Spinal Drug Delivery. Edited by Tony L. Yaksh, M.D.Amsterdam, Elsevier, 1999. Pages: 614. Price: $127.00

Spinal Drug Delivery  is a deep, sometimes tough, but always efficient, compendium edited by Yaksh et al.  Its aim is to describe spinal drug delivery in human therapy. For more than a century, considerable work has been done to deliver medicines (e.g. , local anesthetics and, more recently, numerous other drugs) near the central nervous system and essentially close to the dorsal horn of the spinal cord for provision of anesthesia, and, later, sustained analgesia for painful chronic (e.g. , cancer) and degenerative diseases. During the past 3 decades, a growing number of preclinical and clinical studies related to epidural or spinal drug delivery have been published. Yaksh and others were involved deeply in the preclinical studies that led to a better understanding of the mechanisms of action of opioid and nonopioid drugs in the dorsal horn of the spinal cord. Spinal Drug Delivery  is a comprehensive review and analysis of the tremendous amount of data available.

This book is in the straight line of previous textbooks, such as The Management of Pain  (Bonica J, ed.) and Neural Blockade  (Cousins M, Bridenbaugh P, eds.). Spinal Drug Delivery  is complementary to these texts, but its overall direction is toward anesthesiologists involved in pain treatment or regional anesthesia and also toward neurologists, chemists, and researchers. This book provides substantial information and new insights regarding the topics that will be helpful for these readers. This is not a handbook for residents, and some experience and a knowledge of the related literature is advisable.

The text, organized in 26 chapters, is clearly written, with nice iconography. The first chapter details the history of local anesthetic formulation and delivery since J. L. Corning’s pioneer administration in 1885. In the second section of chapters, the embryology and gross anatomy of the spinal column and the anatomy and physiology of the spinal meninges in animals and humans are reviewed extensively. The chapter dedicated to the mechanisms of neurotoxicity is especially interesting. The third section of chapters regards the factors that govern the movements of spinally delivered drugs through the parenchyma, vessels, and meninges. The mechanics and chemistry of the cerebrospinal fluid are emphasized by A. A. Artru in a well-documented chapter, and C. M. Bernards explores the drug movements in the epidural space and cerebrospinal fluid. This chapter is particularly relevant for anesthetists who administer opioids and local anesthetics in the cerebrospinal fluid and in the epidural space. The two following chapters by C. Nicholson and S. Shafer present a high level of mathematical modeling of drug movements that is perhaps overly complex for the uninitiated.

The fourth section of chapters reviews the technical problems related to spinal delivery, such as tissue inflammation, validity of animal models, evaluation of description of catheter properties, and pharmacologic problems, including delivery through liposomes and microspheres. Practical details are provided regarding the spinal devices and the formulation of infused drugs; these chapters are of special interest for physicians working in pain clinics.

The fifth section begins with a chapter by T. L. Yaksh and J. C. Eisenach, who describe preclinical and clinical considerations regarding the safety of spinally delivered drugs. Laboratory and clinical investigators can benefit from these pages; useful guidelines are provided for the development and receipt of new drugs approved for spinal administration. Finally, the last chapters focus on the therapeutic effects of drugs used in analgesia, regional anesthesia, treatment of spasticity, chemotherapy, and radiology. Trends for the near future regarding neurotrophins in degenerative diseases or cellular implants in severe pain are presented.

In conclusion, a valuable feature of this book is the provision of important theoretical and practical information for pain medicine practitioners and anesthesiologists and the highlighting of critical considerations that enhance the safety of spinal drug administration.