Mayo Clinic Analgesic Pathway: Peripheral Nerve Blockade for Major Orthopedic Surgery. By Robert L. Lennon, D.O., and Terese T. Horlocker, M.D. Rochester, Minnesota, Mayo Clinic Scientific Press, 2006. Pages: 137. Price: $69.95.

Merriam-Webster defines pain as “usually localized physical suffering associated with bodily disorder (as a disease or an injury) … a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action.” Pain can certainly seem the anesthesiologist’s opponent, because it often is the cause of morbidity, prolonged hospital stay, and patient dissatisfaction. Much effort has been devoted to “evading” pain for our patients by improving postoperative pain control. Past and present regional anesthesia techniques have played an integral part in the development of pain control strategies and continue to be supported as means of improved patient comfort1; however, it is observed that regional anesthesia is persistently underutilized both in many residency training programs and in private practice settings.

Noting that anatomical knowledge and technical skill are required to become competent at performing effective peripheral blocks, Drs. Lennon and Horlocker intended to provide “a practical guide in the application, performance, and management of lower extremity peripheral regional techniques.” The realization of their efforts is this approachable volume, in which they impart the details of the multimodal, multidisciplinary approach to anesthetic and analgesic management of patients presenting for lower extremity surgery at their institution.

After briefly tracing the roots of regional anesthesia at the Mayo Clinic, the authors use the first of four sections to build the framework for their pathway via  a review of general principles of peripheral nerve blockade including anatomy, pharmacology, monitoring, techniques for localization, and complications, all targeted to the lower extremity. Although somewhat superficial, the review is appropriate to the scope of the book, and the reader is referred at the conclusion of each chapter to classic texts and recent studies for more exhaustive details on each topic.

Following this review is the heart of the book, divided into two sections based on neuroanatomy. Approximately five colorfully and aptly illustrated pages of anatomical landmarks, clinical applications, positioning hints, techniques, complications, side effects, and needle redirection tips are dedicated to each peripheral nerve block within first the lumbar plexus and then the lumbosacral plexus. Again, brevity of discussion is present, and the reader is directed to corresponding resources. This portion of the book, brimming with particularly thorough illustrations providing patient, anesthesiologist, and needle positioning as well as neuromuscular relationships, is invaluable as a refresher for the private practitioner on seldom-used blocks or as a quick reference to the resident presented with the opportunity to perform an infrequently observed block.

The final section of the book gives specific guidelines used in the Mayo Clinic Total Joint Anesthesia and Analgesic Pathway. Goals include adequate analgesia and minimal opioid-related side effects. Patient selection and preoperative, intraoperative, and postoperative management are discussed in specific detail, including strategies for nausea prophylaxis, limitation of parenteral opioids, supplemental surgical anesthesia, complications, and postoperative catheter infusion management in both inpatient and ambulatory settings. More comprehensive references are again provided and recommended for the practitioner’s application of such management strategies. The book ends with a reiteration of the important role that peripheral blockade has in improving postoperative analgesia, as well as a mention of new techniques to facilitate the efficacy of peripheral blockade. Readers are left with encouragement that learning, practicing, and implementing regional anesthetic techniques will be to the benefit of their patients. In a straightforward, easily absorbable, and impeccably illustrated guidebook, Drs. Lennon and Horlocker have effectively produced a title for the shelves of practitioners at various levels who want to further their technical expertise and thereby allow an improved perioperative experience for patient and surgeon.

*Virginia Mason Medical Center, Seattle, Washington.

Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL: Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006; 102:248–57