Long-range afferents in the rat spinal cord. 1. Numbers, distances and conduction velocities

A perspective: neuraxial therapeutics in pain management: now and future

The neuraxial delivery of drugs for the management of pain and other spinal pathologies is widely employed and is the subject of a large volume of ongoing research with several thousand papers appearing in the past 5 years alone on neuraxial delivery. Several learned texts have been recently published. A number of considerations have contributed to this widespread interest in the development of the use of neuraxial therapeutics to manage pain. In the following section, major topics relevant to spinal encoding and in the use of neuraxial therapeutics are considered by the Frontiers in Pain Research editors of the research topic: "Neuraxial Therapeutics in Pain Management: Now and Future". This paper seeks to serve as a perspective to encourage the submission of manuscripts reflecting research in this exciting area.

Refinement of intrathecal catheter design to enhance neuraxial distribution

BACKGROUND

Delivery of therapeutics via indwelling intrathecal catheters is highly efficacious for targeting of pain, spasticity, neuraxial cancer and neurodegenerative disorders. However, current catheter designs have some major limitations. Given limited CSF flow, fixed intrathecal volume and the large distance of the rostro-caudal spinal axis, current intrathecal delivery routes fail to achieve adequate drug distribution. Additionally open catheter systems are plagued with cellular ingrowth and debris accumulation if used intermittently.

NEW METHOD

RESULTS/COMPARISON WITH EXISTING METHOD(S): High speed imaging showed micro-valve catheters greatly increase fluid exit velocities compared to typical open-ended catheters, which prevents pooling of injectate proximal to the opening. When implanted intrathecally in rats, small injection volumes (7.5 μL) of dye or AAV9-RFP, resulted in an even rostro-caudal distribution along the spinal axis and robust transfection of neurons from cervical to lumbar dorsal root ganglia. In contrast, such injections with an open-ended catheter resulted in localized distribution and transfection proximal to the delivery site. Our poly micro-valve catheter design resulted in equivalent transfection rates of cervical DRG neurons using 100x lower titer of AAV9-RFP. Unlike open port catheters, no debris accumulation was observed in the lumen of implanted catheters, showing potential for long-term intermittent use.

CONCLUSIONS

This catheter platform, suitable for small animal models is easily scalable for human use and addresses many of the problems observed with common catheter systems.

Neuraxial drug delivery in pain management: An overview of past, present, and future

Activation of neuraxial nociceptive linkages leads to a high level of encoding of the message that is transmitted to the brain and that can initiate a pain state with its attendant emotive covariates. As we review here, the encoding of this message is subject to a profound regulation by pharmacological targeting of dorsal root ganglion and dorsal horn systems. Though first shown with the robust and selective modulation by spinal opiates, subsequent work has revealed the pharmacological and biological complexity of these neuraxial systems and points to several regulatory targets. Novel therapeutic delivery platforms, such as viral transfection, antisense and targeted neurotoxins, point to disease-modifying approaches that can selectively address the acute and chronic pain phenotype. Further developments are called for in delivery devices to enhance local distribution and to minimize concentration gradients, as frequently occurs with the poorly mixed intrathecal space. The field has advanced remarkably since the mid-1970s, but these advances must always address the issues of safety and tolerability of neuraxial therapy.

Intrathecal Drug Delivery: Advances and Applications in the Management of Chronic Pain Patient

Advances in our understanding of the biology of spinal systems in organizing and defining the content of exteroceptive information upon which higher centers define the state of the organism and its role in the regulation of somatic and automatic output, defining the motor response of the organism, along with the unique biology and spatial organization of this space, have resulted in an increased focus on therapeutics targeted at this extracranial neuraxial space. Intrathecal (IT) drug delivery systems (IDDS) are well-established as an effective therapeutic approach to patients with chronic non-malignant or malignant pain and as a tool for management of patients with severe spasticity and to deliver therapeutics that address a myriad of spinal pathologies. The risk to benefit ratio of IDD makes it a useful interventional approach. While not without risks, this approach has a significant therapeutic safety margin when employed using drugs with a validated safety profile and by skilled practioners. The present review addresses current advances in our understanding of the biology and dynamics of the intrathecal space, therapeutic platforms, novel therapeutics, delivery technology, issues of safety and rational implementation of its therapy, with a particular emphasis upon the management of pain.

