Neuroanatomy of the pain system and of the pathways that modulate pain

Functional imaging and the neural systems of chronic pain

Pain remains a serious health care problem affecting millions of individuals, costing billions of dollars, and causing an immeasurable amount of human suffering. In designing improved therapies, there is still much to learn about peripheral nociceptor, nerves, and the spinal cord, and brain stem modulatory systems. Nevertheless, it is the brain that presents us with an incredible opportunity to understand the experience we call pain. Functional neuroimaging is helping to unlock the secrets of the sensory and emotional components of pain and its autonomic responses. These techniques are helping us to understand that pain is not a static disease with the pathologic findings localized to the periphery but is instead a highly plastic condition affecting multiple central neural systems. Functional neuroimaging is transforming our understanding of the neurobiology of pain and will be instrumental in helping us to design more rational treatments ultimately aimed at reducing the impact of pain on our patients. It is opening windows into the function of the brain that were previously closed.

The functional anatomy of neuropathic pain

The generation of neuropathic pain is a complex phenomenon involving a process of peripheral and central sensitization producing enhanced transmission of nociceptive inputs to the brain associated with the loss of discriminatory processing of noxious and innocuous stimuli. This increased flow of abnormally processed nociceptive inputs to the brain may overcome the ability of descending modulatory pathways to produce analgesia, causing further worsening of the pain. Several crucial locations involved in the physiologic generation of pain inputs (eg, peripheral nociceptors, dorsal horns, thalamus, cortex) show evidence of functional reorganization and altered nociceptive processing in association with chronic pain. These locations present the best targets for therapeutic intervention, including systemic administration of drugs able to counteract the chemical storm induced by neural injuries in the nociceptive afferents and dorsal horns, or for more focused intervention, such as neuroablative procedures; intrathecal drug delivery; and spinal cord, deep brain, or motor cortex stimulation.

Lamina I, but not Lamina V, Spinothalamic Neurons Exhibit Responses That Correspond With Burning Pain

Single-unit recordings from monkey spinothalamic tract (STT) neurons reveal that the responses of polymodal nociceptive lamina I STT neurons correspond with the profile of burning pain elicited in human subjects by repeated brief-contact heat. In contrast, lamina V wide-dynamic-range (WDR) neurons show a significantly different response pattern. This finding indicates that burning pain is signaled by modality-selective lamina I neurons and not convergent lamina V WDR neurons.

Nociception in vertebrates: key receptors participating in spinal mechanisms of chronic pain in animals

Our view of vertebrate nociceptive processing is ever changing with the discovery of novel molecules that differentially affect sensory responses to noxious and innocuous stimulation and might be involved specifically in chronic pain states. In order to understand the physiology of nociception and design novel analgesics for intractable chronic pain, it is essential to uncover precisely what changes occur between a normal nociceptive processing state and hypersensitive chronic pain states in the spinal cord following different types of injury. An important area of focus for future work in this area will be the cellular and molecular mechanisms of neuronal plasticity that occur.

Differential expression of GABAB(1b) receptor mRNA in the thalamus of normal and monoarthritic animals

GABA(B) receptors have been implicated in the plastic changes occurring in the spinal cord during the development of chronic inflammatory pain. In this study, we evaluated whether the expression of GABA(B(1b)) receptor mRNA is regulated supraspinally, namely in the thalamus, as part of the response to chronically enhanced noxious input arising from experimental monoarthritis (MA). In situ hybridization with [(35)S]-labelled oligonucleotide probes was performed in sections of control, 2, 4, 7 and 14 days MA rats' brains (n = 6/group). The distribution of GABA(B(1b)) mRNA was determined bilaterally in the ventrobasal complex (VB), posterior (Po), centromedial/centrolateral (CM/CL) and reticular (Rt) thalamic nuclei. The amount of GABA(B(1b)) mRNA was expressed as times fold of background values. In normal animals, values of mRNA expression were very similar in VB, Po and CM/CL, ranging from 2.2 +/- 0.2 to 2.7 +/- 0.4 (mean +/- S.E.M.) times higher than background levels. No expression of GABA(B(1b)) mRNA was found in the Rt of control or MA animals. A significant decrease of 26% at 4 days, and 37% at 7 days of MA, was observed in the VB contralateral to the affected joint. On the contrary, in the Po there was a significant bilateral increase at 2 days (38% contralaterally, 25% ipsilaterally), returning to basal levels at 4 days MA. No significant changes were observed in CM/CL. These results suggest that the expression of GABA(B(1b)) in the VB and Po is regulated by noxious input, and might contribute to the functional changes that occur in the thalamus during chronic inflammatory pain.

Distribution of trigeminothalamic and spinothalamic lamina I terminations in the macaque monkey

Thalamic terminations from trigeminal, cervical, and lumbosacral lamina I neurons were investigated with Phaseolus vulgaris leucoagglutinin (PHA-L) and labeled dextrans. Iontophoretic injections guided by physiological recordings were restricted to lamina I or laminae I-II. PHA-L-labeled trigemino- and spinothalamic (TSTT) terminations were identified immunohistochemically. TRITC- and FITC-labeled dextrans were injected at different levels to confirm topography. Terminations consistently occurred in two main locations: a distinguishable portion of posterolateral thalamus identified cytoarchitectonically as the posterior part of the ventral medial nucleus (VMpo) and a portion of posteromedial thalamus designated as the ventral caudal part of the medial dorsal nucleus (MDvc). In addition, isolated fibers bearing boutons of passage were observed in the ventral posterior medial and lateral (VPM and VPL) nuclei, and spinal terminations occurred in the ventral posterior inferior nucleus (VPI). Isolated terminations occasionally occurred in other sites (e.g., suprageniculate, zona incerta, hypothalamic paraventricular n.). Terminations in MDvc occurred in concise foci that were weakly organized topographically (posteroanterior = rostrocaudal). Terminations in VMpo consisted of dense clusters of ramified terminal arbors bearing multiple large boutons that were well organized topographically (anteroposterior = rostrocaudal). Terminations in VMpo colocalized with a field of calbindin-immunoreactive terminal fibers; double-labeled terminals were documented at high magnification. This propitious marker was especially useful at anterior levels, where VMpo can easily be misidentified as VPM. These findings demonstrate phylogenetically novel primate lamina I TSTT projections important for sensory and motivational aspects of pain, temperature, itch, muscle ache, sensual touch, and other interoceptive feelings from the body.

