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Wall and Melzack’s Textbook of Pain, 5th E-dition.

Section Editor(s): Ellison, NorigRathmell, James P. MD; Hill, Bradley DO

doi: 10.1213/01.ANE.0000220485.92210.D3
Book and Multimedia Reviews: Media Review

Professor of Anesthesiology, University of Vermont College of Medicine (Rathmell)

Fellow in Pain Medicine, Fletcher Allen Health Care, Center for Pain Medicine, South Burlington, VT (Hill)

Wall and Melzack’s Textbook of Pain, 5th E-dition. McMahon SB, Koltzenburg M, eds. Philadelphia: Elsevier/Churchill Livingstone, 2005. Book: ISBN 0-443-07287-6. 1,239 pages, $279.00. E-dition: ISBN 0-443-06791-0, $359.00. Web: ISBN 0-443-06781-3, 1,239 pages, $279.00.

Patrick Wall and Ronald Melzack made numerous contributions to our understanding of pain and its treatment during their careers. Their paper, “Pain Mechanisms: A New Theory,” (Science: 150, 171–179, 1965) described what is known as the Gate Control Theory and has been described as “the most influential ever written in the field of pain.” Together, they assembled the first edition of The Textbook of Pain in 1984 in an attempt to highlight both the latest research and clinical information about pain; the book has become a prominent reference text in the emerging field of pain medicine. Wall and Melzack themselves saw the textbook through the first four editions. Prior to the death of Patrick Wall in 2001, they selected Stephen McMahon, a neurophysiologist from King’s College London, and Martin Koltzenburg, a neurologist and research scientist at University College London, to edit this 5th edition of The Textbook of Pain.

When asked to read, rate, and write about one of the longstanding reference texts in our specialty, we took pause. Can we really provide a reasonable analysis? Seventy-six chapters, 1,239 pages, 131 contributing authors with perhaps the most recognizable group of pain experts ever assembled. We have used the previous edition of Wall and Melzack as the core text for our fellowship’s didactic curriculum. Here is the honest assessment of two pain medicine clinicians, both familiar with the previous edition of The Textbook of Pain. We aim to give you the perspectives of a pain medicine physician who has practiced for some time and a pain medicine physician-in-training on the usefulness of this new edition of a classic textbook.

The new editors point out several differences in the organization and structure of the 5th edition. The previous edition outlines information into three categories: basic aspects, clinical states, and therapeutic aspects. The new edition is composed of nine sections: neurobiology of pain, assessment and psychology of pain, pharmacology and treatment of pain, five different sections on clinical states, and a special cases section. The new organization is well thought out and makes information far easier to find; every section has many new or updated chapters. The chapters themselves are also easier to read, each beginning with a concise summary of the topic to be discussed. The black and white diagrams of previous editions have been replaced with two-tone color images and there are also a number of new radiographic images. As with previous editions, each chapter is exhaustively referenced.

The great strength of The Textbook of Pain is its diversity and depth of coverage of the scientific underpinnings of pain. This is a detailed text about the science of pain written and edited by basic and clinical scientists. The section on the neurobiology of pain provides an in depth look at the science behind what is known with respect to the generation, transmission, modulation, and perception of pain. The coverage of this topic is detailed and well illustrated, providing an in-depth and up-to-date discussion of topics ranging from peripheral mechanisms of cutaneous nociception to a detailed discussion of the neurophysiology of itch. Noted leaders in our field provide logical and understandable coverage of several of the psychological aspects of pain medicine: the chapter on the cognitive-behavioral therapy (CBT) in pain management is a practical discussion of how these experts apply CBT in clinical practice; in another chapter the neurobiology of placebo analgesia is nicely detailed and illustrated. Among the largest sections in the text, the pharmacology and treatment of pain provides a thorough discussion of mechanisms of common and uncommon analgesic agents. The section on pharmacology is quite variable, with no uniform approach taken to the structure or detail from one chapter to the next. Nonetheless, there are notable chapters, including the detailed coverage of cannabinoids, which covers the neurophysiology of endocannabinoids, as well as the chemistry and mechanisms of analgesia and ends with an honest analysis of the dearth of human trials aimed at understanding the clinical utility of these compounds in treating chronic pain. The coverage of neuropathic pain is extraordinary. A chapter on painful peripheral neuropathy details pathophysiology, clinical features, nerve biopsy, imaging, and sensory testing as well as discussing the numerous and disparate etiologies causing these disorders; the chapter is well illustrated, comprehensible, and clinically relevant. In similar fashion, another notable chapter assembles the many disparate approaches to diagnosis and treatment of complex regional pain syndrome in to a cohesive, evidence-based treatment algorithm.

The editors’ stated aim was to produce a well-balanced text that covers the scientific as well as the clinical aspects of pain medicine and thus appeals to researcher and clinician alike. For the average clinician, the text can be impenetrable and difficult to apply to daily practice. Indeed, the authors of the chapter on itch tell us that “guidelines for an antipruritic therapy are beyond the scope of this article.” The coverage of opioids is divided in to two chapters: basic mechanisms and clinical use. The first chapter provides a clearly written and detailed discussion of the basic mechanisms underlying opioid pharmacology, including molecular aspects and structure-activity relationships of opioid receptors. The second chapter is a cursory overview of the clinical use of opioid analgesics on the level that you would expect in an introductory text in general medicine. For those deeply involved in the treatment of chronic pain, low back pain is among the most common problems we encounter. The coverage of this topic is also disappointing for the clinician. There are two chapters that are most relevant to this topic, one addressing surgical treatment of back pain and the other a broad overview of treatment for low back pain. Both are cursory and lack any detailed discussion of the pathophysiology, biomechanics, or broad range of treatment options used for treating this group of patients.

Finally, in this the day and age of electronic media, no text of this magnitude can survive without an electronic companion. Full access to both the hard cover text and the full electronic text on-line is an additional $80.00 (the hardcover text or Web access alone are available for $279.00; both for $359.00). The on-line version is easily accessible and well formatted. All of the figures from the text can also be downloaded for use in presentations. The e-text also offers the advantage of online updates to various sections, and these updates are highlighted for easy access. The odd part about the updates is that they are written, not by the original authors of each chapter, but by a “science writer.” The updates (there are currently six updates available) all appear to highlight a single scientific article relevant to the chapter. They are concise and well-written summaries of that single article, but it is not clear if they add to the original text in any meaningful way.

The editors of this 5th edition of The Textbook of Pain are to be congratulated for their enormous efforts. The book has improved on previous editions and remains the most comprehensive scientific reference text in the field of pain medicine. Pain clinicians and researchers alike will indeed find detailed information that covers the entire discipline. But, as in the past, the average clinician will often look elsewhere for a more practical guide to daily pain practice.

© 2006 International Anethesia Research Society