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Pain in peripheral nerve diseases
  1. Michael Donaghy

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    Edited by C Sommer (Pp 202, US$170.50). Published by Karger, Basel, 2001. ISBN 3-8055-7268-9

    Despite having a subspeciality interest in peripheral nerve disease, often I am perplexed by patients with neuropathic pain. Yet pain is a leading symptom of neuropathy, and the ability to manage it is essential to the compleat neurologist. So I was delighted to have the opportunity to improve my own understanding of neuropathic pain from this volume edited by Claudia Sommer. Her experience in linking clinical and experimental aspects of pain is a welcome thread running throughout this volume.

    We are reminded that so much of our knowledge of neuropathic pain phenomena derives from American Civil War nerve injuries studied so carefully by Weir-Mitchell. Pain pathways are dealt with pragmatically in standard anatomical and physiological terms. Gate control theory is not even listed in the index, allowing simple thought about the self evident modulation of pain transmission and perception. Cytokines receive welcome attention; if tumour necrosis factor is not a fundamental cause of pain, it may mediate the nerve injury resulting in a pain state.

    The various terms used to describe painful phenomena are covered succinctly, and pain rating scales are introduced. The chapter on mononeuropathies lacks extensive coverage of the newly introduced terms ‘CRPS I and II’ (complex regional pain syndrome). Many use these terms now to replace reflex sympathetic dystrophy and causalgia because of uncertainties about the part played by the autonomic nervous system in generating the former of these two chronic pain states. Those polyneuropathies responsible for neuropathic pain, and conversely analgesia, are covered extensively and will be of particular value to non-neurologists who manage pain. Hereditary motor and sensory neuropathy uncommonly causes pain and merits less attention. More attention could have been given to the awful burning foot syndrome that can occur in nutritional neuropathies or to the vexatious question of differentiating pain due to the neuropathy of HIV from that caused by antiviral drugs. Morphometric differences underlying the hereditary sensory and autonomic neuropathies provide an interesting perspective on the anatomical transmission of pain and would have merited more systematic coverage.

    Neurologists should read Sommer’s excellent chapter on the treatment of neuropathic pain. The useful information about the number you need to treat so as to relieve pain satisfactorily in one patient endorses our use of anticonvulsant drugs, sodium channel blockers, tricyclic antidepressants, and dextromethorphan. Mexiletine, gabapentin, and lamotrigine are useful in resistant states. Dr Sommer’s personal experience shows through strongly in this chapter, which culminates in a useful algorithm. This will be a useful book for pain clinicians and in libraries, despite a swingeing price for only 202 pages.

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