[Functional neuroanatomy for pain stimuli. Reception, transmission, and processing]

This short overview presents some of the current neuroanatomical knowledge concerning pathways and nuclei mediating pain sensations. The axonal membrane of the nociceptor is equipped with a multitude of receptor molecules that specifically bind pain-producing and sensitizing substances. Recently, adenosine triphosphate and protons have attracted much interest. The different nociceptor types are probably characterized by different sets of receptor molecules in the membrane of the nociceptive ending. Nociceptive cells are present in the superficial laminae and the neck of the dorsal horn. The cells in the former region include nociceptive-specific ones that receive input from nociceptors exclusively, whereas in the neck of the dorsal horn a convergent input from nociceptive and non-nociceptive afferent fibers prevails. At the spinal level, neuroplastic sensitizing processes take place that are assumed to underlie the allodynia and hyperalgesia of pain patients. In addition to the lateral spinothalamic tract, the spinoreticular and spinomesencephalic tracts are involved in pain sensations. The medial and lateral thalamus contains several nociceptive nuclei, the medial ones mediating the affective-emotional component of pain, the lateral ones the sensory-discriminative component. In contrast to other sensory modalities, the modality of pain does not have a specific cortical center. The cortical areas that are activated by painful stimuli are distributed over large parts of the cortex surface. During chronic painful conditions, at all levels massive neuroplastic changes take place that lead to rewiring of connections and structural alterations in the nuclei of the nociceptive pathways. In chronic pain patients the neuroanatomy of pain probably differs from that of healthy people.

Persistent Pain as a Disease Entity: Implications for Clinical Management

Pain has often been regarded merely as a symptom that serves as a passive warning signal of an underlying disease process. Using this model, the goal of treatment has been to identify and address the pathology causing pain in the expectation that this would lead to its resolution. However, there is accumulating evidence to indicate that persistent pain cannot be regarded as a passive symptom. Continuing nociceptive inputs result in a multitude of consequences that impact on the individual, ranging from changes in receptor function to mood dysfunction, inappropriate cognitions, and social disruption. These changes that occur as a consequence of continuing nociceptive inputs argue for the consideration of persistent pain as a disease entity in its own right. As with any disease, the extent of these changes is largely determined by the internal and external environments in which they occur. Thus genetic, psychological and social factors may all contribute to the perception and expression of persistent pain. Optimal outcomes in the management of persistent pain may be achieved not simply by attempting to remove the cause of the pain, but by addressing both the consequences and contributors that together comprise the disease of persistent pain.

Effects of ketamine anesthesia on central nociceptive processing in the rat: a 2-deoxyglucose study

Ketamine is a dissociative anesthetic with complex actions on the CNS. We investigated here the effects of ketamine anesthesia on somatosensory processing in the rat spinal cord, thalamus, and cerebral cortex, using the quantitative 2-deoxyglucose mapping technique. Unanesthetized or ketamine-anesthetized male Sprague-Dawley rats received a s.c. injection of a dilute formaldehyde solution (5%, 0.08 ml) into a forepaw, inducing prolonged noxious afferent input, or an equal volume of isotonic saline as a control stimulus. The 2-deoxyglucose experiments started 30 min after the injection. In the cervical enlargement of the spinal cord, ketamine had no significant effect on glucose metabolic rates in saline-injected animals, whereas it prevented the metabolic increases elicited by prolonged noxious stimulation in unanesthetized animals. At the thalamic level, ketamine increased glucose uptake in both saline- and formalin-injected rats in the lateral posterior, lateral dorsal, medial dorsal, gelatinosus, antero-ventral and antero-medial thalamic nuclei, whereas it decreased metabolic activity in the ventro-basal complex. At the cortical level, the drug increased metabolic activity in both control and formalin groups in the lacunosus-molecularis layer of the dorsal hippocampus, posterior parietal, retrosplenial, cingulate and frontal cortex; significant metabolic decreases were found in the CA1 region of the dorsal hippocampus and in the parietal 1 and 2 cortical areas. In the investigated brain regions, ketamine did not abolish noxious-evoked increases in glucose uptake, which were in fact enhanced in the forelimb cortex and in the lacunosus-molecularis layer of the hippocampus. The dissociation between the spinal and supraspinal effects of ketamine suggests a specific antinociceptive action on spinal circuits, in parallel with complex changes of the activity of brain circuits involved in somatosensory processing. More generally, this study shows that functional imaging techniques are able to quantitatively assess the effects of anesthetic drugs on nociceptive processing at different levels of the neuraxis.

Pain management in the intensive care unit

Pain management is an essential component of quality care delivery for the critically ill patient. Because outcomes are difficult to predict in the intensive care unit (ICU), high-quality pain management and palliative therapy should be a goal for every patient. For those patients actively dying, palliation may be among the main benefits offered by the health care team. Appropriate palliation of pain begins with the use of effective strategies for recognizing, evaluating,and monitoring pain. Skill in pain management requires knowledge of both pharmacologic and nonpharmacologic therapies. This article focuses on expertise in the use of opiates to facilitate confident and appropriate pain therapy. To optimize palliative therapy, symptoms are best addressed by interdisciplinary care teams guided by models that acknowledge a continuum of curative therapies and palliative care.

Steady-State Levels of Monoamines in the Rat Lumbar Spinal Cord: Spatial Mapping and the Effect of Acute Spinal Cord Injury

Monoamines in the spinal cord are important in the regulation of locomotor rhythms, nociception, and motor reflexes. To gain further insight into the control of these functions, the steady-state extracellular distribution of monoamines was mapped in the anesthetized rat's lumbar spinal cord. The effect of acute spinal cord lesions at sites selected for high resting levels was determined over ∼1 h to estimate contributions to resting levels from tonic descending activity and to delineate chemical changes that may influence the degree of pathology and recovery after spinal injury. Measurements employed fast cyclic voltammetry with carbon fiber microelectrodes to give high spatial resolution. Monoamine oxidation currents, sampled at equal vertical spacings within each segment, were displayed as contours over the boundaries delineated by histologically reconstructed electrode tracks. Monoamine oxidation currents were found in well defined foci, often confined within a single lamina. Larger currents were typically found in the dorsal or ventral horns and in the lateral aspect of the intermediate zone. Cooling of the low-thoracic spinal cord led to a decrease in the oxidation current (to 71–85% of control) in dorsal and ventral horns. Subsequent low-thoracic transection produced a transient increase in signal in some animals followed by a longer lasting decrease to levels similar to or below that with cooling (to 17–86% of control values). We conclude that descending fibers tonically release high amounts of monoamines in localized regions of the dorsal and ventral horn of the lumbar spinal cord at rest. Lower amounts of monoamines were detected in medial intermediate zone areas, where strong release may be needed for descending activation of locomotor rhythms.

Afferent pain pathways: a neuroanatomical review

Painful experience is a complex entity made up of sensory, affective, motivational and cognitive dimensions. The neural mechanisms involved in pain perception acts in a serial and a parallel way, discriminating and locating the original stimulus and also integrating the affective feeling, involved in a special situation, with previous memories. This review examines the concepts of nociception, acute and chronic pain, and also describes the afferent pathways involved in reception, segmental processing and encephalic projection of pain stimulus. The interaction model of the cerebral cortex areas and their functional characteristics are also discussed.

