UNDERSTANDING DEMENTIA. A PRIMER OF DIAGNOSIS AND MANAGEMENT . 2001. By Rockwood Kenneth and MacKnight Chris . Published By Pottersfield Press Ltd. 194 pages. C$30.00 approx

Volume 29, No. 1 – February 2002 105 ago. The pearls and pitfalls were interesting in that they detailed many of the important philosophies learned during residency and practice, but omitted or buried in standard textbooks. What I disliked about this book: While histories are usually complete, physical examinations as presented can be unfocused and incomplete, particularly with respect to neurological details. There is a wide variation in operative descriptions: in some cases the contributors have tried to present finer details about operative techniques; in some cases the operative details read like a pre-dictated operative note; and finally in others no operative details are provided at all. It is not clear to me what the principle authors wished to achieve in this regard. Clinical decision-making, particularly for complex problems, relies very heavily on personal judgment. It is inherently risky to present a large number of cases in textbook format, not subjected to peer-review. Odds are that at least a few of the cases are not going to be as illustrative as the authors had hoped. For example: Case 1 – Axial Neck Pain: Nonoperative Approach. The MRI, obtained within the first week of symptoms, details a relatively large midline C4/5 disc herniation with quite obvious spinal cord compression. Physical examination showed mildly weak elbow flexion with a diminished biceps jerk. Diagnoses of cervical sprain and strain, myofascial pain, and a C5 radiculopathy were made. The Masters elected to treat conservatively with a cervical pillow. No mention of follow-up was given. In my experience, anyone with spinal cord compression bears close follow-up. In addition, impaired biceps function with a diminished deep tendon reflex most often is associated with a C5/6 disc herniation in my experience. Typically the herniation is lateral, not central. Case 2 – Whiplash Injuries: Nonoperative Approach. The “Masters” review pertinent radiographic findings and conclude that there was no evidence of pathological cervical subluxation. Unfortunately, the neutral lateral cervical spine x-ray depicted in Figure 1 shows a suspicious kyphotic deformity centred at C5/6. It is not so surprising to find bilateral perched facets at C5/6 posteriorly as well as a widened interspinous distance on closer inspection of the same film. Flexion and extension views are not provided, but clearly this case is highly suspicious for occult i n s t a b i l i t y. Misdiagnosis in such a setting could constitute malpractice. Case 6 – Cervical Spondylosis – Myelopathy: Posterior Approach. The MR sequence depicts buckling of the ligamentum flavum from C4-C6 in the presence of maintained cervical lordosis. Postoperative films show an instrumented fusion from C2-T1, potentially incorporating four more motion segments than necessary. The “Masters” do not discuss the need for such an extensive approach, nor do they acknowledge the benefits / risks of a shorter construct. Case 19 – Intradural Disc Herniation – Lumbar Spine. A preoperative sagittal MR shows what might be a huge intradural disc herniation. Although surgery is proposed as the treatment of choice in symptomatic patients, no details are presented about the surgical techniques and pitfalls. Formal intradural excision is not acknowledged causing the more experienced reader to at least wonder about the “Master ’s” experience with this particular type of lesion. Case 35 – Spinal Cord Injury: Pharmacological and Nonoperative Management. Because of my own personal interests I couldn’t help but to look closely at this case. I wasn’t totally surprised to learn that the presenting clinician championed methylprednisolone according to NASCIS III guidelines. The usual theories on lipid peroxidation were also well-represented. However it was somewhat embarrassing to read what (in addition to steroids) had become a standard of care in this “Master’s” mind, presented in tabular form at the end of the chapter. Clearly an objective evidencebased approach would have been more helpful to the average reader, and far more valuable as an educational tool. Summary This is one of the most thorough collections of Class III evidence pertaining to the human spine that I have come across. As such it provides an interesting read of anecdotal experience, but falls far short of achieving reference text quality. Dr. Garfin quotes Oliver William Holmes in the Foreword as saying “the bedside is always the true center of medical teaching”. I couldn’t agree more. Despite honorable intent, Vaccaro and Albert serve to provide only a highly filtered imitation of such a learning process, predictably denying the reader of the spontaneity and interactivity of the real experience. I believe this book will be most valuable to the Orthopedic or Neurosurgical resident whose training program provides limited access to outpatient clinics and the operating room.