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Atlas of Pain Management Injection Techniques

Article  in  BJA British Journal of Anaesthesia · August 2013

DOI: 10.1093/bja/aet264

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British Journal of Anaesthesia 111 (3): 519–21 (2013)
BOOK REVIEWS
The Woman’s Guide to Managing Migraine: Understanding the
Hormone Connection to Find Hope and Wellness. S. Hutchinson
(editor). Published by Oxford University Press. Pp. 243. Price
£13.00. ISBN 978-0-19-974480-0
This is a book for patients, written by a Californian Family Prac-
titioner and Associate Clinical Professor. It was obvious from
first glance that it is packed with anecdotes. I am afraid I
started with a Marvin the Android view that I really was not
going to enjoy this at all. In fact, and to my surprise, I did
enjoy reading it greatly, although not necessarily for the
obvious reasons.
There are many good things to say. The writing style is clear,
lucid, and engaging. Key points are summarized in boxes. The
explanation of the pathophysiology of migraine makes sense
of a confusing condition. The classification of headaches, and
the importance of diagnosis would be comfortingly familiar to
any UK reader acquainted with the current NICE guidelines.
Medication overuse (probably the most common form of head-
ache I see) is given the prominence it deserves. Non-medical
treatments (including homeopathy) are discussed sensibly.
The collaborative approach between patient and practitioner is
praiseworthy and brought out in the author’s comment that
understanding of the condition can ‘help you be a better advo-
cate for yourself’. It is well referenced, and given that this is a
book directed at patients, it is impressive that the author
expects them to have the potential to visit source material.
However, my particular enjoyment in reading the book is in-
extricably entwined with its problems for a UK audience.
George Bernard Shaw reportedly remarked that we and our
American cousins are ‘two countries divided by a common
language’. This book demonstrates splendidly that in fact we
are separated by a vast range of cultural differences, both in
general terms and particularly in the practice of medicine.
I was fascinated to see among the anecdotes that patients’
husbands (remember this is a ‘Woman’s Guide’) might deal
with their spouse’s headache by going off to play beach volley-
ball on their own. I can reliably report that this is a coping strat-
egy that has absolutely never come up in my own clinic in
Swindon (perhaps in Truro or Weston-super-Mare. . .). Similarly,
husbands can go to a tee party; no not Lapsang-Souchong and
cakes, rather golf with your mates.
Some of the differences around medical context are equally
fun; I doubt that many British gynaecologists routinely call
their patients, ‘Honey’; at least not those wishing to stay in
practice for any length of time. Other differences are more
problematic. Drug names of course are different; however,
even when I thought I had caught the gist; Fioricet (butalbi-
tal –acetaminophen –caffeine)—surely that is going to be
one of those odd over the counter combinations related to
co-codamol?—it turns out I was hopelessly wrong. Yes I
knew acetaminophen was paracetamol (although a patient
& The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
might not), but I was shocked to discover that butalbital is
not a weak opioid, it is an addictive barbiturate. In all fairness,
the author is not advocating Fioricet, she is pointing out its
dangers. However, I was taken aback at the recommendation
that a home supply of injectable strong opioids is worth consid-
ering. Of course, context is all, and my point is less that these
ideas are absolutely wrong; they may be reasonable in the
context of Californian healthcare (although I would need to
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be convinced about the availability of an addictive barbiturate),
they are not translatable to the UK.
So in conclusion, I really did enjoy this book. It is an excellent
overview of migraine, particularly in the context of fluctuating
hormonal levels. It is also a fascinating text about cultural dif-
ferences. But it is not really a book that is going to appeal to a UK
doctor. It might be a book for the already well-informed patient
wanting to extend her knowledge; it would be utterly perfect if
she already had a background in cross-cultural studies and a
degree in pharmacology.
M. O’Connor
Swindon, UK
E-mail: mike.oconnor@btinternet.com
doi:10.1093/bja/aet263
Atlas of Pain Management Injection Techniques. S. D. Waldman
(editor). Published by Elsevier. Pp. 506. Price £130.00. ISBN
978-1-4377-3793-6.
Most of us who practice interventional pain management will
own a copy of one of the many and usually very excellent pro-
cedural ‘bibles’. Whether to brush up on a seldom performed
procedure, to learn something new, or simply to reassure your-
self that you are performing a particular intervention correctly,
these books are invaluable.
Waldman is the author of perhaps the most respected and
admired of the ‘bibles’—the Atlas of Interventional Pain Man-
agement, described in a previous review in this journal as a
work of ‘genius’ and a ‘pain specialist’s essential’.
Having owned two editions of the Atlas of Interventional
Pain Management, I would attest to this. It is nothing short of
perfection. A fantastic, detailed account of every image-guided
pain clinic injection procedure you are ever likely to need.
So why would we need the Atlas of Pain Management In-
jection Techniques? What void is there left to fill?
Waldman clearly believes that there is such a void—and
a pretty big one, too (506 pages and free online access to
ExpertConsult.com to be exact).
You only need look at the contents page though, to realize
that this book is filling a niche. It is a compendium of injection
procedures that might be performed in the outpatient clinic
BJA
rather than in an operating theatre with access to fluoroscopy
or CT.
There are 159 such injection procedures described. Some