Metabotropic glutamate 1 receptor distribution and occupancy in the rat brain: a quantitative autoradiographic study using [3H]R214127

We used the selective metabotropic glutamate (mGlu) 1 receptor antagonist [3H]1-(3,4-dihydro-2H-pyrano[2,3-b]quinolin-7-yl)-2-phenyl-1-ethanone ([3H]R214127) to investigate the distribution of mGlu1 receptor binding sites in rat brain. We found high mGlu1 receptor binding in the cerebellum, thalamus, dentate gyrus and medial central gray, moderate binding within the CA3 of the hippocampus and hypothalamus, and low mGlu1 receptor binding in the basal ganglia and cortex. The mGlu1 receptor is also present in variable degree in the dorsal lateral septal nucleus, amygdala, interpeduncular nucleus and median raphe nucleus. Additionally, we employed [3H]R214127 autoradiography as a means of investigating the occupancy of central mGlu1 receptors following in vivo administration of mGlu1 receptor antagonists that prevent binding of this radioligand. We found that the mGlu1 receptor antagonist (3aS,6aS)-6a-naphtalan-2-ylmethyl-5-methyliden-hexahydro-cyclopenta[c]furan-1-on (BAY 36-7620), administered subcutaneously (s.c.) at 10 mg/kg, only occupied about 30% of cerebellar and thalamic mGlu1 receptors. The mGlu1/5 receptor antagonist 2-quinoxaline-carboxamide-N-adamantan-1-yl (NPS 2390) exhibited a relatively high potency in occupying mGlu1 receptors in rat cerebellum (ED50 = 0.75 mg/kg, s.c.) and thalamus (ED50 = 0.63 mg/kg, s.c). In the future, this method can be employed to gain more insight into the in vivo profile and central activity of potential therapeutic agents that act upon the mGlu1 receptor.

Treatment of Pain Syndromes with Venlafaxine

Major depressive disorder (MDD) and anxiety disorders such as generalized anxiety disorder (GAD) are often accompanied by chronic painful symptoms. Examples of such symptoms are backache, headache, gastrointestinal pain, and joint pain. In addition, pain generally not associated with major depression or an anxiety disorder, such as peripheral neuropathic pain (e.g., diabetic neuropathy and postherpetic neuralgia), cancer pain, and fibromyalgia, can be challenging for primary care providers to treat. Antidepressants that block reuptake of both serotonin and norepinephrine, such as the tricyclic antidepressants (e.g., amitriptyline), have been used to treat pain syndromes in patients with or without comorbid MDD or GAD. Venlafaxine, a serotonin and norepinephrine reuptake inhibitor, has been safe and effective in animal models, healthy human volunteers, and patients for treatment of various pain syndromes. The use of venlafaxine for treatment of pain associated with MDD or GAD, neuropathic pain, headache, fibromyalgia, and postmastectomy pain syndrome is reviewed. Currently, no antidepressants, including venlafaxine, are approved for the treatment of chronic pain syndromes. Additional randomized, controlled trials are necessary to fully elucidate the role of venlafaxine in the treatment of chronic pain.

Decreased pain tolerance and mood in recreational users of MDMA

RATIONALE

3,4-Methylenedioxymethamphetamine (MDMA) is known to affect brain serotonin (5-HT) neurons in experimental animals. However, its effects on humans are more difficult to infer. Serotonin is implicated in the body's ability to modulate the effects of pain and to regulate mood.

OBJECTIVE

The aim of this research is to test nociceptive responses and mood in MDMA users as an index of central 5-HT function.

METHOD

Measurements of pain tolerance were obtained using the cold-pressor test for 15 polydrug users who regularly use MDMA, 3-4 days after the most recent usage, and ten matched polydrug users who do not use MDMA. A rating on mood was obtained for each participant using the Nowlis Mood Adjective checklist.

RESULTS

Measurements of pain tolerance and mood were significantly lower in the MDMA group. A positive correlation between mood and pain tolerance was found in the MDMA group, whereas no correlation was found between these variables in the non-MDMA group

CONCLUSION

This study found an association between pain tolerance and MDMA usage and confirmed the association between MDMA and depressed mood. The current results suggest that MDMA, at least in the short term, may cause serotonin-mediated alterations in pain sensitivity.

Brain processing of esophageal sensation in health and disease

This case study demonstrates that patients with NCCP can be subclassified on the basis of sensory responsiveness and neurophysiologic profiles. This approach identifies specific abnormalities within the CNS processing of esophageal sensation in individual patients, allowing us to objectively differentiate those with sensitized esophageal afferents from those that are hypervigilant to esophageal sensations. The importance of this approach is to underline that NCCP comprises a heterogeneous group of patients. and only when we have defined the phenotype of this condition and identified groups of patients with specific CNS abnormalities will it be possible to perform clinical studies aimed at answering specific hypotheses. The development of a comprehensive pathophysiologic model that identifies the specific causes of symptoms in patients with esophageal hypersensitivity will allow the future management strategies of these patients to be targeted more specifically and efficiently. This will have great benefits to patients'well-being and health care use.

Effects of duloxetine on painful physical symptoms associated with depression

Painful physical symptoms are common features of major depressive disorder and may be the presenting complaints in primary care settings. The effect of the dual serotonin (5-HT) and norepinephrine reuptake inhibitor duloxetine on emotional and painful physical symptoms in outpatients with major depressive disorder was evaluated in three randomized, double-blind, placebo-controlled trials. The trials' primary objective was to evaluate the effect of duloxetine on mood, and subjects were not enrolled on the basis of presence, type, or severity of pain. However, the pain-relieving effects of duloxetine were evaluated by a priori defined analyses of results from a visual analogue scale and the Somatic Symptom Inventory. Compared with placebo, duloxetine was associated with significant reduction in pain severity. The authors concluded that duloxetine reduces the painful physical symptoms of depression.

Widespread thalamic terminations of fibers arising in the superficial medullary dorsal horn of monkeys and their relation to calbindin immunoreactivity

The relay of pain fibers from the spinal and medullary dorsal horn in the thalamus has become a controversial issue. This study analyzed the relationship of fibers arising in lamina I to nuclei in and around the caudal pole of the ventral posterior nuclear complex and especially to a zone of calbindin-dense immunoreactivity (VMpo) identified by some authors as the sole thalamic relay for these fibers. We show that the densest zone of calbindin immunoreactivity is part of a more extensive, calbindin-immunoreactive region that lies well within the medial tip of the ventral posterior medial nucleus (VPM), as delineated by other staining methods, and prove that the use of different anti-calbindin antibodies cannot account for differences in interpretations of the organization of the posterior thalamic region. By combining immunocytochemical staining with anterograde tracing from injections involving lamina I, we demonstrate widespread fiber terminations that are not restricted to the calbindin-rich medial tip of VPM and show that the lamina I arising fibers are not themselves calbindin immunoreactive. This study disproves the existence of VMpo as an independent thalamic pain nucleus or as a specific relay in the ascending pain system.

The Problem of Pain

Pain problems, especially posttraumatic headache, are very common following head trauma. Pain may be the most significant problem, more disabling than any brain or other injuries, and interfering with aspects of cognition or other function. However, posttraumatic headache and most other chronic posttraumatic pain problems remain poorly understood. This article reviews fundamental issues that should be considered in understanding the nature of chronic pain including the distinction between acute and chronic pain; neurobiological distinctions between the lateral and medial pain system; nociceptive versus neuropathic or other central pain; sensitization effects; the widely accepted view of chronic pain as a multidimensional subjective experience involving sensory, motivational-affective and cognitive-behavioral components; the problem of mind-body dualism; the role of psychosocial factors in the onset, maintenance, exacerbation or severity of pain; plus issues of response bias and malingering.

