British Journal of Anaesthesia, 2003, Vol. 91, No. 3 454
© 2003 The Board of Management and Trustees of the British Journal of Anaesthesia
Book Review |
Atlas of uncommon pain syndromes
London, UK
Atlas of Uncommon Pain Syndromes.
S. D. Waldman (editor).
Published by W. B. Saunders, Philadelphia.
Pp. 262. Price $99. ISBN 072169375.
This book about uncommon pain syndromes is a companion to a volume describing common pain syndromes also written by Dr Steven D. Waldman. He has produced two other so-called atlases devoted to injection techniques and interventional techniques for pain management.
Frequently, anaesthetists who practice pain medicine are faced with patients for whom the cause of the pain is unknown or uncertain. A typical out-patient clinic may contain a mix of patients with presenting complaints drawn from neurology, orofacial medicine, cardiology, gastrointestinal medicine, urology, gynaecology, orthopaedics, rheumatology, clinical psychology, and psychiatry. In many instances, the patients have been extensively investigated prior to referral to the pain specialist. In some cases, the pathology has been identified, but in a significant proportion of cases no pathology sufficient to explain the pain is ever found. It is important to know when to call a halt to further investigations because continuing a fruitless search for a cause may have a detrimental effect on the patient’s future management. The worry for some practitioners is that an obscure condition has been missed, although it is unrealistic to expect an anaesthetist to be aware of all the uncommon potential causes of pain from a wide range of medical and surgical specialties. Doctors in the UK are advised to recognize the limits of their professional competence and to seek help from colleagues.
The book is described as an atlas but it does not contain any maps or charts. Instead, there are descriptions of 71 different syndromes. Each section follows an identical formula: clinical syndrome, signs and symptoms, testing, differential diagnosis, treatment, complications and side-effects, and clinical pearls. First impressions are important and things did not start well in the preface with mention of the ‘pathopneumonic’ features of diseases. Readers might be interested in unusual conditions such as Parsonage–Turner syndrome, neck–tongue syndrome, cheiralgia paresthetica, and Secretan’s syndrome. Unfortunately, no references are provided about these uncommon conditions. The clinical descriptions of the various syndromes are informative and the book might have survived on this material alone. It is, however, seriously flawed by the inclusion of a treatment section for each condition. Throughout the book, unsubstantiated claims are made for the benefit of various therapies and most especially for injection techniques. Injection of local anaesthetic and steroid is recommended as ‘a reasonable next step’ for well-over 50 of the 71 uncommon pain syndromes. This includes conditions as diverse as Eagle’s syndrome, liver pain, Bornholm’s disease, multiple myeloma of the spine, Paget’s disease of bone, orchialgia, proctalgia fugax (why use intercostal blocks for this condition?), prostadynia, vulvadynia, and sesamoiditis. The lack of any references or supporting evidence for the treatments is a serious deficiency. The author claims that caudal or lumbar epidural blocks have been shown to be ‘extremely effective’ in the treatment of pain secondary to spondylolisthesis. This view does not accord with published evidence.
Unfortunately, the text is repetitive in the extreme and there are numerous examples of exactly the same text being repeated word for word. Presumably, a book on uncommon syndromes is not aimed at the tyro pain specialist. Thus one would hope that the reader will be aware of the potential side-effects of tricyclic medication without having to be reminded of them every time a tricyclic drug is mentioned. Also it might be expected that practising pain specialists will know that infection is a potential complication of any injection technique without being repeatedly reminded of this. It is all rather reminiscent of my recent experience on a trans-atlantic flight where each packet of peanuts displayed the following: ‘Instructions: open packet, eat nuts. Warning: contains peanuts’.
There is a heavy bias in this book towards medical practice in the United States. For example, MRI scans are recommended for virtually every condition. Details of ICD-9 coding are included to help physicians to ‘get paid’. This is a pain book in the old style and it represents a regression to the era before evidence-based medicine. The idea is very good but the formula is flawed, it is strangled by needless repetition, and there are no references. This book is unlikely to find wide uptake in pain medicine practice in the UK, although the descriptions of the symptoms and signs of uncommon pain syndromes may appeal to pain specialists who worry that they are missing one of those obscure syndromes.
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