CT-guided Botox adds new wrinkle to pain control

By Chris Kaiser
Diagnostic Imaging
June 20, 2002

When you eliminate those unsightly crow's-feet, why not take care of that nagging backache at the same time? A pain management specialist in New York City is using CT to guide injections of the popular cosmetic drug Botox into spasmed muscles deep within the body.

CT image (left) shows placement of the spinal needles into the left and right piriformis muscles of a man in his mid-30s who presented with chronic back pain. Botox injection (right) follows contrast media used to confirm needle placement. (Provided by A. Leff)

Dr. Alan M. Leff, medical director of the Pain Management and Rehabilitation Medical Services, says that by using CT imaging, he can administer smaller doses of the muscle relaxant and do so with pinpoint accuracy. Pain relief typically lasts for three months, he said.

Leff uses the CT-guided procedure to treat chronic muscle spasms, particularly in the back and neck. But it can be administered in the forearm, lower leg, and other areas where chronic spasm occurs. He also uses Botox to treat poststroke spasticity.

Although no significant literature suggests that Botox injections relieve pain, the drug is known to be fairly safe in soft tissues, according to Dr. Wayne J. Olan, director of neuroradiology and MRI at Suburban Hospital in Bethesda, MD.

"If it's providing relief, empiric data may be enough for people who are in chronic pain to seek out the treatment," he said.

Botox, made by Allergan, is currently approved for the treatment of cervical dystonia, blepharospasm associated with dystonia, and neurological-based spasticity. In 1997, Medicare approved Botox injections for muscle spasm, but in 1999, it stopped coverage in New York, according to Leff. Some insurance companies cover the procedure, but about half of all patients seeking treatment are not covered.

Leff was trained in image guidance by a pioneer in neurolytic cancer blocks at Memorial-Sloan Kettering Cancer Center in New York City. He uses Botox injections mainly for the psoas and piriformis muscles. First, he identifies the area of spasm by taking 10-mm CT cross-sectional images. He inserts a 20-gauge needle to the depth indicated by the CT measurements and injects contrast to confirm the accuracy of the delivery point. The procedure takes approximately 20 minutes. Relief is generally achieved over one to two weeks.

Performing this procedure without consulting an imaging specialist or radiologist may not be in the patient's best interest, according to Olan. Although it is not necessary to have interventionalists do this procedure, they are more adept at translating 2D images into 3D knowledge.

"There are multiple specialties that can do this safely. But when image guidance is used, it's best to consult with someone who has knowledge of the anatomy, just to ensure it is as safe as possible for the patient," he said.

back to news list

© 2002 Pain Management & Rehabilitation Medical Services of New York. All rights reserved.