Assessment of acute thermal nociception in laboratory animals

Models of acute nociception using a thermal stimulus are widely employed as screening methods for nociceptive properties of new drug compounds. In this chapter, detailed descriptions for conducting of two of the most commonly used models; the hot plate test and the "Hargreaves test," are described. These models are applicable to both rats and mice and have the advantage of allowing repeated and multiple testing using a single animal because the stimulus is transitory and produces no tissue damage. Additionally, a modification of these models using a skin-twitch reflex that is applicable to large laboratory animals such a dogs or sheep is described. Guidance concerning potential confounding variable are discussed, as are tips for reducing variably among testing sessions.

A critical review of the role of the proposed VMpo nucleus in pain

The evidence presented by Craig and his colleagues for an important projection from lamina I spinothalamic tract neurons to a renamed thalamic nucleus (the posterior part of the ventral medial nucleus or VMpo), as well as to the ventrocaudal medial dorsal and the ventral posterior inferior thalamic nuclei, is critically reviewed. Of particular concern is the denial of an important nociceptive lamina I projection to the ventrobasal complex. Contrary evidence is reviewed that strongly favors a role of spinothalamic projections from both lamina I and deep layers of the dorsal horn to the ventrobasal complex and other thalamic nuclei and from there to the SI and SII somatosensory cortices in the sensory-discriminative processing of pain and temperature information.

Anatomy and physiology of chronic pain

Although much has been accomplished in the past several decades, treatment of chronic pain remains imperfect. This article presents the anatomy and physiology of the pain system along with the neurobiologic changes that occur in the establishment and maintenance of chronic pain states.

The rodent amygdala contributes to the production of cannabinoid-induced antinociception

The amygdala is a temporal lobe region that is implicated in emotional information processing. The amygdala also is associated with the processing and modulation of pain sensation. Recently, we demonstrated that in nonhuman primates, the amygdala is necessary for the full expression of cannabinoid-induced antinociception [J Neurosci 21 (2001) 8238]. The antinociceptive effect of the cannabinoid receptor agonist (R)-(+)-[2,3-dihydro-5-methyl-3-(4-morpholinylmethyl)pyrrolo(1,2,3-de)-1,4-benzoxazin-6-yl]-1-naphthalenylmethanone (WIN55,212-2) was significantly reduced in rhesus monkeys with large bilateral lesions of the amygdaloid complex. In the present study, we investigated the contribution of the amygdala to cannabinoid-induced antinociception in the rat. Using bilateral local microinjections of the GABA(A) receptor agonist muscimol, we inactivated neurons originating from the central nucleus of the amygdala (CeA) or basolateral nucleus of the amygdala (BLA). In rats injected with intra-CeA saline, the cannabinoid receptor agonist WIN55,212-2 produced dose-dependent antinociception on the noxious heat-evoked tail flick assay. In rats treated with intra-CeA muscimol, however, the antinociceptive effect of WIN55,212-2 was significantly reduced. Rats treated with intra-BLA muscimol showed no deficit in WIN55,212-2-induced antinociception. The effect of CeA inactivation on WIN55,212-2-induced suppression of prolonged pain in the formalin test also was tested. In rats treated with intra-CeA saline, WIN55,212-2 reduced the incidence of formalin-induced nociceptive behaviors and also reduced formalin-evoked c-fos expression in both superficial and deep laminae of the spinal cord dorsal horn. In rats treated with intra-CeA muscimol, however, these effects of WIN55,212-2 were significantly reduced. The results constitute the first causal data demonstrating the necessity of descending pain-modulatory circuitry (of which the CeA is a component) for the full expression of cannabinoid-induced antinociception in the rat. Furthermore, the results complement previous findings suggesting an overlap in neural circuitry activated by opioids and cannabinoids.

Pain mechanisms: labeled lines versus convergence in central processing

The issue of whether pain is represented by specific neural elements or by patterned activity within a convergent somatosensory subsystem has been debated for over a century. The gate control theory introduced in 1965 denied central specificity, and since then most authors have endorsed convergent wide-dynamic-range neurons. Recent functional and anatomical findings provide compelling support for a new perspective that views pain in humans as a homeostatic emotion that integrates both specific labeled lines and convergent somatic activity.

Pain processing in dementia and its relation to neuropathology

Most clinical studies of pain in dementia have focused on assessment procedures that are sensitive to pain in "demented" or "cognitively impaired" elderly patients. The neuropathology of dementia has not played a major part in pain assessment. In this review, the neuropathological effects of dementia on the medial and the lateral pain systems are discussed. We focus on Alzheimer's disease (AD), vascular dementia, and frontotemporal dementia. Lewy-body disease and Creutzfeldt-Jakob disease are briefly reviewed. The results of the studies reviewed show that, although the subtypes of dementia show common neuropathological features (such as atrophy and white-matter lesions), the degree by which they occur and affect pain-related areas determine the pattern of changes in pain experience. More specifically, in AD and even more so in frontotemporal dementia, a decrease in the motivational and affective components of pain is generally present whereas vascular dementia might be characterised by an increase in affective pain experience. Future studies should combine data from experimental pain studies and neuropathological information for pain assessment in dementia.

Role of thalamic phospholipase C[beta]4 mediated by metabotropic glutamate receptor type 1 in inflammatory pain

Phospholipase C (PLC) beta4, one of the four isoforms of PLCbetas, is the sole isoform expressed in the mouse ventral posterolateral thalamic nucleus (VPL), a key station in pain processing. The mouse thalamus also has been shown to express a high level of metabotropic glutamate receptor type 1 (mGluR1), which stimulates PLCbetas through activation of Galphaq/11 protein. It is therefore expected that the thalamic mGluR1-PLCbeta4 cascade may play a functional role in nociceptive transmission. To test this hypothesis, we first studied behavioral responses to various nociceptive stimuli in PLCbeta4 knock-out mice. We performed the formalin test and found no difference in the pain behavior in the first phase of the formalin test, which is attributed to acute nociception, between PLCbeta4 knock-out and wild-type mice. Consistent with this result, acute pain responses in the hot plate and tail flick tests were also unaffected in the PLCbeta4 knock-out mice. However, the nociceptive behavior in the second phase of the formalin test, resulting from the tissue inflammation, was attenuated in PLCbeta4 knock-out mice. In the dorsal horn of the spinal cord where PLCbeta1 and PLCbeta4 mRNAs are expressed, no difference was found between the wild-type and knock-out mice in the number of Fos-like immunoreactive neurons, which represent neuronal activity in the second phase in the formalin test. Thus, it is unlikely that spinal PLCbeta4 is involved in the formalin-induced inflammatory pain. Next, we found that pretreatment with PLC inhibitors, mGluR1 antagonists, or both, by either intracerebroventricular or intrathalamic injection, attenuated the formalin-induced pain behavior in the second phase in wild-type mice. Furthermore, activation of mGluR1 at the VPL enhanced pain behavior in the second phase in the wild-type mice. In contrast, PLCbeta4 knock-out mice did not show such enhancement, indicating that mGluR1 is connected to PLCbeta4 in the VPL. Finally, in parallel with the behavioral results, we showed in an electrophysiological study that the time course of firing discharges in VPL corresponds well to that of pain behavior in the formalin test in both wild-type and PLCbeta4 knock-out mice. These findings indicate that the thalamic mGluR1-PLCbeta4 cascade is indispensable for the formalin-induced inflammatory pain by regulating the response of VPL neurons.

