© The Board of Management and Trustees of the British Journal of Anaesthesia 2005
BOOK REVIEW |
Regional Nerve Blocks and Infiltration Therapy, 3rd Edn. D. Jankovic (editor). Published by Blackwell Publishing, Oxford. Pp. 430; indexed; illustrated. Price £130.00. ISBN 1-4051-2263-3
E-mail: david.m.coventry{at}tuht.scot.nhs.ukAnaesthetists looking for a textbook on regional anaesthesia, or those considering updating their library, are currently spoilt for choice. With the recent proliferation of texts, it must be increasingly difficult for editors to find titles to differentiate them. In addition, textbooks in this essentially practical field, are having to compete with other media such as internet web sites and CD-ROMs, which can illustrate techniques with the aid of video clips. With this thought in mind, I examined what is a beautifully presented textbook, to see how it compared with other standard texts, how up-to-date the concepts were and exactly what was encompassed within infiltration therapy alluded to in the title.
What was immediately obvious is that the target recipient for this book was more in the regional anaesthesia/invasive pain specialist niche rather than being aimed specifically at the practice of regional anaesthesia for surgery and acute pain relief, although it could be used for this purpose.
The book begins with a brief but essential chapter concerned with safe practice and pharmacology, including some discussion of the newer agents.
The text then covers each region of the body in turn beginning with the head and neck, shoulder, elbow and hand and continuing with the thorax, abdomen, lower extremity and finally neuraxial anaesthesia, including a brief chapter on epidural anaesthesia in obstetrics and adjuncts used in neuraxial blocks. The chapters cover most of the major nerve blocks but in addition cover such areas as infiltration of myofascial trigger points, ganglion blocks, intra-articular blocks, i.v. sympathetic blocks, epidural steroid injections, chemical intraspinal neurolysis and percutaneous epidural neuroplasty.
The text follows a simple pattern, initially examining the relevant anatomy before looking at the details of nerve block including indications, contraindications and preparation, then describing the block procedure in more detail. Most focus on using paraesthesia techniques or peripheral nerve stimulation, with little discussion of recent advances in ultrasonic techniques or imaging. The chapters are, however, beautifully illustrated with additional photographic images of surface anatomy and needle positions, which are amongst the best I have seen. This is very much a practical manual and an additional brief discussion on the merits of certain approaches or strategies would be beneficial. For example, in the ophthalmology chapter, retrobulbar block is described first, followed by peribulbar block. Finally, sub-Tenon's block, considered by many to be the technique of choice, is described as an alternative to the former two techniques. On reading this chapter it could appear that retrobulbar block was still the technique of choice. This criticism could also be levelled at a number of other chapters where a short balanced discussion of the approaches and some ‘pearls of wisdom’ on choice and perioperative management would be very welcome. A variety of approaches to sciatic nerve block are described but no information given on which to choose in which circumstances and their relative success rates. From an experienced author, we would wish to know if an anterior or popliteal approach works as consistently as a classical posterior approach and, perhaps, if there is evidence to support it. Similarly, one could find out in chapter 32 how to perform ilioinguinal/iliohypogastric blocks but still not be able to provide regional anaesthesia for a hernia repair after studying the text. Perhaps this is acceptable if the book is not aimed primarily at regional anaesthesia for surgery and acute postoperative pain relief.
So what of the other areas of interest covered by the text? The indications for a particular block are usually straightforward when surgery is involved but some of the other ‘therapeutic’ indications listed in each chapter are debatable. Is lumbar plexus block really indicated for arterial occlusive disease, complex regional pain syndromes, postamputation pain, oedema after radiotherapy, diabetic polyneuropathy and knee joint arthritis or is there evidence to allow its recommendation as prophylaxis against post-amputation pain? Furthermore would you consider repeating this block 6–8 times or more in these situations? Would you really consider using a lumbar plexus block to prevent an obturator reflex during a TURP resection? Therein lies my concern with this text. It lends a certain legitimacy to using many of these techniques for reasons other than regional anaesthesia with little referenced evidence base.
As stated in the foreword, regional anaesthesia has a very important part to play in the treatment of acute pain but the management of cancer pain and chronic non-malignant pain represents a much more major challenge. There is a lack of evidence as to the efficacy of some of these ‘blocking’ techniques and this text presents little to change that view but rather presents a complete ‘practical manual’ of blocks that are still used by some practitioners. The need for a more multi-modal approach in pain management is mentioned briefly and some of the simple injection techniques can certainly be useful for both diagnosis and treatment, but what of the major nerve blocks?
In conclusion therefore I can recommend this book as an addition to your departmental library for the excellent illustrations and photographic images alone but have concerns about some of the indications appearing in the text and its usefulness as an aid to the practice of regional anaesthesia for operative surgery.
Dundee, UK
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