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Neuropathic Pain (NP)

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Botulinum Toxin Treatment of Pain Disorders

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Abstract

Neuropathic pain (NP) is a common form of human pain, often poorly responsive to analgesic medications. This chapter discusses the pathophysiology and conventional treatment of common categories of neuropathic pain and reviews the literature on botulinum neurotoxin (BoNT) efficacy in neuropathic pain. The level of efficacy for BoNT treatment in each category is defined according to the published guidelines of the American Academy of Neurology. The data on type A toxin (mostly onabotulinumtoxinA, onaA) indicates efficacy in postherpetic neuralgia and probable efficacy in post-traumatic neuralgia, and painful diabetic neuropathy. Retrospective studies and anecdotal observations suggest efficacy in residual limb pain of amputees, complex regional pain syndrome, and chemotherapy-induced allodynia. Controlled studies are necessary to assess the efficacy of BoNTs in these conditions. Much remains to be learned about the most effective dosage and technique of injection, optimum dilutions, and differences among BoNTs in the treatment of neuropathic pain.

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Author information

Authors and Affiliations

  1. Botulinum Toxin Treatment Program, Yale School of Medicine, New Haven, CT, USA

    Bahman Jabbari (Professor of Neurology and Director)

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  1. Bahman Jabbari
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Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Patient 3-1(postherpetic neuralgia). Grid-like injection of the right postauricular region (MOV 16826 kb)

Patient 3-1. Interview with the patient with PHN, 2 years after treatment with onaA (MOV 130718 kb)

Patient 3-2. Post-traumatic neuralgia: interview after two treatments (MOV 78315 kb)

Patient 3-2. Post-traumatic neuralgia: subcutaneous injection of onaA into the pain area (third injection) (MOV 65903 kb)

Appendices

Appendix 3.1 AAN Classification of Evidence

Class

Criteria

Level of evidence

Recommendation

I

Prospective, randomized, controlled, outcome masked, representative population with criteria A–Ea

A: Two or more Class I studies

Established as effective, ineffective, or harmful

II

Prospective, matched cohort, representative population, masked outcome and meets A–E or RCT with one criteria in A–E lacking

B: At least one Class I or two Class II

Probably effective, ineffective, or harmful and recommended

III

Controlled trial, representative population, outcome independent of patient treatment

C: At least one Class II

Possibly effective, ineffective, or harmful, may be used at discretion of clinician

IV

Uncontrolled study, case series, case report, or expert opinion

U

Data inadequate or conflicting

  1. Reprinted with permission from Wolters Kluwer Health, French and Gronseth ((2008)
  2. aCriteria A–D: A = primary outcome(s) clearly defined, B = exclusion/inclusion criteria clearly defined, C = adequate accounting for drop-outs and cross-over with numbers sufficiently low to have minimal potential for bias, D = relevant baseline characteristics or appropriate statistical adjustment for differences, E = for non-inferiority or equivalence trials claiming to prove efficacy for one or both drugs meet 3 cited criteria

Appendix 3.2 AAN Classification of Recommendations

A- Established as effective, ineffective, or harmful (or established as useful/predictive or not useful/predictive) for the given condition in the specified population. (Level A rating requires at least two consistent Class I studies)a

B- Probably effective, ineffective, or harmful (or probably useful/predictive or not useful/predictive) for the given condition in the specified population. (Level B rating requires at least one Class I study or two consistent Class II studies)

C- Possibly effective, ineffective, or harmful (or possibly useful/predictive or not useful/predictive) for the given condition in the specified population. (Level C rating requires at least one Class II study or two consistent Class III studies)

U- Data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven

  1. Reprinted with permission from Wolters Kluwer Health, Gronseth and French (2008)
  2. aIn exceptional cases, one convincing Class I study may suffice for an “A” recommendation if (1) all criteria are met, (2) the magnitude of effect is large (relative rate improved outcome 5 and the lower limit of the confidence interval is 2)

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Jabbari, B. (2015). Neuropathic Pain (NP). In: Botulinum Toxin Treatment of Pain Disorders. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2501-8_3

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  • DOI: https://doi.org/10.1007/978-1-4939-2501-8_3

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4939-2500-1

  • Online ISBN: 978-1-4939-2501-8

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