Role of thalamic phospholipase C[beta]4 mediated by metabotropic glutamate receptor type 1 in inflammatory pain

Phospholipase C (PLC) beta4, one of the four isoforms of PLCbetas, is the sole isoform expressed in the mouse ventral posterolateral thalamic nucleus (VPL), a key station in pain processing. The mouse thalamus also has been shown to express a high level of metabotropic glutamate receptor type 1 (mGluR1), which stimulates PLCbetas through activation of Galphaq/11 protein. It is therefore expected that the thalamic mGluR1-PLCbeta4 cascade may play a functional role in nociceptive transmission. To test this hypothesis, we first studied behavioral responses to various nociceptive stimuli in PLCbeta4 knock-out mice. We performed the formalin test and found no difference in the pain behavior in the first phase of the formalin test, which is attributed to acute nociception, between PLCbeta4 knock-out and wild-type mice. Consistent with this result, acute pain responses in the hot plate and tail flick tests were also unaffected in the PLCbeta4 knock-out mice. However, the nociceptive behavior in the second phase of the formalin test, resulting from the tissue inflammation, was attenuated in PLCbeta4 knock-out mice. In the dorsal horn of the spinal cord where PLCbeta1 and PLCbeta4 mRNAs are expressed, no difference was found between the wild-type and knock-out mice in the number of Fos-like immunoreactive neurons, which represent neuronal activity in the second phase in the formalin test. Thus, it is unlikely that spinal PLCbeta4 is involved in the formalin-induced inflammatory pain. Next, we found that pretreatment with PLC inhibitors, mGluR1 antagonists, or both, by either intracerebroventricular or intrathalamic injection, attenuated the formalin-induced pain behavior in the second phase in wild-type mice. Furthermore, activation of mGluR1 at the VPL enhanced pain behavior in the second phase in the wild-type mice. In contrast, PLCbeta4 knock-out mice did not show such enhancement, indicating that mGluR1 is connected to PLCbeta4 in the VPL. Finally, in parallel with the behavioral results, we showed in an electrophysiological study that the time course of firing discharges in VPL corresponds well to that of pain behavior in the formalin test in both wild-type and PLCbeta4 knock-out mice. These findings indicate that the thalamic mGluR1-PLCbeta4 cascade is indispensable for the formalin-induced inflammatory pain by regulating the response of VPL neurons.

Alpha 4 nicotinic acetylcholine receptor subunit links cholinergic to brainstem monoaminergic neurotransmission

Agonists of nicotinic receptors containing the alpha4-subunit produce antinociception accompanied by several adverse side effects. The purpose of this study was to determine the distribution of the alpha4-subunit of nicotinic acetylcholine receptors (nAChR) in brainstem monoaminergic nuclei that may contribute to these effects using dual labeling immunofluorescence methods. The alpha4-subunit immunoreactivity was enriched in serotonergic (nucleus raphe magnus, pallidus, obscurus, and dorsalis) and noradrenergic (A5, locus coeruleus (LC), A7) areas associated with antinociception, where it was commonly colocalized with serotonin (5-HT) or tyrosine hydroxylase (TH) immunoreactivity. However, it was also noted that alpha4 was present in all other brainstem monoaminergic nuclei examined (adrenergic C1-C3, noradrenergic A1-alpha4, dopamine A9 and A10, nucleus raphe medianus). To determine if alpha4 agonists could impact neural activity in brainstem, monoaminergic nuclei that are associated with antinociception, the expression of c-Fos in response to the systemic administration of epibatidine (2.5, 5, or 10 microg/kg) was examined. Epibatidine produced a robust (2-5-fold) increase in c-Fos expression, which was not dose dependent, in all of these areas examined except the nucleus raphe magnus. These results suggest that the alpha4 subunit is positioned to mediate the effects of acetylcholine widely across many, if not all, monoaminergic neurons in the brainstem. These observations emphasize the potential involvement of noradrenergic, as well as serotonergic mechanisms in epibatidine's analgesic effects, and they also suggest that even selective alpha4 ligand may have widespread effects on brain monoamine neurotransmission.

Fos expression in spinothalamic and postsynaptic dorsal column neurons following noxious visceral and cutaneous stimuli

The spinothalamic tract (STT) has been classically viewed as the major ascending pathway for pain transmission while the dorsal column (DC) was thought to be involved primarily in signaling innocuous stimuli. Recent clinical studies have shown that limited midline myelotomy, which transects fibers in the DC, offers good pain relief in patients with visceral cancer pain. Experimental studies provided evidence that a DC lesion decreases the activation of thalamic neurons by visceral stimuli and suggested that this effect is due to transection of the axons of postsynaptic dorsal column (PSDC) neurons. In our study, Fos protein expression in retrogradely labeled STT and PSDC neurons in the lumbosacral enlargement in rats was used as an anatomical marker of enhanced activation to compare the role of these neurons in cutaneous and visceral pain. The noxious stimuli used were intradermal injection of capsaicin and distention of the ureter. Retrogradely labeled PSDC neurons were found in laminae III-IV and in the vicinity of the central canal. STT neurons were located in laminae I, III-VII and X. Ureter distention evoked Fos expression in PSDC and STT neurons located in all laminae in which retrogradely labeled cells were found, with the maximum in the L(2) spinal segment. The Fos-positive PSDC neurons represented a significantly higher percentage of the retrogradely labeled PSDC neurons (19.3+/-2.3% SEM) than of the STT Fos-positive neurons (13.2+/-1.5% SEM). Intradermal capsaicin injection also evoked Fos expression in both PSDC and STT neurons, but with no significant difference between these two, when expressed as a percentage of the retrogradely labeled cells (11.6+/-2.9% SEM, 10.8+/-1.1% SEM). These results show that both PSDC and STT neurons are activated by cutaneous and visceral noxious stimuli. Their particular role in transmission and modulation of painful stimuli needs to be investigated further.

Trigeminofacial reflexes in primary headaches

Nociceptive processing in trigeminal system is likely to undergo to significant changes in chronic pain disorders such as in primary headache. The electrophysiological testing of brainstem reflexes seems to offer a valuable adjunct to the clinical evaluation, providing direct evidence for central dysmodulation of sensory and pain neurotransmission, i.e. dishabituation pattern and reduced pain threshold. We review the contribution of trigeminofacial reflex studies in the light of those recent data supporting the view of a dysfunctional sensory processing in primary headache.

