate use, dystonia results from abnormal brain activity and can be treated with medication which alters brain chemistry and thereby nervous system activity. This medical treatment has side effects, depending on the type and dose of medication used. One way to lessen dependency on the medication, improve patient outcome, and limit medication side effects, is to utilize Botox in the effected muscles. Botox is approved by the FDA for this and only this use. However, it is used safely and effectively for other conditions discussed below.

Botox has been used for various painful disorders thought to be due to muscle spasm including : myofascial pain with trigger points,  tennis elbow, chronic anal fissure, pain following mastectomy and hemorrhoidectomy,  migraines, chronic daily headache, tension headaches, piriformis syndrome, facial pain, temporomandibular joint disorder, low back pain, chronic prostatic pain, and whiplash.  In several small studies it appears to be effective in controlling trigger point pain. It has been shown to be useful in treating chronic back pain due to muscle spasm without underlying anatomic cause which otherwise causes the pain—like a herniated disc. Muscle spasm in the back is often reflective of an underlying disorder such as nerve root compression due to disc herniation, painful facets, pain due to torn but not herniated discs (discogenic pain), or collapse or fracture of a vertebra or bone making up the spine. Data now suggest it is not effective for episodic migraine, chronic tension headache, and chronic daily headache. There is more to these headaches than muscle spasm in the muscles of the scalp!

In theory, an ideal candidate for Botox therapy is the relatively rare piriformis syndrome, and small studies have shown that it may lessen pain in this disorder. However, piriformis syndrome is a very over diagnosed disorder, producing pain in the buttock/groin zone linking the lower abdomen to the front of the thigh, back of the thigh, and lower limb below the knee. Injection of appropriately evaluated and diagnosed patients with Botox may produce gratifying results. The problem is that this disorder is very difficult to diagnose with certainty.

Botox has also been used to improve sweaty palms, various tremors and facial spasms, writer’s cramp, “crossed” eyes, spastic bladder, certain swallowing disorders, muscle tightness following stroke or spinal cord injury, or resulting from cerebral palsy or multiple sclerosis.

Botox should only be injected by a physician experienced in using it. Used properly it is quite safe. Certain muscles should not be injected above and around the eyes and mouth to avoid drooping of facial muscles or eyelids. Similarly injection of certain muscles over the shoulder and others above and between the shoulder blade and the spine should be avoided when dealing with pain in the area surrounding these muscles. However it should not be used in pregnancy, in conjunction with certain antibiotics, in patients with myasthenia gravis, or patients with infections. It should be used with caution in patients with shunts, electrical implants, around breast implants, and in patients with bleeding disorders. Certain Botox injections in neck muscles should be given with caution in patients with asthma, emphysema, and sleep apnea.

Obviously, pain due to focal tightness in muscles may resolve over time completely, requiring no further injection therapy.

Physical therapy often is helpful, if not essential, in relieving muscle spasms on a long-term basis. Prolonged muscle spasm actually weakens muscles and, unless they are reconditioned by active physical therapy involving stretching and strengthening exercises, they are more likely to redevelop spasm once the spasm temporarily abates. In my view, trigger point injections, or Botox injections, often should be combined with physical therapy, depending on the muscle, to obtain the best long term results.

Not all muscles respond to injection therapy. For example, spasm in the tensor fascia lata, a common condition causing pain in a band-like muscle along the outer thigh coursing from the side of the hip down to the side of the knee, does not improve with injection therapy or passive physical therapy alone (local heat, ultrasound, electrical stimulation, passive stretching by the therapist). However, it usually does improve with a course of passive and then active physical therapy.

Trigger point injections, and most Botox injections, are performed in the office. One muscle injection which cannot be performed safely in the office are Botox injections into the iliopsoas. This is a muscle running along each the side of the lower spine which may cause chronic troublesome back and pain in the front of the thigh. Injections into it are best performed using intravenous sedation and CT guidance to inject the muscle safely as it lies behind the intestines. Inadvertent intestinal puncture with a needle may result in a host of serious complications requiring hospitalization and possible surgery.


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Emile M. Hiesiger, M.D.

The Corinthian
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New York, NY 10016
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