The Neurological Basis of Pain

McGraw-Hill invited Dr. Pappagallo to edit this book as a companion to Adams & Victor’s Principles of Neurology (1). Dr. Pappagallo set out “to create a text that would command the respect of neurologists.” He also hoped “a variety” of other “professionals” would “benefit from it.” He has achieved his goals and deserves congratulations.

The book is arranged in four parts dealing, respectively, with the scientific basis of pain, physician-patient issues, the syndromes and disorders, and, finally, the therapies. Naturally, when multiple authors deal with overlapping topics, there is some repetition, but it is only of important points and does not distract from this monumental work.

There are 46 chapters by 76 authors. Fifty-four are medically trained, and 20 of these appear to be attached to neurology and 13 to anesthesiology departments. About nine appear to be surgeons, and two seem to be psychiatrists.

The culture, practice, and structure of medicine is rapidly changing. Pain medicine is a prime example. As Dr. Portenoy points out in the foreword, pain was once considered as a symptom of disease but has recently been conceptualized as a disease itself. Thus, there are many applicants for this essentially vacant property. The Neurological Basis of Pain stakes a claim for the neurologists. In much of the United Kingdom, Europe, and Australia, the anesthetists are the main contenders, but pain management is achieving adulthood and is in the process separating. About seven authors of this book list their attachment to a pain management unit, with no hint of subservience to neurology, anesthesiology, or other parental discipline.

During the maturation period of the last 50 years, pain medicine has been giving two messages: 1) pain needs special, separate consideration, and 2) pain is complex and requires contributions from diverse fields, not only neurology, anesthesiology, and surgery but also pharmacology, psychology, and physical therapy, among others.

The multidisciplinary approach of the book gives a voice to all. The only irritating chapter (which deals with physical therapy) rails against “traditional-thinking clinicians entrenched in a narrow, structurally focused biomedical (impairment) model” and recommends a “patient-centered biopsychosocial model.” This is a bit hard to take because it is many decades since Dr. George Engel (2) provided the concept and label of the biopsychosocial approach, in which medicine is now well marinated.

In chapter 15, Hord and colleagues state, “Chronic pain is the result of plastic changes in the peripheral and/or central nervous systems induced by injury or dysfunction in the nervous system.” Although this is a generalization and there is little doubt that inflammation can result in chronic pain relatively independent of change within the nervous system, it is probably correct that most of the patients treated in chronic pain units have neuropathic pain.

The Neurological Basis of Pain provides the latest thinking and practice in the field and helps the reader grasp much of the vast biology of neuroplasticity, the basis of neuropathic pain. Focusing on symptoms and etiology has not provided a method of intervention, however; similar symptoms may arise from different etiologies, and the same etiology may be associated with a range of symptoms. Thus, research is progressing to describe the underlying mechanisms and the means by which they can be clinically identified and managed. Dr. Portenoy, in the foreword, states that the development of new drugs and other treatments “holds the promise of true mechanism-based therapy.” Thus, the wheel may turn again and the biopsychosocial approach may become redundant.

There is a dearth of psychiatrists among the authors, but psychologists are well represented. This reflects real-world pain management, although psychiatrists have much to offer this field, and the work is rewarding. In a chapter on spinal pain, Wheeler and Murrey state that training should be made available to neurologists and psychiatrists so they can establish “competence in using electrodiagnostic skills for diagnosis and performing spinal interventional treatments with spinal injections.” I hope this comes to pass.

The Neurological Basis of Pain is a magnificent contribution to pain management. It has the combination of readability and scholarship that will make it a classic. It should be in every medical library and on the shelf of everyone with a serious interest in pain medicine.