Evaluation of methods for eliciting somatosensory-evoked potentials in the awake, freely moving rat

To standardise the method of eliciting somatosensory-evoked potentials (SEPs), SEPs were generated by electrical stimulation of different stimulus sites and recorded bilaterally from the primary somatosensory cortex (S1) and from midline in awake, freely moving rats. Increasing stimulus intensity enhanced amplitudes of all SEPs. At supramaximal stimulation, SEPs following vibrissae and tail stimulation (V-SEP and Ta-SEP, respectively) but not following trunk stimulation (Tr-SEP), fulfilled our criterion of signal-to-noise ratio >or=4. The first V-SEP component coincided with a stimulus artefact, disqualifying these recordings for a standard stimulation protocol. The Ta-SEP generated stable and reproducible recordings and was considered to be the preferred technique. Early components of the contralateral S1 recorded V-SEP and Tr-SEP occurred at latencies different from the other recordings. Increasing stimulus repetition rate (SRR) decreased amplitudes of all SEPs. At the highest obtainable SRR, the amplitude between the V-SEP second positive and second negative components in all recordings was 70-80% of the amplitude at 0.1 Hz, whereas peak amplitudes of subsequent components and those of the Tr-SEP and Ta-SEP were 20-50%. These results indicate that the different SEP components might be generated by different ascending neural pathways.

Botulinum toxin a improved burning pain and allodynia in two patients with spinal cord pathology

OBJECTIVE

To report the effect of botulinum toxin A in two patients with burning pain and allodynia of spinal cord origin.

DESIGN, SETTING, PATIENTS

Two patients with spinal cord lesions at the cervical level (tumor and stroke) experienced exquisite skin sensitivity and spontaneous burning pain in dermatomes corresponding to the cord lesions. Botulinum toxin A (Botox) was injected subcutaneously at multiple points (16 to 20 sites, 5 units/site) in the area of burning pain and allodynia.

RESULTS

Both patients reported significant improvement in spontaneous burning pain and allodynia in visual analogue scale and clinical measures. The analgesic effect of botulinum toxin A lasted at least 3 months and was sustained over follow-up periods of 2 and 3 years with repeated administration at 4-month intervals.

CONCLUSION

Subcutaneous application of botulinum toxin A relieved central burning pain and allodynia in two patients with spinal cord pathology.

Temporal and spatial profiles of pontine-evoked monoamine release in the rat's spinal cord

In the spinal cord, the monoamine neurotransmitter norepinephrine, which is released mainly from fibers descending from the dorsal pons, has major modulatory effects on nociception and locomotor rhythms. To map the spatial and temporal patterns of this release, changes in monoamine level were examined in laminae I-VIII of lumbar segments L3-L6 of halothane-anesthetized rats during pontine stimulation. The changes were measured through a carbon fiber microelectrode at 0.5-s intervals by fast cyclic voltammetry, which presently is the method of best spatiotemporal resolution. When different pontine sites were tested with 20-s pulse trains (50-to 200-microA amplitude, 0.5-ms pulse width, and 50-Hz frequency) during measurement in the dorsal horn (lamina IV), the largest consistent increases were produced by the locus ceruleus, although effective pontine sites extended 1.5 mm dorsally and ventral from the locus ceruleus. When the locus ceruleus stimulus was used to map the spinal cord, increased levels were always seen in lamina I and laminae IV-VIII, whereas 50% of sites in laminae II and III showed substantial decreases and the rest showed increases. These increases typically had short latencies [4.5 +/- 0.4 (SE) s] and variable decay times (5-200 s), with peaks occurring during the stimulus train (mean rise-time: 12.0 +/- 0.6 s). The mean peak level was 544 +/- 82 nM as estimated from postexperimental calibration with norepinephrine. Other significant laminar differences included higher mean peak concentrations (805 nM) and rise times (14.9 s) in lamina I and shorter latencies in lamina VI (3.2 s). Peak concentrations were inversely correlated with latency. When stimulation frequency was varied, increases were disproportionately larger with faster frequencies (> or =50 Hz), hence extrajunctional overflow probably contributed most of the signal. We conclude, generally, that pontine noradrenergic control is exerted on widespread spinal laminae with a significant component of paracrine transmission after several seconds of sustained activity. Relatively stronger effects prevail where nociceptive transmission (lamina I) and locomotor rhythm generation (lamina VI) occur.

Involvement of the anterior pretectal nucleus in the control of persistent pain: a behavioral and c-Fos expression study in the rat

The anterior pretectal nucleus (APtN) participates in nociceptive processing and in the activation of central descending mechanisms of pain control. In this study we used behavioral tests (incisional pain and carrageenan-induced inflammatory pain) and c-Fos expression changes to examine the involvement of the APtN in the control of persistent pain in rats. A 1cm longitudinal incision through the skin and fascia of the plantar region (large incision), or a 0.5cm longitudinal incision through the skin only (small incision) was used, and the postoperative incisional allodynia was evaluated with von Frey filaments. The hyperalgesia produced by the intraplantar administration of carrageenan (25 or 50 microg/100 microl) into a hind paw was evaluated by a modified paw pressure test. The electrolytic lesion of the contralateral, but not ipsilateral, APtN significantly intensified the allodynia produced by a large incision of the hind paw. The incisional allodynia and the carrageenan-induced hyperalgesia were intensified by the microinjection of 2% lidocaine into the contralateral, but not ipsilateral APtN, the effect being significantly stronger when a large incision or a higher carrageenan concentration was utilized. A significant increase in the number of c-Fos positive cells was found in the ipsilateral, and mainly in the contralateral APtN of rats submitted to a large incision. The number of positive cells in the superficial or deep laminae of the contralateral spinal cord of control and incised rats was not significantly different. Positive cells in the superficial or deep laminae of the ipsilateral spinal cord were significantly more numerous than in control, the effect being significantly more intense in rats with large incision. The microinjection of 0.5% bupivacaine into the APtN contralateral to the incised hind paw reduced the number of positive cells bilaterally in the APtN, but the effect was significant in the contralateral nucleus only. The number of positive cells in the superficial and deep laminae of the contralateral spinal cord of incised and non-incised animals was not significantly changed by the neural block of the contralateral APtN. In the ipsilateral spinal cord, the incision-induced increase in the number of positive cells was significantly reduced in the superficial lamina and significantly increased in the deep lamina of animals previously treated with bupivacaine in the contralateral APtN. In conclusion, the integrity of the APtN is necessary to reduce the severity of the responses to persistent injury. The results also are in agreement with the current notion that persistent noxious inputs to the APtN tonically activate a descending mechanism that excites superficial cells and inhibits deep cells in the spinal dorsal horn.

