Pain, 11 (1981) 291--292 Elsevier/North-Holland Biomedical Press

Book Review

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Clinics in Rheumatic Diseases, Low Back Pain, R. Grahame (Ed.), Saunders, Philadelphia, Pa., 1980, £10.00.

Readers of Pain will need no reminding of the importance of chronic back pain, in the community nor of the formidable problems attendant on its management.

This new publication in a well known and much respected series brings the reader up to date with modem ideas in the causation and management of chronic back pain. Eighty thousand patients a day are impaired as a result of low back pain, and several authors highlight the fact that in most patients with chronic back pain it is not possible to make a specific diagnosis. A thoughtful chapter on occupational aspects of low back pain (J.A.D. Anderson) draws attention to the relation of various occupations to the incidence of back ache but concludes that pre-employment medical exami- nation and screaming is of doubtful value for the prevention of back pain. There is an interesting chapter by G.B.J. Anderson on bio-mechanics, but it is a little disappointing to find no discussion of the specific roles of the various spinal muscles in particular the abdominal and extensors of the s p i n e - because many treatment regimes insist on the importance of good abdominal muscle and extensor muscle function. There is an excellent chapter on psycho- social and low back pain (Sidney Crown) which is an extensive review of the relevant literature. The author concludes that there is no relation between pain and personality but that there is a high frequency of psychiatric morbidity in patients with persistent low back pain. He urges doctors con- cerned with such patients to take a history related to mood and somatic disturbances. He concludes that the most convincing link in this field between psychological factors and back pain is in the perpetuation of back pain and the negative response to treatment. There is a most useful section giving advice, to doctors managing back problems, in how to assess whether psychiatric factors are relevant. There is an excellent chapter on the place of radiology (W.M. Park) and investigation of low back pain and a clear statement is made which needs to be appreciated far more widely that the standard X-ray~ of the lumbar spine has little to offer in screening patients with non-specific back ache and that an ESR offers far more valuable infor- mation. The authors are quite enthusiastic about discography and find it most useful in patients with hip, leg or back pain but without focal weakness, reflex changes or cross referral of pain on straight leg raising and with a negative radicutogram.

In discussin6~ surgical management Park states that it is clear that the most successful result would be expected from a single definitive surgical procedure and this therefore demands careful selection of the patient and the use of the most appropriate operation and in his chapter Hamblem gives

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a very clear picture of the various operations available and their indications. A strong plea is made by John O'Brien for multidisciplinary approach

to pain disorders. He points out that there is 30% recurrence of symptoms after surgery and a 10% incidence of further operations. He gives a very good picture of the rake's progress as it were in a patient with chronic low back pain, and the various travails that he may encounter before ending up with chronic intractable pain and sciatica that is totally unresponsive to any form of treatment. He makes a plea for a spinal referral centre where a multi- disciplinary approach is possible. Your reviewers experience of a similar organisation at his hospital amply bears out the importance of this approach. One particular specialty is quite unable to handle the many problems involved in chronic low back pain.

The editor Rcidney Grahame presents a wise and considered critique of clinical trials and reviews the various published trials on the value of epidural injections, traction, the use of Chymoral, manipulation and exe rc i s e s - this is a most useful chapter bringing together a large number of reports, scattered throughout the literature. He concludes that there is little evidence to show that even the few adequate studies carried out in this field, had really changed medical practice.

In general, readers of Pain will find this a useful book to bring themselves up-to-date ill this difficult field. However, if there are to be future editions your reviewer would welcome a section on how to assess and manage the so- called failed back. There are too many patients attending rheumatological, orthopaedic and even psychiatric clinics who have had multiple surgery on the back and for whom no further operative treatment is indicated. One tries the fuli panoply of treatments including electrical stimulation, acupunc- ture, physiotherapy, epidurals, manipulations, behavioural conditioning and alteration of jobs and so on, with disappointing lack of success. It would be nice to hear from someone who has had a lot of experience of this type of problem as to how best to approach these patients and what one can expect from what type of treatment programme.

Finally, practically no mention is made of the value of electromyography in diagnosis of root involvement in the difficult chronic back pain. There are several reports in the literature indicating that this relatively straight- forward investigation can be often of crucial importance in deciding that there is an organic problem and which root is involved.

Dr. Grahame is to be congratulated on bringing together so many experts to give a thoughtful and helpful compendium of information in this difficult field.

C.B. Wynn-Parry Royal National Orthopaedic Hospital,

Gt. Portland Street, London W1 (Great Britain)