Introduction

Since the mid 1990s, botulinum toxins (BoNTs) have been proposed in the treatment of over 100 musculoskeletal conditions. Although initial reports from open-label studies, retrospective reviews, and case series have been encouraging, clinical evidence from large controlled trials is largely lacking, mixed, or negative in regard to the efficacy of botulinum toxins for neck and back pain (Cheshire et al., 1994; Brashear et al., 1999; Brin et al., 1999; Foster et al., 2001; Benzon et al., 2003; De Andres et al., 2003; Lang, 2003, 2004; Gobel et al., 2006; Jabbari et al., 2006; Jabbari, 2007). These differences reflect the complexities of pain syndromes, variations in dosing regimens and injection methodologies, and importance of individual muscles to regional kinematics and function.

The use of BoNT for treatment of myofascial pain (MP), arthritis, and other conditions that are beyond the Food and Drug Administration (FDA)-approved labeling should be considered investigational. Numerous studies have found BoNT type A (BoNT-A) and BoNT type B (BoNT-B) to be safe and well tolerated at doses used for the treatment of cervical dystonia, but side effects can be seen at the higher doses used for cervicothoracic and lumbosacral pain.

Precautions should be taken around breast implants, pacemakers, and other implanted devices. Care should be exercised in regard to the depth of any injection over the trunk so as to avoid pneumothorax.