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Applying salve in complex regional pain syndrome
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    Botox® in the Treatment of Chronic Neuropathic Pain 

    • Gillian C Higgins, Clinical Research Fellow in Plastic Surgery and Cell Engineering Canniesburn Unit of Plastic and Reconstruction Surgery, Glasgow Royal Infirmary
    • Other Contributors:
      • Suzanne E Thomson, ST6 Plastic Surgery, Honourary Clinical Lecturer University of Glasgow
      • Andrew M Hart, Stephen Forrest Professor of Plastic Surgery Research, Consultant Hand and Plastic Surgeon. 

    Dear Editor,
                    in their interesting case report the authors highlight the desperation often felt by patients with intractable chronic neuropathic pain.  
    We present the findings of a single centre case review of 11 patients who lived with chronic neuropathic pain refractory to pain relief regimens for a mean of 11.8 years (range 3-16 years), 100% (n=11) of whom reported benefit following Botox® therapy. 

    Onabotulimum toxin A (Botox®) is a neurotoxin. Botox® causes muscle relaxation or paralysis via inhibition of the presynaptic acetylcholine neuromuscular junction synapse and has analgesic effects via substance P and glutamate neuroinflammatory inhibition. Botox® was first used in the treatment of strabismus in 1980 and it was licensed for use in chronic migraine in the UK in 2010.(1) Attal et al. (2016) conducted a double blind randomised control trial utilising 2 subcutaneous Botox® injections (up to 300U) vs placebo in 152 patients over a 24 week period and demonstrated a significant improvement in peripheral neuropathic pain (p=<0.0001).(2)

    The majority of our patient’s had pain secondary to trauma (55% (n=6)), 36% (n=4) secondary to systemic sclerosis and 9% (n=1) had Raynaud's disease; 90% (n=10) affecting the upper limb and 10% (n=1) the ankle. All of the patients (100% (n=11)) had Botox® therapy intraoperatively, dose range 30-100U (mean 70U) with 45%(n=5) injections administered intradermally, 18%(n=2) intraneurally...

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    Conflict of Interest:
    None declared.