{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T13:54:48Z","timestamp":1778162088119,"version":"3.51.4"},"reference-count":49,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2025,2,21]],"date-time":"2025-02-21T00:00:00Z","timestamp":1740096000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,2,21]],"date-time":"2025-02-21T00:00:00Z","timestamp":1740096000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["European Journal of Pain"],"published-print":{"date-parts":[[2025,4]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Chronic low back pain (CLBP) is a leading cause of disability. Botulinum neurotoxin type A (BoNT\u2010A) has strong anti\u2010spasmodic and analgesic effects, suggesting that its local muscular injection can reduce CLBP compared to other therapies. In this systematic review and meta\u2010analysis, we investigated the efficacy and safety of BoNT\u2010A on patients with CLBP.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We searched PubMed, Scopus, Cochrane, and Web of Science databases for studies comparing BoNT\u2010A to other therapies in terms of functional improvement and pain improvement as measured by visual analog scale (VAS) and clinically significant improvement in pain (50% or greater reduction in VAS score). We employed trial sequential analysis (TSA) to confirm the findings. The GRADE approach was employed to assess the overall quality of the evidence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The search yielded nine studies, seven randomised clinical trials (RCTs), and two prospective observational studies. Compared to the control, BoNT\u2010A increased the incidence of clinically significant improvement in pain (RR\u2009=\u20094.82, 95% CI (3.00, 7.76),\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.00001) and functional improvement (RR\u2009=\u20093.81, 95% CI (2.40, 6.04),\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.00001) (low\u2010certainty evidence), and reduced VAS score (MD\u2009=\u2009\u22121.62, 95% CI (\u22123.13, \u22120.11),\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.04) (very low\u2010certainty evidence). Subgroup analysis showed that BoNT\u2010A is effective against normal saline (moderate\u2010certainty evidence), and it was comparable to steroids and local anaesthetics (very low\u2010certainty evidence). TSA confirmed the findings regarding clinical improvement in pain and functional improvement.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>BoNT\u2010A is a tolerable and effective treatment for CLBP with a longer duration of action. Future high\u2010quality studies are needed to confirm our findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Significance<\/jats:title>\n                    <jats:p>This paper provides good evidence that BoNT\u2010A may be employed in patients suffering from resistant chronic low back pain not responding to normal saline injection due to its higher efficacy and longer duration of action. Compared to steroids and local anaesthetics injections, there is not enough data to draw a firm conclusion and future studies are needed.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ejp.4796","type":"journal-article","created":{"date-parts":[[2025,2,21]],"date-time":"2025-02-21T23:25:11Z","timestamp":1740180311000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["The Efficacy and Safety of Botulinum Neurotoxin Type A in Treating Chronic Low Back Pain: A Systematic Review, Meta\u2010Analysis, Trial Sequential Analysis, and Meta\u2010Regression"],"prefix":"10.1002","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-1911-2167","authenticated-orcid":false,"given":"Waseem","family":"Wagrees","sequence":"first","affiliation":[{"name":"Department of Neurology, School of Medicine University of New Mexico  Albuquerque New Mexico 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R.","family":"Abdelraouf","sequence":"additional","affiliation":[{"name":"Faculty of Medicine Alexandria University  Alexandria Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bahaa","family":"Sharaf","sequence":"additional","affiliation":[{"name":"Faculty of Molecular Biotechnology Helwan University  Helwan Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Moustafa","family":"Elnewishy","sequence":"additional","affiliation":[{"name":"Faculty of Medicine Cairo University  Cairo Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nadia","family":"Albaramony","sequence":"additional","affiliation":[{"name":"Faculty of Medicine Mansoura University  Mansoura Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed","family":"Naeem","sequence":"additional","affiliation":[{"name":"Al\u2010Azhar Faculty of Medicine  Asyut Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed 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