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment

BACKGROUND

Dorsal root ganglion stimulation (DRG-S) is a novel approach to treat chronic pain. Lead placement at L2 has been reported to be an effective treatment for axial low back pain (LBP) primarily of discogenic etiology. We have recently shown, in a diverse cohort including cases of multilevel instrumentation following extensive prior back surgeries, that DRG-S lead placement at T12 is another promising target. Local effects at the T12 DRG, alone, are insufficient to explain these results.

MATERIALS AND METHODS

We performed a literature review to explore the mechanisms of LBP relief with T12 DRG-S.

FINDINGS

Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and enters the DH of the spinal cord at T10. Low back Aδ and C-fibers then ascend via Lissauer's tract (LT) to T8-T9, converging with other low back afferents. DRG-S at T12, then, results in inhibition of the converged low back fibers via endorphin-mediated and GABAergic frequency-dependent mechanisms. Therefore, T12 lead placement may be the optimal location for DRG-S to treat LBP.

Current and Future Issues in the Development of Spinal Agents for the Management of Pain

Targeting analgesic drugs for spinal delivery reflects the fact that while the conscious experience of pain is mediated supraspinally, input initiated by high intensity stimuli, tissue injury and/or nerve injury is encoded at the level of the spinal dorsal horn and this output informs the brain as to the peripheral environment. This encoding process is subject to strong upregulation resulting in hyperesthetic states and downregulation reducing the ongoing processing of nociceptive stimuli reversing the hyperesthesia and pain processing. The present review addresses the biology of spinal nociceptive processing as relevant to the effects of intrathecally-delivered drugs in altering pain processing following acute stimulation, tissue inflammation/injury and nerve injury. The review covers i) the major classes of spinal agents currently employed as intrathecal analgesics (opioid agonists, alpha 2 agonists; sodium channel blockers; calcium channel blockers; NMDA blockers; GABA A/B agonists; COX inhibitors; ii) ongoing developments in the pharmacology of spinal therapeutics focusing on less studied agents/targets (cholinesterase inhibition; Adenosine agonists; iii) novel intrathecal targeting methodologies including gene-based approaches (viral vectors, plasmids, interfering RNAs); antisense, and toxins (botulinum toxins; resniferatoxin, substance P Saporin); and iv) issues relevant to intrathecal drug delivery (neuraxial drug distribution), infusate delivery profile, drug dosing, formulation and principals involved in the preclinical evaluation of intrathecal drug safety.

Impulse propagation over tactile and kinaesthetic sensory axons to central target neurones of the cuneate nucleus in cat

Paired, simultaneous recordings were made in anaesthetized cats from the peripheral and central axons of individual tactile and kinaesthetic sensory fibres. The aim was to determine whether failure of spike propagation occurred at any of the three major axonal branch points in the path to their cuneate target neurones, and whether propagation failure may contribute, along with synaptic transmission failures, to limitations in transmission security observed for the cuneate synaptic relay. No evidence for propagation failure was found at the two major axonal branch points prior to the cuneate nucleus, namely, the T-junction at the dorsal root ganglion, and the major branch point near the cord entry point, even for the highest impulse rates (approximately 400 impulses s(-1)) at which these fibres could be driven. However, at the highest impulse rates there was evidence at the central, intra-cuneate recording site of switching between two states in the terminal axonal spike configuration. This appears to reflect a sporadic propagation failure into one of the terminal branches of the sensory axon. In conclusion, it appears that central impulse propagation over group II sensory axons occurs with complete security through branch points within the dorsal root ganglion and at the spinal cord entry zone. However, at high rates of afferent drive, terminal axonal propagation failure may contribute to the observed decline in transmission security within the cuneate synaptic relay.

