Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine
Rathmell JP. Philadelphia: Lippincott Williams & Wilkins, 2006. ISBN 0-7817-5181-0. 186 pages, $99.00.
For many years advanced procedures involved in chronic pain management had little representation in broadly published texts and were limited to industry-sponsored conferences and monographs. Sensing an unmet need, many interventional pain medicine practitioners have published such manuals in the past decade. The Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine is the most recent of these and, given Dr. Rathmell's position as a leader in the fields of interventional pain medicine and medical education, he is well qualified to publish such a work.
This atlas is well balanced in its depth. Many of the commonly performed interventional pain procedures of note are represented, and each grouping of procedures is prefaced by overview and anatomy sections, which are quite useful in outlining the rationale for the procedure and the basic anatomical considerations.
A major strength of the text is the graphic content provided by the medical illustrator, Gary J. Nelson. Idealized grayscale diagrams are well drawn and include the relevant anatomical content. Each chapter includes copious fluoroscopic images, shown without labels, next to images with superimposed structural outlines and labels. This facilitates easy orientation and identification of relevant anatomical structures and the needles involved in the procedures.
Of course, any text covering interventional pain medicine suffers from the historical paucity of high-quality evidence published in peer-reviewed journals. Dr. Rathmell is open about this, both in the foreword material and in many of the chapters. However, there are also several important omissions and some procedural details that must be particular to the methods used in Dr. Rathmell's practice. As the sole author of a work of this magnitude, he has included primary tools and techniques, but not alternative implements and strategies. This does limit the utility of the text to some extent.
The first section describes basic techniques and safety and is excellent. The radiation safety section will be a helpful resource to any nonradiologist who is using fluoroscopy on a regular basis, and contains helpful information, such as radiation exposure diagrams in various positions, as well as the suggestion to use pulse mode fluoroscopy. However, there is no mention of certain helpful tools that reduce radiation exposure, such as laser pointers and fluoroscopy tables possessing three-dimensional movement capability. Some discussion of stochastic versus deterministic risk would also be appropriate, as this provides the rationale for much of the shielding and beam-avoidance techniques in use.
The pharmacology section includes an excellent piece on steroid pharmacology, but does not include a discussion of topics such as test dose prior to local anesthetic injection, the addition of epinephrine to local anesthetic injections, or fractionated injection. This reviewer was somewhat surprised that there was no section involving appropriate monitoring or sedation safety, as complications of sedation are a cause of much of the morbidity and mortality in interventional pain procedures. There is mention of the need for communication with patients during injection procedures to avoid undetected neural trauma, but given that an increasing number of nonanesthesiologists are using textbooks like this to provide guidance, such a chapter would be of great importance in safety education.
The next two sections involve injection techniques for a significant number of interventional procedures: the first for spinal procedures, the second for sympathetic and a limited number of peripheral procedures. The descriptions and images are excellent representations of the methods described. Detailed descriptions of patient positioning for each procedure are included, as well as the positioning of the C-arm. This sort of detail is lacking in most atlases of this type. Unfortunately, many of the fluoroscopic images suffer from a lack of contrast, which makes them difficult to visualize. However, the overlaying diagrams should prevent any confusion on this front.
Little mention is given to curved needle techniques, which many practitioners find to be a significant technical development, and one in which several companies have developed products to help the clinician to provide safe care. The inclusion of the anatomy for the thoracic medial branch block is particularly useful, as this has previously been available only in the original article, published in a hard-to-find journal, and to members of the International Spinal Injection Society, but not to most practitioners. However, the two-needle technique for thoracic medial branch blocks and the oblique approach to cervical medial branch blocks are not included as therapeutic options. Furthermore, there is no mention of methods of preventing, detecting, or managing epidural hematoma and abscess, which are two serious complications of neuraxial injections.
The section on visceral blocks is extensive. It includes detailed descriptions of the techniques involved in executing most of the commonly performed sympathetic blocks. It is candid regarding the lack of supportive evidence for many of these blocks in the practice of medicine, and makes important safety points. This section would be even stronger if the inferior hypogastric block had been included Also, an expanded discussion of the potential risks of celiac plexus/splanchnic nerve block, such as nutritionally-induced hypocoagulable state, cholesterol emboli syndrome, visceral, and celiac axis injury would have been useful in guiding decisions regarding patient and technique selection.
The final section involves implantable procedures: implanted intrathecal catheters and pump systems and spinal cord stimulators. While the discussion of these modalities is well conceived technically, this section would have been enhanced considerably by a more complete discussion of appropriate medical and psychological evaluation, and relative and absolute contraindications. These modalities are technically challenging to employ, and all are associated with risk of serious (though rare) complications (e.g., failure to achieve hemostasis, CSF leak, or detection and management of epidural abscess or hematoma). Without a clear understanding of the risks and patient selection issues associated with employing these procedures, there is concern in the pain medicine educational community that underqualified practitioners are engaging in these complex therapies, focusing on the technical aspects in absence of a global management vision.
The reading suggestions in each chapter are practical, although there is a general lack of inclusion of negative studies and of evidence based systematic reviews. There are some proofing errors in the text and the table of contents—e.g., “medial branch block” is misspelled as “medical branch block.” The index is complete.
To summarize, this atlas presents some major strengths. The illustrations and graphic images are excellent and quite helpful. The book would have been even more valuable had it included more matter regarding the roles of preprocedural evaluation and safety for patients undergoing pain management related procedures. These would have been beneficial to the practicing clinician, and especially for those learning these procedures and for their patients. The key ingredient of this text is that it provides an interesting method of presenting fluoroscopic images, which anyone performing these procedures will find appealing and useful.