Atlas of Interventional Pain Management, 2ndEdition.  By Steven D. Waldman. Philadelphia, WB Saunders, 2004. ISBN: 0721601081. Pages: 642. Price: $195.

First published in 1998, the Atlas of Interventional Pain Management  quickly became popular with anesthesiology residents, fellows in pain medicine, and practicing clinicians who were adapting to this rapidly evolving field. At that time, there were very few single references available that demonstrated clinically relevant techniques of interest to the practicing regional anesthesiologist as well as the practicing pain clinic physician.

In this new edition, Dr. Waldman states in the Preface that he has tried to update each section to demonstrate the most contemporary approaches to interventional pain management. For example, radiofrequency techniques have been emphasized for neurolysis reflecting the belief that these techniques are perhaps safer and more effective. The Second edition has also added a large number of new fluoroscopic imaging figures and color drawings. There are 129 chapters, each devoted to a specific intervention. Each chapter has the 2003 CPT codes for the detailed procedure, as well as the relative value units for that procedure. The chapters follow a logical sequence with Indications, Clinically Relevant Anatomy, Technique, Side Effects and Complications, Figures demonstrating the technique, and a “Clinical Pearls” section.

In general, the pictures are colorful, but often do not seem to help one orient to the nuances of the underlying anatomy. Many of the computed tomographic or fluoroscopic images are dark and hard to visualize. Further, there are many instances in which the figures are inaccurate or misleading. For example, one of the new chapters, entitled “Lumbar Epidural Nerve Block: Transforaminal Approach” discusses contrast flowing “…proximally around the pedicle into the epidural space” and references a figure. Unfortunately, there is no obvious contrast flow depicted in any of the pictures in that chapter. Another new addition, “Lumbar Selective Spinal Nerve Block,” discusses the technique by making the analogy of pedicle as a clock face and asks the reader to align the fluoro beam to visualize the 4:00 position on the right side or 8:00 position on the left. The figure, however, demonstrates the 4:00 position on the left side. After discussing the selective diagnostic role for this injection, the fluoroscopic image in figure 81–5 shows a nonselective transforaminal epidural injection with contrast clearly seen flowing medially into the epidural space and outlining at least two vertebral segments in the lateral epidural space. In another chapter describing the psoas compartment technique for lumbar plexus nerve block, figure 97–2 appears to show the needle entry site over the sacral alae, which would not seem to be an appropriate location to reach the L4–5 paravertebral area. Several other examples of confusing figures could be cited; these lessen the overall appeal of this book.

In his efforts to be inclusive, the author has included many procedures for which the body of literature support is scanty, at best. For example, the most extensive referenced article validating the Ganglion Impar block is a case series abstract. The author describes a “blind technique” for this procedure, followed by a discussion of computed tomographic guided neurolysis. It seems to make little sense that with the proximity of the rectum, the author would proscribe such wide variations in acceptable technique for such a poorly validated procedure. Most of the Clinical Pearls sections suggest an ease of performing the procedures and dramatic results that are not consistent with the clinical experience of many. For example, the chapter describing the classic superior hypogastric plexus block states that “…hypogastric plexus block is a simple technique that can produce dramatic relief.” Any technique that can involve injury to the iliac vessels, L5–S1 disc, or viscera can hardly be characterized as simple. Further, there is no discussion of the effect of extensive retroperitoneal tumor spread and the effects of this on spread of the neurolytic or efficacy of neurolysis.

The main strengths of this book are its inclusion of a large number of procedures and the sections on relevant anatomy. However, this text leaves much to be desired as a guide for residents, fellows, or anyone who does not have a detailed knowledge of the pain literature. Without the inclusion of pertinent references, or at least suggested readings at the conclusion of each chapter, the reader has no basis on which to judge whether the recommendations made by the author are supported by existing evidence or not. Although clinical experience can certainly vary and supporting literature is often scanty, in my opinion the author is consistently overly optimistic regarding the efficacy of procedures and consistently downplays possible risks. When this lack of attention to evidence-based practice is combined with misleading figures and simplistic pictures, one is left with a book that may be of real utility only for clinicians learning these block techniques who desire a quick bookshelf reference that contains most of the contemporary procedures and CPT codes. A book that combines attention to evidence-based practice with consistent graphical excellence is still sorely needed.

Mayo Clinic College of Medicine, Rochester, Minnesota.