A Practical Approach to Pain Management, M. Lefkowitz and A. H. Lebovits, eds. Boston: Little, Brown, & Co., 1996, ISBN 0-316-51958-8, 336 pp, $39.95.
For those who do not wish to read this entire review, let me state that this "pocket" text contains all of the topics encountered when engaged in the practice of pain management and packages them in a practical, affordable, outline format. This text is a suitable review for the busy clinician who wishes to sit for the pain qualification examination, is an appropriate quick reference for reviewing conditions not regularly encountered (intraoral pain), and is a perfect primer for anesthesiology residents rotating through their pain management training. At the price of $39.95, one does not need to spend a great deal of time deciding whether this book is suitable for one's library, for the book is both a value and relevant to the practice of pain medicine.
The book is arranged into two divisions: therapeutic and diagnostic approaches and pain syndrome. The therapeutic division includes 18 chapters and is further subdivided into six sections: acute pain, pharmacologic management, regional techniques, psychologic approaches, physical techniques, and other approaches to chronic pain management. The pain syndrome division comprises 16 chapters covering virtually all types of conditions likely to be encountered by the pain physician.
The format of each chapter should be familiar to all physicians who used the Washington Manual during residency. Topics are presented in outline style with brief explanations used when necessary. This style has the advantage of presenting the material in an organized step-wise fashion but runs the risk of restricting the description of certain topics. However, this abbreviated approach was not detrimental for the majority of topics.
There were some stark variations detected among the chapters. References vary from as few as 6 to as many as 102. Some chapters merely have a suggested reading list at the end. Chapter lengths range from 3.5 pages up to 25 pages and are largely based on how topics were divided. As an example, "Head and Neck Pain" comprises 5 chapters and 32 pages.
Chapter by chapter review revealed that redundancy was present but minimal, and all chapters treated their respective topics adequately. Particularly strong chapters include those dealing with psychotropic agents, regional anesthetic techniques, neurolytic procedures, psychological assessment, cancer pain, pediatric pain, myofascial pain, head and neck pain, and sickle cell disease pain.
Few weaknesses were detected and generally dealt with the lack of providing current information on drugs or techniques. This observation is true of all texts because of the 6- to 12-month delay between submission and publication. Of note, the acute pain chapter could have mentioned tramadol in anticipation of its release by the time of this book's publication. Some of the acute pain therapies seem narrow in scope and not always reflective of current practice. As an example, on page 9, the following statement appears: "Pain from abdominal malignancy can be relieved by small doses of morphine (0.5 mg spinal or 2 mg epidural) every 24 hours." In our cancer and acute pain practice, these doses are inadequate, and usually, 5-6 times more drug is needed (via continuous infusion) over 24 hours. Finally, a loading dose for toradol is still recommended, and reduced doses with renal impairment are not mentioned.
In the local anesthetics chapter, ropivacaine is not included in the physicochemical Table andis only mentioned briefly in the text. In the neuraxial chapter, there is no discussion regarding the use of either epidural local anesthetic-opioid combinations or clonidine for chronic pain management. Finally, the reflex sympathetic dystrophy chapter does not discuss the new international nomenclature.
In summary, I found myself referring to this text for quick updates on less common topics with satisfying results. While clearly not a resource text, its design in the style of other Little, Brown manuals is successful, useful, and effortless. Its purchase is recommended.
Mark J. Lema, MD, PhD
Department of Anesthesia; Roswell Park Cancer Institute; SUNY at Buffalo; School of Medicine and Biomedical Sciences; Buffalo, NY 14263