Raj's Practical Management of Pain, Fourth Edition.  By Honorio T. Benzon, M.D., James P. Rathmell, M.D., Christopher L. Wu, M.D., Dennis C. Turk, Ph.D., Charles E. Argoff, M.D. Philadelphia, Mosby Elsevier, 2008. Pages: 44. Price: $239.00.

Raj's Practical Management of Pain  provides a comprehensive multidisciplinary approach to the subject of acute, acute on chronic, and chronic pain. The multiauthor contributions take the reader from the history, through classifications or definitions of pain and other general subjects, into the treatments. A color-coded book margin gives the reader a quick reference to sections that include related subjects. For example, a green margin (section) in the middle of the book houses information on the pharmacologic agents used to treat pain, whereas a brown section details nerve block techniques.

The General Considerations section starting the book is an excellent resource for a person to begin establishing either an acute or a chronic pain service.

The target audience for this book would be senior residents who are considering pain fellowships, pain fellows at the beginning of training, and practicing pain anesthesiologists who are updating their knowledge. I approached the book from the aspect of someone who was not fellowship trained but who spent a total of 6 months during his residency working in the pain clinic. For the most part, I am now an ultrasound-based regionalist involved in an acute pain service.

A detailed discussion of pain pathways is presented to give readers a sound platform/basis from which to begin practicing pain medicine. The pharmacology of pain with regard to signaling and the resultant sensitization states give an additional perspective to equip the pain physician with knowledge of complex pain syndromes. This is followed by an explanation of central nervous system changes and clinical correlates such as migraines, neuropathic pain, and fibromyalgia are given.

A thorough treatment of the assessment of patients with pain is covered as well as a review of electrodiagnostic techniques and radiographic studies. An excellent overview of electromyography and nerve conduction studies is presented, which gives those not that familiar with this field a basis from which clinical decisions may be made. I found the chapter on radiologic assessment of patients with spine pain to be a useful and valuable reference and will be an excellent reference for diagnostics. The excellent quality radiographic studies provide clinical correlates to a multitude of spinal disorders. The psychologic, behavioral, and emotional aspects of pain cannot be overlooked and are summarized, giving pain physicians a starting point in the assessment of the patients with pain by providing useful templates for assessing pain.

The section on clinical conditions is extensive and takes physicians through virtually every broad category of acute and chronic pain that would be encountered in both pediatric and adult populations. Of note, the first chapter provides a starting point by giving a general overview of acute postoperative pain treatment modalities. I liked that the author recognized and acknowledged other treatment modalities other than opioid analgesia and held a brief discussion on the emerging problem of opioid hyperalgesia.

The underestimated problem of chronic pain in children is well detailed, giving the reader valuable diagnostic and therapeutic advice in this largely ignored problem in children. I found this chapter to be an extremely useful reference in my practice where I am involved in acute pain medicine across a large age spread. On the other end of the spectrum, valuable references for obtaining useful diagnostic scales and indices for treating the older population are included, thus giving the reader an all-in-one reference for the entire age spectrum. A chapter devoted solely to medications and more common painful conditions in pregnancy is included. This chapter provides, for those uncomfortable with pain medicine in this patient population, a solid basis for diagnosis and treatment. In particular, I found information regarding posterior back pain and treatment to be very helpful. Other topics included in this comprehensive book include low back, phantom limb, cancer, neuropathic, and soft tissue pain. Craniofacial pain, headaches, and abdominal pain are also covered extensively.

A large section is provided for pharmacologic modalities. The first chapter of this section discusses basic opioids and their characteristics, prescribing strategies and rationale and discussing endpoint considerations. The second chapter goes on to educate readers on minor opioids and adjuvants that could also be useful in the treatment of complex chronic pain. The antinociceptive effects of antidepressants are thoughtfully described. Other useful pharmacologic adjuncts such as nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, acetaminophen, and muscle relaxants are reviewed. These chapters provide concise histories, mechanisms, and indications.

Two chapters covering the aspects of physical medicine and rehabilitation depict diagnostic and therapeutic processes that would not normally be in the purview of the anesthesiologist in pain medicine. I found these chapters to be informative in terms of physical modalities used to reduce pain and summaries detailing the abnormalities found using electrodiagnostic studies. Acupuncture has become widely available and expanding in clinical use. A concise summary detailing its usefulness with regard to common problems such as postoperative nausea and vomiting, back pain, and other musculoskeletal disorders is included in this section.

No reference text would be complete without a discussion of pain treatment and addiction issues associated with it. Useful tools to assess alcohol and opioid addictions are included as well as treatment strategies to deal with an addicted patient with pain. Starting points are described to assist physicians with the difficult task of weaning long-term opioid users from narcotics.

There are a variety of chapters on interventional techniques. I liked the presentation of neuraxial anesthesia because it was done with clear anatomic drawings. The chapter dealing with intrathecal drug delivery was interesting from the standpoint that it gives pain physicians who are unfamiliar with this process a launch point to initiate this treatment. Intraarticular analgesia is described within a broad review of various opioid and other pharmacologic compounds for differing surgeries. Unfortunately, comparison studies of this technique and nerve block techniques are not presented, leaving readers to decide how useful intraarticular analgesia really is.

An excellent synopsis of nerve stimulators is given detailing placement procedures and outcomes of treatments for particular diseases such as complex regional pain syndrome and failed back. Of particular interest is a detailed algorithm that covers not only the use of interventional techniques but also the rehabilitative and psychologic treatments and considerations of complex regional pain syndrome. A brief overview of epidural steroid injections is presented with outcomes, techniques, and complications. Similarly, a comprehensive chapter on facet joint pain delves into diagnosis, treatment, and outcomes. Both these sections contain numerous tables that document results and outcomes. The last part of this section is a review of intradiscal procedures that assist in diagnosis through discography and treatment with intradiscal electrothermic therapy. I found the tables of disk stimulation data, interpretations of discograms, and radiographic examples to be very informative. The last chapter of this section reviews epidurography. This chapter provides a great starting point to provide readers with familiarity of this subject.

The concluding portion of the book reviews outcomes of treatments of many of the conditions presented throughout the text. I found this section to be very informative and useful as it gave me tools to convince skeptical colleagues, educate residents, and continue both my professional and business education.

I found this text to be amazingly comprehensive and helpful. It is a great read for pain fellows and practitioners.

Acute Pain and Regional Service, University Medical Center, University of Arizona, Tucson, Arizona. joshua19pb@aol.com