will be familiar (intraarticular injection of the shoulder, oc-
cipital nerve block, suprascapular nerve block) but most
very unfamiliar (styloid process injection, Injection tech-
nique for Anconeus Syndrome, sesamoid joint injection of
the hand).
Of the 159 procedures described, I estimate that in my prac-
tice I have performed, or imagine I would ever need to perform,
less than a dozen. Of the familiar procedures such as injection
of the sacroiliac and sacro-coccygeal joint or the trigeminal
nerve, the reader is presented with an injection technique
based on surface anatomy and the use of anatomical land-
marks. I would argue that the use of image guidance for proce-
dures like this is mandatory.
In terms of the content then, for a sports medicine phys-
ician or perhaps a rheumatologist, this would be a useful ref-
erence book. Many of the conditions described would no
doubt be found in any sports injury clinic where injections of
local anaesthetic and steroid may help an acute injury. As a
reference for the pain physician, I fear only a fraction of this
book would be of value.
I do not wish to be too disparaging—if outpatient-based
joint and muscle injections (and the occasional nerve block)
are part of your regular practice or you intend them to be,
then there is much to admire here.
The book is clearly laid out and divided into eight anatomic
sections. Each procedure is described in terms of the indica-
tions and clinical considerations, clinically relevant anatomy,
technique, and side-effects and complications. Most proce-
dures have an accompanying ‘clinical pearl’.
Waldman writes with his usual clarity and if all you wanted
from this book was an excellent overview of some common and
not so common musculoskeletal pain conditions then you
would need look no further.
X-ray and MRI scan images where applicable are used to ac-
company the text and the plentiful illustrations are nothing
short of beautiful.
This is the third edition of the book and now includes, where
relevant but often a little too briefly described, ultrasound-
guided injection techniques.
Some of the sections, particularly those where a muscular
injection technique is described might have benefited from
some judicious editing. When describing a particular condition,
large swathes of text (the description of myofascial pain and
trigger points—some 500 words) are repeated verbatim. This
is also apparent when reading some of the ‘Side Effects and
Complications’ sections and because of this, the statements are
nonsensical. For example, the description of an injection to the
triceps and biceps muscle is followed by a warning that ‘the prox-
imity of the spinal cord and exiting cervical nerve roots makes it
imperative that this procedure be carried out only by those well
versed in regional anatomy’ and that ‘given the proximity of the
brain and brainstem, ataxia caused by vascular uptake of local
anaesthetic is not an uncommon occurrence’. A minor irritation
in an otherwise excellently written book.
520
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Book reviews
So, well written, well laid out, and beautifully illustrated.
Does the Atlas of Pain Management Injection Techniques deserve
to take pride of place on your reference bookshelf? Will it be
one of your procedural ‘bibles’?
Sadly, and for the jobbing interventional pain physician, I do
not think so. Save your money and buy his other book.
S. Ward
Sussex, UK
E-mail: spslward@gmail.com
doi:10.1093/bja/aet264
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Physics in Anaesthesia. B. Middleton, J. Phillips, R. Thomas and
S. Stacey (editors). Published by Scion Publishing Ltd. Pp. 306.
Price £28.99. ISBN 978-1-904842-98-9.
This textbook is true to its name. It describes physics that apply
to anaesthesia. This is a very wide brief, but the book copes with
this very well in a relatively small package. The size of the book
inevitably means that there are a few areas that could be more
fully dealt with as described below, but overall it is a very effect-
ive text. The initial chapters cover the basic physics of atoms,
simple mechanics, energy and power, temperature and heat,
waves, and pressure. These are all easily understandable with
an appropriate level of simple supporting equations and ex-
planation. Definitions are highlighted in summary boxes, al-
though sometimes these are expressed in terms that are
perhaps too simple, but generally are very helpful. Diagrams
such as the series showing work done by a ventilator vs work
done in the lung are a useful sequence.
Considering waves, the differences between sound and
electromagnetic waves are well described, together with an
interesting section summarizing harmonic series and Fourier
analysis. Worked examples are helpful, for example, delivery
of pressure from different sized syringes with the same force
applied to the plunger. The chapter goes on to describe the
applications of pressure to valves and measuring devices in
anaesthesia and usefully the implications of siphon effects.
Humidity, flows, and their measurement are well dealt with,
together with the effects we see in different systems such as
Venturi and Coanda. The properties of gases and the related
gas laws are summarized. Osmosis and areas regarding, iso-
tonic, hypertonic, and hypotonic solutions could have usefully
been expanded or better defined. The book deals with mea-
suring gases and vapours, including the Clark, Sanz, and Sever-
inghaus electrodes, then goes on to delivering vapours via
vaporizers, summarizing the principles involved, medical gas
supplies including cylinder design, and the behaviour
of gases that liquefy in a cylinder. This is followed by breathing
systems including the Mapleson classification and CO2 re-
moval. Unfortunately, modes of ventilation were a disappoint-
ing section, which perhaps was not strictly relevant to this
text, although the physics of flow in, for example, high-
frequency oscillation might be more in keeping with the
ethos of the book. Basics of electricity were well covered, as