A Singular Source of Contemporary Information on Pain Management

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The fourth edition of Raj's Practical Management of Pain continues to upgrade and expand what is widely regarded as a definitive standard for textbooks in the field of pain management. As the specialty itself rapidly changes, it becomes more difficult to consolidate the plethora of evolving knowledge into an easily accessible reference. Yet, this new textbook seems to have met that challenge. Intended initially in 1986 by Raj to be “a resource for a pain trainee who had one year to learn everything about pain management,” the scope of this new text has been broadened by the inclusion of input from a multidisciplinary group of distinguished experts. The stated goal of this edition is to serve “pain clinicians looking for application in their daily practice, pain researchers seeking adequate background on relevant topics, fellows reviewing for the pain boards, and residents who want a complete discussion of the breadth of the field.” This text achieves these lofty goals in admirable fashion.

The book is divided into nine sections, each part containing a varied number of chapters. For ease of indexing, color coding has been added to the top of each page, which is referenced to the Contents listings. Each chapter is essentially self-contained and logically organized. The text is easy to follow and accompanied by a sufficient number of figures, images, and tables, which are not mere duplicates of the text but serve to illustrate and illuminate. Many will be excellent slides for lecture presentations given their clarity and precision. At the end of each chapter is a summary and/or conclusion section, which highlights the salient points of the text.

Part I, General Considerations, serves as a resource for understanding the logistical issues that accompany the practice of pain management, including taxonomy, organization, and development of a practice; health care policy legislation, which overarches our professional activity and reimbursement; and the evolution of the education/training/certification process. Part II, Basic Considerations, focuses on the basic science foundation of pain as it is currently understood and includes neuroanatomy, physiology, and neuropharmacology. This section is well referenced and effectively ordered, making difficult and sometimes overwhelming subjects manageable on an instructional level.

Part III, Evaluation and Assessment, reviews the essentials of physical examination, neurophysiologic testing, radiological assessment, and psychological evaluation. The information in this section is vital to the all-important appraisal of the patient with pain, as only from a thorough and comprehensive assessment can a diagnosis be determined and an appropriate therapeutic plan created. Part IV, Clinical Conditions, is the largest section of the book, as it covers a broad scope of commonly encountered pain conditions, ranging from postoperative conditions and low back pain to the harder-to-find management of pain during pregnancy and lactation. Within each chapter, epidemiology, pathophysiology, treatment, and outcomes are discussed. Clinical studies are referenced throughout and, when available, current practice standards are outlined. Part V continues the treatment theme by presenting pharmacologic, psychological, and physical modalities. The provided information covers the major pharmaceutical classes used in pain management as well as contemporary psychological and physical therapy interventions, including acupuncture. Other non-Western forms of treatment are not covered. At the end of this section, there is a chapter dealing with the challenges and opportunities presented by patients with addictive disorders.

Part VI, Nerve Block Techniques, includes chapters appropriately divided by anatomical region, followed by information regarding neuraxial anesthesia, neurolysis in the sympathetic nervous system, intrathecal drug delivery, and intra-articular analgesia. These chapters include relevant color and corresponding fluoroscopic images, which contribute mightily to the learning experience. Although the individual nerve block sections are inadequate for a clinician who is unfamiliar with the basics of a technique, the text serves very effectively as an efficient review. Each section includes adequate references if more detailed information is desired. Interventional Techniques are presented in Part VII. This section includes a chapter dedicated to spinal cord and peripheral nerve stimulation therapy. Also included is a chapter on intradiscal procedures and contemporary minimally invasive procedures for vertebral compression fracture repair. The chapters cover the fundamental techniques as well as the indications, complications, and evidence basis for the treatments.

Part VIII, Pain Management in Special Situations and Special Topics, covers varied subjects that do not fit easily elsewhere. Included here are discussions of palliative care, the emergency department management of pain, as well as radiation safety and the proper use of radiologic contrast agents. Consideration of pain management in the patient's home environment is a futuristic addition. The final section, Part IX, addresses the vital topic of outcomes. It provides an easily referenced and academically critical source for current studies that support or refute the value of some of the most commonly practiced interventions, the medications most often prescribed and surgical procedures used in pain management. The necessary commentary about efficacy and complications of pain management techniques is telling. Appendices at the end of the text include a list of Current Procedural Terminology codes for routine treatments and International Classifications of Diseases - 9th revision codes that are routinely used, as well as a patient evaluation and management template and a list of useful websites for journals and professional societies.

The undertaking and stated mission of Raj's Practical Management of Pain is one of enormous ambition. The text continues to set a high mark toward which other pain management textbooks should aspire. Because it is intended to be a one-book-covers-it-all text, there is some overlap of material but this serves only to reinforce the relevance of the concepts and information. The quality and extent of the referencing for the reader who wants more detail is a noteworthy feature of the text. The organization and ease of use one encounters with this textbook makes it an excellent choice for those across the disciplines involved in pain medicine who are looking to possess a singular source of contemporary information relevant to the field of pain management.