Neuromuscular Disease: Evidence and Analysis in Clinical Neurology by Michael Benatar

The discipline of “evidence-based medicine” has taken center stage in medical education and the practice of clinical medicine in the past 10 years, and perhaps no neurologist has sought to enlighten the neurology community on the quality of the evidence that informs our practice more than Michael Benatar. Following on the heels of his 2002 monograph, Analytic Neurology, in Neuromuscular Disease: Evidence and Analysis in Clinical Neurology, Dr. Benatar provides a comprehensive, yet concise summary and critique of the studies that form the cornerstone of the evidence-based practice of neuromuscular disease.

After an introduction in which he implores us to avoid the shortcut of skipping the methods and results section of research articles, then a brief refresher on basic statistics, followed by a discussion on the biases present in study design, Dr. Benatar reviews and analyzes the evidence behind four broad categories of neuromuscular disease in adults: spinal cord, anterior horn cell, and nerve root disorders; peripheral nerve disease; neuromuscular junction disorders; and primary muscle disease. The scope of disorders covered in the book includes “classical” neuromuscular diseases such as myasthenia gravis and motor neuron disease; more esoteric problems such as vasculitic neuropathy and paraproteinemic neuropathy; and widespread ones that often remain in the jurisdiction of the primary care physician such as cervical and lumbar spondylosis, idiopathic hyper-CK-emia, and statin-induced myopathy. As one might expect from an evidence-based neurology text, careful attention is paid to the literature behind the treatments employed for these conditions. An emphasis is also placed on the evidence for use of diagnostic studies, such as single-fiber electromyography (EMG) and muscle biopsy, and on neuromuscular disease prognosis, such as the natural history of amyotrophic sclerosis and polyneuropathy. He adopts a Socratic format in which questions such as, “What is the efficacy of epidural steroid injections for the treatment of sciatica?“ are followed by detailed discussion of several paragraphs in length of papers that have attempted to answer such questions with analysis of their strengths and weaknesses. For most of the questions presented, this format is effective, except for one notable chapter, which addresses metabolic myopathy, that does not lend itself so readily to this approach. Each chapter is concluded with a summary of the important evidence and a comprehensive bibliography.

The sobering reality of this text is that the evidence that forms the basis for practice of neuromuscular disease is often scant and of poor quality. Randomized, controlled trials are few, and even when available, direct applicability of such studies to individual patients is frequently unclear or inappropriate. If the reader is looking for the “answer” to how to practice neuromuscular medicine, Dr. Benatar does not provide it, and it was not his intention to do so. Rather, he seeks to understand and illuminate the basis for what is currently accepted as best clinical practice. He remains largely objective throughout, although he is not shy to point out the shortcomings of poorly designed studies or consensus statements that are constructed without adequate support. He urges the reader to proceed with caution when the evidence is spotty or contradictory, and generally avoids pooling disparate studies in an attempt to pass final judgment on a diagnostic technique or treatment.

Dr. Benatar has written this book to educate on the available evidence for neuromuscular disease practice rather than to summarize it, although it is clearly effective in both respects. Although he states that the purpose of this text is not “to simply provide the reader with an easy reference to the publications that are most clinically relevant to neurologists,” this book will certainly be employed as CliffsNotes for neuromuscular practitioners who have not examined the primary sources firsthand, as a shortcut by medical residents to prepare for pimping sessions, and as an index for the selection of journal club articles. Despite these unintended uses, or perhaps because of them, Neuromuscular Disease: Evidence and Analysis in Clinical Neurology is a worthy addition to the library of both the general neurologist and the neuromuscular specialist. It is reassuring to note that Dr. Benatar plans to direct his attention toward other subspecialties of neurology, with a series of books planned for each of these disciplines and a volume dedicated to neuro-ophthalmology currently in preparation.