An approach to the complexity of the brain

The establishment of ordered neuronal connections is supposed to take place under the control of specific cell adhesion molecules (CAM) which guide neuroblasts and axons to their appropriate destination. The extreme complexity of the nervous system does not provide a favorable medium for the development of deterministic connections. Simon's [112] theorems offer a mean to approach the high level of complexity of the nervous system. The basic tenet is that complex systems are hierarchically organized and decomposable. Such systems can arise by selective trial and error mechanisms. Subsystems in complex systems only interact in an aggregate manner, and no significant information is lost if the detail of aggregate interactions is ignored. A number of nervous activities, which qualify for these requirements, are shown. The following sources of selection are considered: internal and external feedbacks, previous experience, plasticity in simple structures, and the characteristic geometry of dendrites. The role played by CAMs and other membrane-associated molecules is discussed in the sense that they are either inductor molecules that turn on different homeobox genes, or downstream products of genes, or both. These molecules control cellular and tissular differentiation in the developing brain creating sources of selection required for the trial and error process in the organization of the nervous tissue.

Correlation between functional and electrophysiological recovery in acute ischemic stroke

BACKGROUND AND PURPOSE

There is still controversy about the prognostic value of motor evoked potentials (MEPs) in the assessment of hemiplegia. The aims of this study are to determine the relationship between functional and electrophysiological recovery and thus the value of MEP as a prognostic indicator of clinical outcome in acute ischemic stroke.

METHODS

Seventeen healthy subjects and 38 stroke patients were included in this study. Functional recovery was assessed with the Modified Canadian Neurological Scale (MCNS), the Barthel Activities of Daily Living Index (BI), and the Rankin scale. Transcranial magnetic stimulation was used to determine the change in central motor conduction time (CMCT). Stroke outcome was assessed at the end of 2 weeks. One-way ANOVA with post hoc comparisons using the Scheffé procedure as well as t tests were used to assess the significance of the results in this study.

RESULTS

Unpaired t test showed significantly higher mean scores of the MCNS (2P=0.001), BI (2P=0.002), and Rankin scale (P<0.001) at day 14 in the group of patients with recordable MEP at day 1. A better clinical improvement with a higher mean score of the MCNS (2P<0.001), BI (2P<0.001), and the Rankin scale (2P<0.001) was also observed in the patients in whom the CMCT improved.

CONCLUSIONS

These data show that there is a close relationship between clinical and electrophysiological improvement and that MEP is a useful prognostic indicator of clinical outcome.

Spinal cord injury in small animals. 1. Mechanisms of spontaneous recovery

Spinal cord injury causes obvious clinical deficits early in the course of lesion evolution, but it is commonly observed that recovery can occur spontaneously during a period of days, weeks or even months afterwards. Spinal cord dysfunction arises after injury because of a combination of reversible alterations in the concentration of intra- and extracellular ionic constituents and irreversible tissue destruction. Recovery can therefore occur through re-establishment of the normal microenvironment of the spinal cord, which occurs soon after injury induction, and also by formation of new patterns of central nervous system circuitry. Alterations in circuitry, termed 'plasticity', can occur during the immediate period after injury but apparently continue for many weeks or months. There are differences in the extent and nature of recovery between complete and incomplete experimental spinal cord injuries that illustrate the roles played by reorganisation of intra- and suprasegmental circuitry. Information that is available on mechanisms of spontaneous recovery may aid development of novel therapies for clinical spinal cord injury.

Estimation of fiber diameters in the spinal dorsal columns from clinical data

Lack of human morphometric data regarding the largest nerve fibers in the dorsal columns (DC's) of the spinal cord has lead to the estimation of the diameters of these fibers from clinical data retrieved from patients with a new spinal cord stimulation (SCS) system. These patients indicated the perception threshold of stimulation induced paresthesia in various body segments, while the stimulation amplitude was increased. The fiber diameters were calculated with a computer model, developed to calculate the effects of SCS on spinal nerve fibers. This computer model consists of two parts: 1) a three-dimensional (3-D) volume conductor model of a spinal cord segment in which the potential distribution due to electrical stimulation is calculated and 2) an electrical equivalent cable model of myelinated nerve fiber, which uses the calculated potential field to determine the threshold stimulus needed for activation. It is shown that the largest fibers in the medial DC's are significantly smaller than the largest fibers in the lateral parts. This finding is in accordance with the fiber distribution in cat, derived from the corresponding propagation velocities. Moreover, it is shown that the mediolateral increase in fiber diameter is mainly confined to the lateral parts of the DC's. Implementation of this mediolateral fiber diameter distribution of the DC's in the computer model enables the prediction of the recruitment order of dermatomal paresthesias following increasing electrical stimulation amplitude.

