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M A Stiles, S Mitrirattanakul, J J Evans. Oxon: Abingdon, 2007, £55.00 (hardcover), pp 101. ISBN 10-1-84214-253-4
According to the preface, this book is written both “to enhance the knowledge of clinicians who treat patients with trigeminal neuralgia” and “so that patients will be able to read these chapters and increase their knowledge of the treatment options that are available to them”. These rather different aims lead to some uncertainty about how, and at what level, to pitch the writing, a dilemma that is not really resolved.
Few doctors, and no neurologists, need reminding about history taking and other basic tools of the trade set out in the first chapter, “Evaluation of the facial pain patient”. While the occasional patient with facial pain will present diagnostic difficulties, the features of trigeminal neuralgia are often so characteristic as to make diagnosis straightforward. Thus the extensive review of differential diagnoses, ranging from giant cell arteritis to various types of migraine, seems rather laboured. An excellent inclusion, however, is the account of dental pains, an important and relevant subject about which many neurologists are unfamiliar.
When considering the underlying processes, the authors discuss the various causes sometimes identified, and set out well the issues supporting both central and peripheral mechanisms. The authors also reflect on some enduring enigmas, such as how innocuous triggers cause pain—yet only sometimes; and how microvascular decompression might work. But the superficial account of the gate control theory is superfluous, and much of the discussion of various mechanisms subserving pain has nothing to do specifically with trigeminal neuralgia.
The chapters on medical and surgical management are refreshingly practical, realistic and honest. In particular, it is honest to say “The debate regarding surgical versus medical management continues without resolution” and, of drug treatments, “Unfortunately, the clinical trials for trigeminal neuralgia are not robust enough to enable us to fully analyze the usefulness of each medication…” and “With the lack of controlled trials, strong evidence for comparison of compounds is unavailable”. The chapter on surgical management (which includes gamma knife radiosurgery) is particularly clear, and succinctly summarises for non‐surgeons the different procedures available, with details of their benefits and side effects.
This clinical manual, which does not claim to be exhaustive or groundbreaking, gives a useful overview of a serious and usually extremely painful condition. The authors have certainly confirmed how many questions remain about trigeminal neuralgia, and how poor is the evidence base for our attempts at treatment.