Atlas of Common Pain Syndromes. By Steven D. Waldman, M.D., J.D. Philadelphia, WB Saunders, 2002. Pages: 336. ISBN: 0721692117. Price:$116.30.
This volume provides practicing physicians, including pain specialists, with an easy and practical guide to diagnosing common pain syndromes, determining investigations, and formulating an initial treatment plan. The targeted readers are physicians who evaluate and treat patients with painful conditions as well as trainees in pain medicine. Dr. Waldman has attempted to provide readers having these different levels of experience with a very user-friendly tool to help them prepare not only for their day-to-day practice but also for their subspecialty examinations.
Although many textbooks have been written on pain management, few have had a how-to-do-it approach. The greatest strengths of this attractive volume, which comprises 16 sections and 78 chapters, are that it is very clearly written and easy to read. It has been divided into different sections, each of which concentrates on the commonly found pain syndromes pertaining to a specific region of the body.
The author has organized the book so that the reader can conveniently locate a relevant chapter and quickly learn about a particular pain syndrome while he or she is seeing a patient in the clinic. Every chapter has been written with the same overall structure, starting with a heading and International Classification of Diseases–Ninth Revision code and a brief description of the clinical syndrome, followed by separate sections on signs and symptoms, diagnostic testing, differential diagnosis, treatment, complications, and side effects, and ending with Clinical Pearls. To a busy clinician, this method of organizing the material provides a very straightforward way of efficiently obtaining useful information and thereby fills an important void in the pain literature. This book complements very well previous textbooks written by the author, specifically, Interventional Pain Management, Atlas of Interventional Pain Management, Atlas of Pain Management Injection Techniques , and a companion volume to this textbook, Atlas of Uncommon Pain Syndromes .
This well-structured volume has noteworthy strengths but also several shortcomings. Although a major strength is the material on clinical presentation and diagnosis of specific pain syndromes, the author occasionally has a very idiosyncratic approach to diagnosis. For example, in the discussion of a syndrome he terms fibromyalgia of the cervical musculature , it is stated that “. . .fibromyalgia is a chronic pain syndrome that affects a focal or regional portion of the body . . .,” and that the “. . .sine qua non of fibromyalgia of the cervical spine is the finding of myofascial trigger points on physical examination.” This material is not consistent with current approaches to diagnosing fibro-myalgia, which are based on American College of Rheumatology criteria emphasizing a history of widespread pain of at least 3 months’ duration and a report of pain on palpation of at least 11 of 18 specific tender points.
The weakest sections in the volume, however, are on diagnostic testing and, in certain cases, the treatments that the author recommends. In many instances, the depth of the testing recommended is neither practiced nor practical in many clinical settings. For example, not every patient with a recent onset of headaches in clinical practice must be referred for magnetic resonance imaging or magnetic resonance angiography or even routine blood work. For back pain, not every patient requires human leukocyte B27 testing to rule out ankylosing spondylitis. Given the intended target audience for this type of book, readers can be easily misled.
Some of the material on treatment is also problematic. For example, although stated authoritatively, the author’s recommendation that patients with trigeminal or thoracic herpes zoster must have local anesthetic neural blockade with or without steroid has no supporting basis in randomized, controlled trials. Furthermore, the statement that if such blocks are not performed, patients will be condemned to lifelong, intractable postherpetic neuralgia is a frightening assertion for which there is no supporting evidence. Additional examples include the recommendations of daily steroid injections for brachial plexopathy, intercostal neuralgia, and rib fracture pain, and of local anesthetic and steroid injections for diabetic truncal neuropathy. Each of these treatments, except for the first two, is done infrequently, and even if they are done, there is no evidence that steroid injections should be repeated daily. Such a statement can mislead readers because there is no consensus on total dosages of steroid to be injected, how many injections should be done, or how frequently they should be repeated. For rib fracture, the much more often-used strategy is a thoracic epidural with a continuous infusion of local anesthetic for acute pain control. A final example is the recommendation that neurolytic celiac plexus blocks should be used for the treatment of chronic benign pancreatitis, which is very controversial and for which the evidence base is again limited.
Because treatment recommendations have been based on the author’s personal experiences and many of the recommended treatments lack evidence of efficacy, the reader should be very careful if he or she is using this volume as a resource to determine the latest evidence-based approaches to the management of pain. Nevertheless, it is important to acknowledge the lack of such evidence in much of current pain medicine, and that for patients who are refractory to established therapies with evidence of efficacy, treatment must often be based on anecdotal reports and personal experience.
Overall, Dr. Waldman’s Atlas of Common Pain Syndromes is well written, the information is very accessible, and the text covers a wide variety of common pain syndromes with especially helpful attention to differential diagnosis. It would be a much more valuable contribution if the author had included caveats highlighting which treatments are not backed by evidence of efficacy from randomized controlled trials, but noting that such treatments can still be considered. Readers should be able to determine from a text such as this which treatment recommendations are based on systematic evaluations of their efficacy, which are based on uncontrolled case series or anecdotal reports, and which are based on the author’s personal experience, which are not, of course, mutually exclusive categories. Nevertheless, this book is worth buying and reading, but it should be read with caution and with a critical eye to the basis of the treatment recommendations.