The effects of high- and low-intensity percutaneous stimulation on nitric oxide levels and spike activity in the superficial laminae of the spinal cord

Nitric oxide (NO) was measured using a new electrochemical method with a carbon fibre microelectrode at depths of up to 400 microm in the lumbar dorsal horn of the anaesthetised rat. The method allowed extracellular spike recording from single units together with the electrochemical recording at the same electrode. Thirty-six cells with low threshold cutaneous (brush/touch) or wide dynamic range receptive fields (brush/touch plus pinch) were studied. Adequate stimulation of the receptive fields did not alter the extracellular NO level for any cells. Percutaneous needle electrodes inserted into the receptive fields were used to stimulate the cells electrically. Twenty-one cells were stimulated using 10 mA current with 0.05 ms duration (low intensity) pulses to stimulate predominantly A-fibre afferents. Single shock stimuli gave short latency spike responses but no change in nitric oxide level. Tetanic bursts of stimuli (400 stimuli at 50 Hz) generated a burst of spikes (spike count 548+/-42) and a transient increase in NO (2.61+/-0.11 microM NO). Nitric oxide synthesis inhibition with N(G)-nitro-L-arginine methyl ester (L-NAME) nearly abolished the stimulus-evoked increase in nitric oxide and increased the response of the cells (spike count 694+/-34). However, the inhibition of nitric oxide synthesis had no effect on the receptive fields. Fifteen cells were stimulated with shocks using 5 ms pulses (high intensity), to recruit C-fibre afferents into the input volley. This more intense stimulation increased the evoked NO release to 3.63+/-0.15 microM and the spike response to 647+/-54 in control conditions. Following L-NAME, the evoked NO release was reduced and the evoked spike response was significantly decreased. These results show that tetanic activity in afferent fibres increases NO synthesis in the dorsal horn and that inhibition of nitric oxide synthesis may be associated with a selective attenuation of the spike responses to C-fibre inputs. NO may be necessary to maintain proper function of C-fibre afferent synapses when they are subjected to sustained or tetanic inputs.

The cerebellum: organization, functions and its role in nociception

Our vision of the cerebellum has been gradually transformed throughout the last century from a 'little brain' to a 'neuronal machine' capable of multitasks, all arguably based on a principle computational model. We review here the main functions of the cerebellum in light of its organization and connectivity. In addition to providing a clear and extensive review of the cerebellar literature, we emphasize the role of the cerebellum in nociception, which is novel to the neurophysiology of pain. However, it is premature to conclude that the cerebellum influences sensory experience in the absence of clinical data.

Noxious-evoked c-fos expression in brainstem neurons immunoreactive for GABAB, mu-opioid and NK-1 receptors

Modulation of nociceptive transmission at the brainstem involves several neurochemical systems. The precise location and specific characteristics of nociceptive neurons activated in each system was never reported. In this study, the presence of GABA(B), mu-opioid, and neurokinin-1 (NK-1) receptors in brainstem nociceptive neurons was investigated by double-immunocytochemical detection of each receptor and noxious-evoked induction of the c-fos proto-oncogene. Noxious cutaneous mechanical stimulation significantly increased the proportions of neurons double-labelled for Fos and GABA(B) receptors in several brainstem regions, namely, the reticular formation of the caudal ventrolateral medulla (VLMlat and VLMrf), lateral reticular nucleus, spinal trigeminal nucleus, pars caudalis (Sp5C), nucleus of the solitary tract, dorsal reticular nucleus, ventral reticular nucleus, raphe obscurus nucleus and dorsal parabrachial nucleus (DPB). For mu-opioid receptors, the proportions of double-labelled neurons in noxious-stimulated animals were higher than in controls only in the VLMlat, VLMrf, Sp5C, DPB and A5 noradrenergic cell group. As for the NK-1 receptor, no significant differences were found between control and stimulated animals. According to these results, neurons expressing GABA(B), mu-opioid and NK-1 receptors at several pain control centres of the brainstem are differentially involved in processing nociceptive mechanical input. The data provide the definition of new supraspinal targets for selective modulation of nociceptive neurons in order to define better strategies of pain control.

Brainstem modulation of pain during sleep and waking

Moderately painful stimuli applied during sleep evoke motor and neural responses indicative of arousal, but seldom cause awakening. Different reactions occur in response to acute pain stimulation across behavioral states; pain reactions are modulated by the activity of serotonergic and non-serotonergic cells in the raphe magnus (RM). Serotonergic RM cells have state-dependent discharge and may inhibit simple motor withdrawal responses during waking. ON and OFF cells are non-serotonergic RM neurons thought to facilitate and inhibit pain, respectively. These cells display reciprocal spontaneous discharge patterns across the sleep-wake cycle, with ON cells most active during waking and OFF cells most active during sleep. We propose that they also play an important role in modulating the alertness evoked by any brief external stimulus, either noxious or innocuous. ON cells may facilitate alertness during waking and OFF cells suppress arousals during sleep. In the presence of chronic pain, both ON and OFF cell discharge appear to increase. The increase in ON cell discharge may contribute to enhancing pain sensitivity and alertness. Future research is needed to understand why sleep is so adversely affected in chronic pain patients, whereas sleep is minimally disrupted, even by acutely painful stimuli, in humans and animals without chronic pain.

Discharge of raphe magnus ON and OFF cells is predictive of the motor facilitation evoked by repeated laser stimulation

Medullary raphe magnus (RM) on and off cells are thought to modulate spinal nociception by gating withdrawals evoked by noxious stimulation. To test whether withdrawal initiation is the target of RM modulation, we examined the relationship between on and off cell discharge and motor withdrawal evoked by noxious laser heat in halothane-anesthetized rats. The cellular responses of both cell types began during the 50 msec after onset of the tail flick, peaked within 200 msec, and outlasted the duration of the motor reaction. Thus, it is unlikely that the target of on and off cell modulation is withdrawal initiation; instead, on and off cells may modulate reactions to repeated noxious stimulation. We therefore tested whether laser heat-evoked changes in RM cell discharge were predictive of the modulatory effects of one noxious stimulus on the reaction to a subsequent noxious stimulus. Two pulses of laser heat were presented at interpulse intervals of 0.8, 2.0, or 10.0 sec. The motor withdrawal evoked by the second pulse was significantly enhanced relative to that evoked by the first pulse. The observed motor enhancement depended on supraspinal input because it was not present in spinalized rats. Comparison of the relative changes in motor and cellular activity preceding double laser heat stimulation revealed parallel changes between motor facilitation, decreases in off cell discharge, and increases in on cell discharge. This finding suggests a preparatory role for RM on and off cells in enhancing reactions to a noxious stimulus that closely follows another noxious stimulus.

