Atlas of Spine Injection. By Donald Renfrew, M.D. Philadelphia, WB Saunders, 2004. Pages: 240. Price: $99.00.

This is the second publication by Donald Renfrew, M.D., following closely on the heels of his first book, “Atlas of Spine Imaging.” The latter has already found an important niche in the ever-developing field of radiologic imaging. It is refreshing in this age of multiauthor texts to review what is essentially a single-author book, one that can either be read from cover to cover or used as a reference source describing injection techniques.

Each chapter is constructed in a similar format, with definition followed by literature review, rationale for procedure, equipment and supplies, informed consent issues, patient selection, and description of the particular procedure. In addition, evidence-based criteria to support the different procedures that are described in this book are provided when available. With the exception of the longer chapter about epidural injection, each chapter is of approximately the same length, commencing with a review of spinal pain, followed by nerve root blocks, sacroiliac joint injections, facet joint procedures, discography, percutaneous needle biopsy, vertebroplasty and kyphoplasty, intradiscal electrothermal annuloplasty, and myelography. Two useful appendices complete the text.

The first chapter, although concise, covers a history of spinal pain and adequately lays the foundations for the use of the different diagnostic and therapeutic injections described in the book. Also important to the subsequent chapters is a final section in this chapter discussing the rhetoric of back pain in which the author discusses the placebo effect. This is brief and to the point, but conforms to Aristotle’s definition of rhetoric as “the faculty or skill of discovery of the available means of persuasion in a given case.” This introductory chapter should be read first by those who use this book as a reference source.

It is interesting that a radiologist should devote a considerable amount of time to epidural steroid injection, a technique mostly performed by anesthesiologists. An excellent discussion of the debate for the past 20 yr surrounding the efficacy of epidural steroid injection provides the reader with a critical rationale for this procedure. Indications for interlaminar versus  transforaminal injection are provided. The chapter is profusely illustrated with radiographs, computerized tomography images, and magnetic resonance images. Characteristic of this chapter (and the rest of the book) are extensive legends that walk the reader through the nuances of each image.

A case for nerve root block is placed squarely in the context of modern imaging techniques and recent understanding of pathophysiology. In fact, as suggested by the author, this procedure should perhaps be called a “transforaminal epidural steroid injection.” Chapters 4 and 5, describing sacroiliac joint and zygapophyseal joint injections, together occupy 30 pages. Intraarticular injection or block of the nerve supply to a joint is perhaps the best way of demonstrating whether pain is arising in the particular joint. However, caution in this simplistic approach is illustrated by the author to consider also synovial cyst and pars interarticularis defects as other sources of anterior or posterior compartment spinal pain. The literature is more than adequate, and the author admonishes the would-be interventionalist to recognize the many possible sources of spinal pain and the need to repeat the injection on more than one occasion. The illustrations and detailed legends again augment the usefulness of this text.

Perhaps no diagnostic technique for spinal pain engenders more controversy than discography, as nicely reviewed in chapter 6. Some of the best illustrations in this atlas demonstrate how computerized tomography in conjunction with discography can aid in the demonstration of ancillary pathology. The reader is provided with an excellent description and guide to the interpretation of discography.

Chapter 7, which describes percutaneous needle biopsy, is concise, technically important, and a good lead into the chapters about treatment that describe vertebroplasty, kyphoplasty, and intradiscal electrothermal annuloplasty. As a new and relatively restrictive intervention for patients with osteoporotic vertebral collapse, malignancy of the spine, and vertebral angiomas, vertebroplasty and kyphoplasty have enjoyed recent popularity for this type of axial spinal pain. As pointed out by the author, although percutaneous vertebroplasty with polymethyl methacrylate was introduced in 1984 by Galiburt and Deramond, its recent application has a literature dating only from 1998. Although the technique is extremely well described in a step-by-step fashion, adequately supported by excellent radiographs, and could well prepare interventionalists who are new to the technique, this reviewer suggests good mentoring and a visit to the anatomy laboratory before soloing on the procedure.

The last chapter, about myelography, is a welcome inclusion to an atlas of mostly therapeutic techniques. In fact, understanding myelography helps immensely in the interpretation of other spinal injection techniques. Two valuable appendices are included. The first addresses aspects such as choice of needle (e.g. , Quincke vs.  Sprotte), contrast material, and choice of medications for diagnosis and treatment. The second answers rhetorical questions such as, “Does the patient have any symptoms to suggest neurologic compromise?,”“Does the patient have symptoms to suggest an infection?,”“Does the patient have a postprocedure headache?,”“Does the patient have a pain flare from a procedure?,” and “Does the patient have steroid side effects?”

It is enjoyable to read a book that is not only well written but also addresses interventions in a nondenominational fashion. This text is of value for novices, experienced clinicians, and educators and should be included in medical libraries as a reference source.

The Cleveland Clinic Foundation, Cleveland, Ohio.