CORRESPONDENCE 307

pRE-OPERATIVE CERVICAL SPINE RADIOGRAPHY IN RHEUMATOID ARTHRITIS

Sin - It is with interest that we read the article 'A continuing role for pre-operative cervical spine radiography in rhematoid arthritis' [1]. As trainee anaesthetists we would value the opportunity to comment.

Whilst it is true that airway patency can usually be maintained with the use of a laryngeal mask airway (LMA) or facemask plus oral airway without excessive neck extension, this is not always the case. In some patients, LMA insertion may be difficult and, in inexperienced hands, may involve degrees of neck extension comparable to those employed during laryngoscopy. Once sited, the seal obtained may be inadequate thus necessitating tracheal intubation. In some patients and for some operative procedures, tracheal intubation is mandatory. Regional techniques may obviate the need for airway manipulation but not all patients are either suitable or compliant and the procedures involved may be technically challenging.

We disagree with the authors that support during laryngoscopy fails to stabilize the cervical spine. In numerous studies, manual in-line stabilization (MILS) has been shown to be an effective procedure during laryngoscopy and intubation [2]. Soft collars have no place in the management of a potentially unstable cervical spine.

In practical terms, if routine pre-operative radiography is not to be offered, then all cases will have to be treated as having an unstable cervical spine as 15% (13.5% to 28%) would in fact be so. This would presumably involve the use of MILS in all cases of laryngoscopy and also in cases of difficult LMA insertion. The use and availability of fibreoptic intubating equipment would also necessarily increase. We personally do not have objection to either of these approaches but recognize that the appropriate skills are not universally held and that the procedures involved are expensive in terms of time and resources.

It is fight to question whether pre-operative investigations are appropriate rather than to follow tradition and dogma. The best approach may be to determine the need for cervical spine radiography only after careful clinical assessment on an individual patient basis.

R. J. H. BAYLIS

J. COOPER Department of Anaesthesia Royal United Hospital

Bath, UK

References

1 Campbell RSD, Wou P, Watt I. A continuing role for pre-operative cervical spine radiography in rheumatoid arthritis. Clinical Radiology 1995;50:157-159.

2 Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilising manoeuvres. Anaesthe- siology, 80, 825.

We thank Dr Baylis and Dr Cooper for their comments. We would reiterate the fact that in our study, neither the presence nor absence of cervical instability had any determining factor upon the decision to operate or upon the method of anaesthesia employed. The question to be asked is; cannot all asymptomatic rheumatoid patients be treated as if they have unstable spines, utilizing such techniques as manual in line stabilization of the cervical spine? If this is the case then there is justification for discontinuing routine radiography.

We agree that there will be instances of either operative procedure or lack of expertise where radiography may be deemed necessary, and it is gratifying to see that Drs Baylis and Cooper propose a selective approach to radiographic examination.

R. CAMPBELL Middlesborough General Hospital Ayresome Green Lane

Middlesborough Cleveland, UK

Book Reviews

Fundamentals of Mammography. By Lee, Strickland, Roebuck and Wilson. W. B. Saunders, UK, 1995, 144 pp. £27.95.

This is a book that all radiographers embarking on a career in mammography should read. Written by well respected authors from the Nottingham Breast Screening Training Centre, its purpose is to provide the mammographer with a more rounded knowledge and approach to the subject than just basic background and technical information. Topics dealt with include equipment, processing, positioning, quality control, anatomy, quality assurance, radiological procedures and the basis of interpretation. All this is very well done. Throughout this book constant attention is drawn to the necessity of the radiographer to consider the individual needs and concerns of each woman during the various procedures involved, in particular the requirement to diminish unnecessary anxiety. There is an excellent chapter dedicated to psychological considerations which underlines the crucial role of inter play between the radiographer and a woman undergoing mammography, whether it be in the symptomatic or screening programme.

Each chapter is prefixed by a summary list of major items covered within and there are two valuable appendices covering quality control tests and investigation protocols. There is a short glossary. In future editions it may become necessary to expand still further the psycholo- gical aspects, to provide more detail on ultrasound examination of the breast and to discuss radiographic double reading of screening mammograms. As it stands, the book achieves its aim of providing a good grounding in the subject with clear advice and attention to detail. It is well finished with good quality paper, illustrations and diagrams, providing good value within the expected price range.

This is an essential purchase for any breast unit and fundamental reading for any radiographer performing mammographic examinations.

Radiological registrars will find this volume rewarding at the onset of their mammographic training.

N. Perry

Atlas of Neuroradiology. By S. J. Willing. W. B. Saunders, UK, 1995, 625 pp.

This is a hefty tome: 614 pages, thousands of images, and a substantial index. Had it been published a few years ago, when comprehensive single-volume textbooks of nenroradiology were scarce, it would easily have found a market. But things have changed, and any new volume must be judged against numerous competitors. The balletomane or bullfight aficionado may devour books as a substitute for attending performances, but few radiologists have reached that stage of addic- tion, and most need one or, at most, two wide-ranging books.

The British radiologist is being constrained to think of purchasers and providers, however inappropriate that may be to societies in which the provider is the purchaser. Some purchasers like to learn from atlases, while others prefer textbooks; some providers delight in assembling instructive images, while others think, rightly or wrongly, that what they have to say is at least as important as what the pictures show. I must declare myself as belonging to the second group in both cases. Dr Willing has assembled a collection of cases many students of radiology will find useful but, by his own account, not 'a thorough treatment of [his] chosen subject'. He explains that those who are 'visually oriented find a picture is superior to a thousand w o r d s - i t takes less time to assimilate'. That would be an estimable rule of thumb were one to illustrate all the possible imaging variants o f each condition but, o f course, that is not possible; a supporting text is indispensable and I am afraid this is Dr Willing's Achilles heel. That he is not a born

© 1996 The Royal College of Radiologists, Clinical Radiology, 51, 305-308.