Botox: A Novel Therapeutic Modality for PostHand Trauma CRPSRSD

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Botox A Novel Therapeutic Modality for Post-Hand
Trauma CRPS-RSD

• Dr. Oren Tessler, MD, MBA
• Dr. L. Lessard, MD, FRCSCENT, FRCSCPS, FACS

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Chronic Regional Pain Syndrome (CRPS)
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Chronic Regional Pain Syndrome (CRPS)

• Chronic neuropathic pain, sudomotor vasomotor
  instability
• Sympathetically maintained
• 3 described stages
• 1. Severe pain, edema, autonomic instability
  (1-3 mo)
• 2. Skin color texture changes, edema, stiffness
  (3-6 mo)
• 3. Severe damage with muscle atrophy,
  contractures, and irreversible skin changes

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Chronic Regional Pain Syndrome (CRPS)

• Highly refractory to traditional treatments
• Current treatments
• Massage physiotherapy
• Stretching strengthening exercises
• TENS
• Ultrasound
• Heat cold therapy
• Local, regional, and sympathetic analgesia

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Botox
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Botox Chronic Neuropathic Pain

• Demonstrated long-term efficacy in chronic
  neuropathic pain syndromes
• Conditions that have been treated with Botox
• Myofascial pain syndrome
• Focal cervical dystonia
• Postherpetic neuralgia
• Brachial Plexus injuries
• Spinal cord injury-induced pain syndromes
• Mechanism of action poorly understood

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Methods

• CSST patients with clinical diagnosis of CRPS I
  or II
• Non-responders to regional sympathetic nerve
  blocks
• S/C injections of Botox directly to areas of
  maximum symptoms
• Technique held constant throughout all visit
• Pain level recorded on 1-10 scale at each visit
• OT for all patients to maintain ROM prevent
  misuse contractures

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Patients

• Mean age 50yrs (35-64)
• 5 males, 3 females
• 3 amputations
• 1 arm replant 2 finger amputations
• 2 crush injuries
• 2 penetrating injuries with foreign bodies
• 1 combined crush injury laceration
• Mean number of treatments 9.5
• Range 5-13

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Pain Scores Per Treatment
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Results

• Significant improvement in pain scores
• One-way ANOVA p-value 0.0128
• Linear regression analysis
• R2 0.594
• Mean pain reduction from 8 to 5.5 / 10
• 31.25 absolute mean reduction
• Max pain relief by injection 9

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Discussion

• Botox effective in producing significant
  reduction in self-assessed pain severity
• Series of patients with difficult to treat severe
  CRPS / RSD refractory to traditional treatments
• Results continue to be maintained
• Mean 9 months follow-up
• Up to 20 months post-final treatment

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Future Horizons

• Continued follow-up to assess long-term efficacy
• Increasing number of patients larger series
• Investigate effectiveness of Botox in combination
  with traditional treatments