The second edition of this comprehensive work on the adult spine is an excellent treatise that places pathology, diagnosis, and treatment in the milieu of the economic, social, and disability-related issues surrounding spinal disorders. In tune with contemporary themes, the opening chapters address quality of care as well as the use of algorithms to ensure consistency of treatment and, it is hoped, of outcomes. Discussions on the development and use of databases and the design of clinical research programs precede consideration of pathology and treatment. A discussion of the impact of insurance issues, disability determinations, and litigation on subjective reports of pain by patients leads into a description of the methods of objective documentation of impairment. A carefully crafted chapter reviews numerous psychological testing instruments and discusses the problem of chronic back pain and its treatment in multidisciplinary pain centers. The experienced authors do not take the opportunity to address the role of behavioral specialists in the preoperative assessment of patients who are candidates for operative treatment, and perhaps more attention could have been given to patient selection in a multidisciplinary setting.
The author of the section on the use of invasive electrical stimulation for the treatment of chronic pain was hampered by a paucity of series with five-year follow-up in the international literature. Although the technique is described as promising, the reader is left with no sense of its lasting utility.
The chapters on imaging are comprehensive and clear. The excellence of the illustrations is matched by the in-depth assessment of the limitations and optimum use of each modality. The chapter on sensitivity and specificity draws attention to the fact that imaging studies often reveal unexpected structural changes in the spine, such as stenosis and foraminal osteophytes. Such a plethora of information may make it difficult to correlate the images with the patient's symptoms. A well written, well illustrated overview of invasive techniques of pain provocation (such as discography) and of analgesic block (such as nerve-root injection) makes it clear that such modalities have a real place in establishing the clinical importance of radiographic abnormalities. One omission in this section is the absence of any reference to either diagnostic or therapeutic injections of the sacroiliac joint. Also, although injections of the facet joints are described briefly, arthrography is not linked to methods of ablation of the medial branch of the dorsal ramus to the facet joint.
The four sections on regional anatomy are superbly illustrated; of particular note is the section on the lumbar spine, which incorporates cryosections made by Wolfgang Rauschning. Detailed diagnostic criteria precede the description of each form of non-operative treatment. The various types of operative treatment then are presented, from minimally invasive microdiscectomy and endoscopic bone-grafting to extensive decompression and circumferential arthrodesis. I believe that there may be a place for a chapter on postoperative management. Diet, level of activity, bracing, and the use of pulsed electromagnetic-field stimulation are neglected. In order to reduce the number of failures of operative treatment, it is necessary to steer patients, after such treatment, to a successful outcome.
Over-all, this is a wonderful account of the adult spine. Gifted specialists have contributed chapters covering the entire field, and the quality of the writing and illustrations is superb. The bibliographies at the end of the chapters are exhaustive and up-to-date. Frymoyer and his associates are to be congratulated for their fine work.
Arnold Graham Smith, M.D., F.R.C.S.
Jacksonville, Florida