Discharge of raphe magnus ON and OFF cells is predictive of the motor facilitation evoked by repeated laser stimulation

Medullary raphe magnus (RM) on and off cells are thought to modulate spinal nociception by gating withdrawals evoked by noxious stimulation. To test whether withdrawal initiation is the target of RM modulation, we examined the relationship between on and off cell discharge and motor withdrawal evoked by noxious laser heat in halothane-anesthetized rats. The cellular responses of both cell types began during the 50 msec after onset of the tail flick, peaked within 200 msec, and outlasted the duration of the motor reaction. Thus, it is unlikely that the target of on and off cell modulation is withdrawal initiation; instead, on and off cells may modulate reactions to repeated noxious stimulation. We therefore tested whether laser heat-evoked changes in RM cell discharge were predictive of the modulatory effects of one noxious stimulus on the reaction to a subsequent noxious stimulus. Two pulses of laser heat were presented at interpulse intervals of 0.8, 2.0, or 10.0 sec. The motor withdrawal evoked by the second pulse was significantly enhanced relative to that evoked by the first pulse. The observed motor enhancement depended on supraspinal input because it was not present in spinalized rats. Comparison of the relative changes in motor and cellular activity preceding double laser heat stimulation revealed parallel changes between motor facilitation, decreases in off cell discharge, and increases in on cell discharge. This finding suggests a preparatory role for RM on and off cells in enhancing reactions to a noxious stimulus that closely follows another noxious stimulus.

Hypnic headache syndrome: association of the attacks with REM sleep

We describe the polysomnographic data of two patients with nocturnal headache attacks fulfilling the clinical criteria for hypnic headache syndrome. Two overnight polysomnographic studies were performed in each patient. Four nocturnal headache attacks were captured, all emerging from the REM phase of sleep. Our findings suggest a close relationship between the REM phase of sleep and the appearance of hypnic headache attacks.

Pain and the defense response: structural equation modeling reveals a coordinated psychophysiological response to increasing painful stimulation

The defense response theory implies that individuals should respond to increasing levels of painful stimulation with correlated increases in affectively mediated psychophysiological responses. This paper employs structural equation modeling to infer the latent processes responsible for correlated growth in the pain report, evoked potential amplitudes, pupil dilation, and skin conductance of 92 normal volunteers who experienced 144 trials of three levels of increasingly painful electrical stimulation. The analysis assumed a two-level model of latent growth as a function of stimulus level. The first level of analysis formulated a nonlinear growth model for each response measure, and allowed intercorrelations among the parameters of these models across individuals. The second level of analysis posited latent process factors to account for these intercorrelations. The best-fitting parsimonious model suggests that two latent processes account for the correlations. One of these latent factors, the activation threshold, determines the initial threshold response, while the other, the response gradient, indicates the magnitude of the coherent increase in response with stimulus level. Collectively, these two second-order factors define the defense response, a broad construct comprising both subjective pain evaluation and physiological mechanisms.

Peripheral axotomy affects nicotinamide adenine dinucleotide phosphate diaphorase and nitric oxide synthases in the spinal cord of the rabbit

Using nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd) histochemistry and nitric oxide synthase (NOS) immunocytochemistry combined with radioassay of calcium-dependent NOS activity, we examined the occurrence of NADPHd staining and NOS immunoreactivity (NOS-IR) in the dorsal root ganglia (DRG) neurons, dorsal root afferents, and axons projecting via gracile fascicle to gracile nucleus 14 days after unilateral sciatic nerve transection in the rabbit. Mild to moderate NADPHd staining and NOS-IR appeared in a large number of small and medium-sized to large neurons in the ipsilateral L4-L6 DRG, accompanied by enhanced NOS-IR of thick myelinated fibers in the ipsilateral L4-L6 dorsal roots. A noticeable increase in the density of punctate NADPHd staining occurred throughout laminae I-IV in the ipsilateral medial part of the dorsal horn in L4-L6 segments. Concurrently, a statistically significant decrease in the number of small NADPHd-exhibiting neurons in laminae I-II and, in contrast to this, a statistically significant increase of medium-sized to large NADPHd-stained somata in the ipsilateral laminae III-VI of L4-L6 segments were found. A detailed compartmentalization of L4-L6 segments into gray and white matter regions disclosed substantially increased catalytic NOS activity and inducible NOS mRNA levels in the dorsal horn and dorsal column ipsilaterally to the peripheral injury. A noticeable increase in the number of thick myelinated NADPHd-exhibiting and NOS-IR axons was noted in the ipsilateral gracile fascicle, terminating in dense, punctate NADPHd staining in the neuropil of the gracile nucleus. These observations indicate that the de novo-synthesized NOS in the lesioned primary afferent neurons resulting after sciatic nerve transection may be involved in an increase in NADPHd staining and NOS-IR in the ipsilateral dorsal roots and dorsal horn of L4-L6 segments, whence NOS could be supplied to ascending axons of the gracile fascicle.

Sensory function in spinal cord injury patients with and without central pain

Spinal cord injury (SCI) frequently results in neuropathic pain. However, the pathophysiology underlying this pain is unclear. In this study, we compared clinical examination, quantitative sensory testing (QST) and somatosensory evoked potentials (SEPs) in SCI patients with and without pain below spinal lesion level, with a control group of 20 subjects without injury. All patients had a traumatic SCI with a lesion above T10; 20 patients presented with spontaneous central neuropathic pain below lesion level, and 20 patients had no neuropathic pain or dysaesthesia. Patients with and without pain had a similar reduction of mechanical and thermal detection and pain thresholds, and SEPs. SCI patients with central pain more frequently had sensory hypersensitivity (brush- or cold-evoked pain, dysaesthesia or pinprick hyperalgesia) in dermatomes corresponding to lesion level than SCI patients without pain. There was no difference in intensity of pain evoked by repetitive pinprick at lesion level between patient groups. There was a significant correlation between intensity of brush-evoked dysaesthesia at lesion level and spontaneous pain below lesion level of SCI. These data suggest that lesion of the spinothalamic pathway alone cannot account for central pain in SCI patients, and that neuronal hyperexcitability at injury or higher level may be an important mechanism for pain below injury level.

Functional plasticity in the human primary somatosensory cortex following acute lesion of the anterior lateral spinal cord: neurophysiological evidence of short-term cross-modal plasticity

The primary somatosensory cortex (S1) in adult animals and humans is capable of rapid modification after deafferentation. These plastic changes may account for a loss of tonic control by nociceptive inputs over inhibitory mechanisms within structures of the dorsal column-medial lemniscal system. Most studies, however, have been performed under conditions where deafferentation of C and A delta fibres coexists with large-diameter fibres deafferentation. In this study the effect of the acute lesion of one ascending anterior lateral column on neuronal activity within the dorsal column-medial lemniscal system was assessed by recording somatosensory evoked potentials (SEPs) in seven patients who underwent unilateral percutaneous cervical cordotomy (PCC) as treatment for drug-resistant malignant pain.Spinal, brainstem and cortical SEPs were recorded 2h before and 3h after PCC by stimulating the posterior tibial nerve at both ankles. Amplitudes of cortical potentials obtained by stimulation of the leg contralateral to PCC were significantly increased after PCC. No significant changes in spinal or brainstem potentials were observed. PCC did not affect SEP components obtained by stimulation of the leg ipsilateral to PCC. Our results suggest that nociceptive deafferentation may induce a rapid modulation of cortical neuronal activity along the lemniscal pathway, thus providing the first evidence in humans of short-term cortical plasticity across the spinothalamic and lemniscal systems.