Botox for intractable neck pain....any studies?

[Doctodd]

I have a workmans comp patient who was sent to me after being seen by a neurologist who recommended and was going to do Botox, but she refused cuz it sounded unusual. I was asked a 2nd opinion and to take over care. She fell out of a golf cart at work and has a couple cervical HNP's and some DJD which hasnt responded to conservative tx. I have done a few injections, but no long term response. In my support, they havent authorized synergistic PT with the injections, and i have stated that. RF might be next, but she is so frustrated that she hasnt come back.

Ironic that the neurology field has studies against what we do. Is there anything that goes against his recommendation of Botox? I said it would be an option after the injections. Now i may have to. So are there any studies about Botox and acute/chronic neck pain due to the above?

---

Members don't see this ad.

 

[Tenesma]

i have done botox for quite a few necks - results are poor for the most part... cosmetically it does wonders though - i am always impressed...

 

[Doctodd]

did you get paid?....any studies? thx Tenesma....you are always a wealth of information....i really appreciate it.....especially with the week i just had.

T

 

[lobelsteve]

IMHO- good for wrinkles and spasticity, not pain.

C4-7 MBB on more painful side, pillar view, waist of body, 0.5cc lidocaine 2% and if 4-8 hrs of 70+% relief, repeat with Marcaine 0.5% the next visit.
If 8-24hrs 70% relief. RF

I have cheated for the traumatic induced arthropathy folks and dropped in some Celestone with the hopes they could avoid RF. It works for about 50%- not good science, but it can save them from a procedure.

 

[Doctodd]

i forgot to mention that her biggest complaint is pain with ROM(which she moves very little), so she basically has a chronic stiff neck she would like to move. Her work status is nonworking right now cuz she cant drive due to minimal ROM of her neck.

T

 

[SSdoc33]

if there is an indication for botox in this case, it would be for chronic myofascial pain. you are not gonna touch any pain from the facets or from the HNPs with botox.

 

[olafa]

I have a workmans comp patient who was sent to me after being seen by a neurologist who recommended and was going to do Botox, but she refused cuz it sounded unusual. I was asked a 2nd opinion and to take over care. She fell out of a golf cart at work and has a couple cervical HNP's and some DJD which hasnt responded to conservative tx. I have done a few injections, but no long term response. In my support, they havent authorized synergistic PT with the injections, and i have stated that. RF might be next, but she is so frustrated that she hasnt come back.

Ironic that the neurology field has studies against what we do. Is there anything that goes against his recommendation of Botox? I said it would be an option after the injections. Now i may have to. So are there any studies about Botox and acute/chronic neck pain due to the above?

Botox for myofasscial pain is theorized to work on substance -p and has yet to be proven to have significance. Studies are also small. As the prior psters state its useful for spasticity. Is her ROM limited by pain or muscle tone?

see attached study...

 

[Doctodd]

thx for the study.....exactly what i needed. She does have a very taut SCM and other paraspinal muscles. Is it from the HNP? Is the HNP directly associated with the injury? Only if she had a preinjury MRI would i know....of course she didnt have a preinjury MRI.......who knows. Maybe there would be some edema or higher signal intensity on an acute HNP. But these workmans comp patients never get any studies done quickly.

T

 

[stim4u]

There was a study by Ferrante et al. in Anesthesiology about 1.5yrs ago in terms of cervical botox vs. traditional tpi's vs. placebo. Take home message; no appreciable benefit....

 

[Tenesma]

for my chronic neck patients i always end up getting a thin-slice CT scan with reconstruction --- best way to visualize the facet joints...

i had a patient who was convinced her (lack of) ROM was due to muscle stiffnes but on imaging most of her facets were fused... so i told her that muscles don't have much to do with her lack of ROM...

botox i use a diagnosis of torticollis - it is a reach but the diagnosis of torticollis is broad in its definition.

i have gotten paid so far - and botox usually doesn't bill until 60-90 days after drop-shipment... medicare pays about $10 over invoice cost, and the chemodenervation codes haven't been a problem...

but i have seen better results with chronic headaches then with chronic neck pain...


to be honest, i hate getting consults on chronic neck pain - because invariably these patients do poorly - and even more so if there is litigation involved... i find that the elderly do best with cervical RF or pulsed RF... or just cervical facet steroids PRN...

 

[PMR 4 MSK]

I get some good temporary results for chronic myofascial pts with botox - mostly female. I just hit the common trigger points. 25 or so units per spot seems to do well for 6 - 12 weeks. Insurance coverage varies greatly.

 

[joshmir]

over the past year or so, Ferrante (at UCLA) has been giving presentations at metings, sometimes with ELVIS simulation dummies at workshops, on how some patients have subtle postural imbalances associated with spasmodic torticollis that you'll see if you really look for. in these pts, botox injections into the bellies of veryspecific muscles are very useful of they follow up with PT to stretch/ROM/exercise, etc. there were plans on submitting this data to the NEJM. pretty impressive.

if you know anybody who was at the ASA or ASRA Fall meeting this past year they would have the presentation in their program books.

 

[ampaphb]

for my chronic neck patients i always end up getting a thin-slice CT scan with reconstruction --- best way to visualize the facet joints...

i had a patient who was convinced her (lack of) ROM was due to muscle stiffnes but on imaging most of her facets were fused... so i told her that muscles don't have much to do with her lack of ROM...

botox i use a diagnosis of torticollis - it is a reach but the diagnosis of torticollis is broad in its definition.

i have gotten paid so far - and botox usually doesn't bill until 60-90 days after drop-shipment... medicare pays about $10 over invoice cost, and the chemodenervation codes haven't been a problem...

but i have seen better results with chronic headaches then with chronic neck pain...


to be honest, i hate getting consults on chronic neck pain - because invariably these patients do poorly - and even more so if there is litigation involved... i find that the elderly do best with cervical RF or pulsed RF... or just cervical facet steroids PRN...

What diagnosis do you bill when you are treating chronic headches?

 

[ampaphb]

I get some good temporary results for chronic myofascial pts with botox - mostly female. I just hit the common trigger points. 25 or so units per spot seems to do well for 6 - 12 weeks. Insurance coverage varies greatly.

Is that significantly greater duration than you get with basic trigger point injections?

 

[PMR 4 MSK]

Is that significantly greater duration than you get with basic trigger point injections?

about 2 -3 x ave of TPI. Keeps the patient entertained for a few more months until they get tired of injections altogether. Expensive way to do it, I know.

 

[ampaphb]

botox i use a diagnosis of torticollis - it is a reach but the diagnosis of torticollis is broad in its definition.

i have gotten paid so far - and botox usually doesn't bill until 60-90 days after drop-shipment... medicare pays about $10 over invoice cost, and the chemodenervation codes haven't been a problem...

but i have seen better results with chronic headaches then with chronic neck pain...

Billing headaches as torticollis is fraud

 

[Tenesma]

of course it is fraud - however i think you may have misunderstood (or i may have miscommunicated) my post

i was referring to chronic neck pain w/ diagnosis of torticollis...

for chronic headaches i bill w/ diagnosis of headaches and the patients understand there is a good chance they will get stuck with the bill