James C. Eisenach, M.D., Editor.
By P. P. Raj. St. Louis, Mosby Year Book, 1995. Price: $49.95.
More and more anesthesiologists are pursuing fellowship training in pain medicine. Pain management training programs have burgeoned throughout the United States with many new pain fellowships appearing during the last 2 yr. Pain medicine is rapidly approaching recognition as a distinct medical discipline. The American Board of Anesthesiology (ABA) offers an examination leading to a Certificate of Added Qualifications in Pain Management for anesthesiologists certified by the ABA. The American Board of Pain Medicine offers the Certification Examination in Pain Medicine for physicians board-certified in other specialties recognized by the American Board of Medical Specialties. Raj, the text's editor and a leader in the field of pain medicine, tells us in the preface that Pain Medicine: A Comprehensive Review was "... conceived to fill the void for a comprehensive review of the theoretical knowledge and scope of pain medicine."
Raj has combined contributions from 42 authors, many of whom are recognized experts in pain medicine. The text is comprised of 53 chapters spanning more than 500 pages. It is divided into six sections: overview, special examinations, modalities of pain management, special techniques, pain syndromes, and test banks. Part 1 (overview) includes concise and easy-to-read chapters on such topics as the history of pain medicine, evaluation of the pain patient, and pain measurement, which add to the completeness of the text. Chapters on laboratory investigations and radiography and imaging were disappointing; the former was superficial and largely covered in other chapters, whereas the latter focused on a detailed discussion of the physics behind magnetic resonance imaging (interesting but hardly appropriate review material for the pain practitioner).
Part 2 (special examinations) discusses several techniques that may be employed in evaluation of the pain patient. I was pleasantly surprised by the chapter on thermography; it is a well-written and critical review of the literature concerning use of this technique in evaluating the pain patient. The chapter on psychologic evaluation and treatment is also particularly good, with clear discussions of psychologic evaluation, psychometric testing, and the techniques and applications of various psychologic therapies (biofeedback, relaxation training, and cognitive approaches). The nine chapters comprising part 3 (modalities of pain management) are comprehensive and understandable. The first half of this section covers pharmacology, including chapters on opioids, nonsteroidal antiinflammatory agents, and coanalgesic agents. This material is presented in a succinct and understandable way with extensive references and helpful discussions of the usefulness and limitations of individual agents. The latter half of this section includes chapters on central nerve blocks, peripheral nerve blocks, and autonomic nerve blocks that are clear and easy-to-read and make good use of high-quality illustrations to demonstrate the anatomy and techniques of neural blockade.
Chapters covering techniques from facet blocks and epidural steroids to implantable drug-delivery systems, radiofrequency neurolysis, and spinal cord stimulation are included in part 4 (special techniques). Although such techniques are employed commonly in many pain clinics, the efficacy of many of them remains unstudied. Several authors in this section put forth noble attempts to review the literature concerning efficacy. The chapter on epidural steroids is a good example: The current data examining efficacy of epidural steroid injections for the treatment of low back pain is presented along with reasonable criticism of the information--a refreshing approach.
Individual chapters concerning a wide range of acute and chronic pain syndromes appear in part 5 (pain syndromes). The chapters in this section tended to be more in depth and well referenced than earlier chapters. One highlight is the chapter on pain management in trauma. Here the author presents current data on the usefulness of pain management modalities for patients who have suffered trauma. A useful paradigm for guiding the choice of pain management techniques in the trauma patient is included. A second chapter in this section gives a detailed and informative overview of reflex sympathetic dystrophy (RSD). This author includes current theoretical explanations of the pathophysiology leading to RSD and an indepth discussion of its clinical presentation and management. Detailed and well referenced information is presented with a balanced summary of the limits of our knowledge and ability to effectively treat RSD.
This review manual is largely designed to aid the prospective examinee in preparation for one of the certifying examinations in pain medicine. To this end, the authors have included five test questions after each chapter and two test banks of 75 questions each at the end of the text. However, the test questions more often than not are based only on the factual material presented in each chapter. Too few of these questions will test your conceptual understanding of the material rather than facts alone. (WARNING: The board examination may be more difficult!)
More than half of the contributors to Pain Medicine also authored similar chapters in the second edition of Raj's Practical Management of Pain published in 1992 by Mosby Year Book (St. Louis, MO). In many respects, Pain Medicine is a duplication of this earlier book; the authors, the scope and organization of the text, and the figures are largely the same. Nonetheless, Pain Medicine adds board examination-style questions and comes packaged in a soft-cover edition; the attractive price and study-guide format make it well suited for residents and fellows in training. While Pain Medicine is not the "comprehensive review" described in the title and the book's preface, it is a reasonably complete, albeit not-so-in-depth text that can serve as an affordable starting point for physicians to begin preparation for pain medicine examinations.
James P. Rathmell, M.D., Director, Pain Management Center, Department of Anesthesia, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115.