Properties of individual embryonic primary afferents and their spinal projections in the rat

Embryonic (E19-E20) and early postnatal (P2) spinal cords with intact saphenous and sciatic nerves were isolated and placed in aerated artificial cerebral spinal fluid (CSF). Intracellular recordings were made from cells in the L2-L6 dorsal root ganglia using microelectrodes filled with 3 M potassium acetate or 5% neurobiotin (NB) in 1 M potassium acetate. Several physiological properties of adequately impaled cells were measured, including peripheral conduction velocity, action potential (AP) amplitude and duration, duration of afterhyperpolarization (AHP), input impedance, rheobase, presence of inward rectifying current, and maximum somal firing frequency. The extent to which these properties are correlated also was determined. One cell per ganglion was injected with NB. Stained somata and their central projections in the spinal cord were visualized in serial 50 microm sections. Cell size was determined and the central morphology of the central projections examined. Although some fibers were in the process of growing into the spinal cord, others had established projections over several millimeters in the dorsal columns. Although most of these fibers supported projections in the gray matter, 22% only maintained fibers in the dorsal columns. Fibers with projections in the dorsal horn exhibited three types of morphology: projections confined to the superficial dorsal horn (laminae I, II); terminals confined to laminae III-V; and projections spanning laminae II-V. In addition, some embryonic fibers maintained projections to the dorsal horn that extended over five lumbar segments. Somal APs could be divided into two groups: broad spikes with inflections on their falling phase and narrow spikes without inflections. On average, cells with broad spikes (BS) had the following characteristics: slower peripheral conduction velocity, larger amplitude, higher rheobase and input impedance, longer AHP duration, and lower maximum firing frequency. There were significant correlations between conduction velocity and several of the physiological properties. Conduction velocity was negatively correlated with AP duration, rheobase, and input impedance and positively correlated with maximum firing frequency. Comparisons between spike shape and central morphology revealed that cells lacking collaterals in the gray matter and those with projections in the superficial dorsal horn always had broad somal spikes with inflections. Those with projections confined to laminae III-V always had narrow somal spikes (NS).

Variation of dorsal horn cell dendritic spread with map scale

Cells in laminae III, IV, and V of cat dorsal horn were injected with horseradish peroxidase or neurobiotin. Dorsal views of the dendritic domains were constructed in order to measure their lengths, widths, areas, and length/width ratios in the horizontal plane (the plane of the somatotopic map). Dendritic domain width and area in the horizontal plane were negatively correlated with fractional distance between the medial and lateral edges of the dorsal horn. These results are consistent with the hypothesis that dendritic domain width varies with map scale, which is maximal in the medial dorsal horn. This is similar to the variation in widths of primary afferent bouton distributions. The parallel variation of dorsal horn cell dendritic domain width and primary afferent bouton distribution width with map scale suggests that there is a causal relation between morphology and map scale in the dorsal horn representation of the hindlimb. This variation of adult morphology with map scale must reflect mechanisms responsible for the assembly of receptive fields.

Development of the longitudinal projection patterns of lumbar primary sensory afferents in the chicken embryo

The literature on the anatomical organization of primary sensory afferents, though extensive, contains relatively little information about the longitudinal extent of the central collateral projections. Our understanding of intersegmental sensorimotor integration in the spinal cord and of the developmental mechanisms that establish its underlying circuitry could be significantly enhanced by a more complete description of these projections. To address this issue from a developmental perspective, we labeled the central projections of lumbar primary afferents in fixed preparations of the chicken embryo with the lipophilic tracer DiI. At late embryonic stages, the afferent projections had the following characteristics: Primary afferents originating from a single lumbar dorsal root ganglion bifurcated to project longitudinally in the dorsal funiculus or Lissauer's tract. Dorsal funiculus axons extended up to seven segments caudally and to at least ten segments rostrally, whereas axons in Lissauer's tract extended up to seven segments in each direction. Collaterals branched off the longitudinal axons over a range of about seven segments in each direction. Within this range, collaterals to specific terminal fields exhibited more restricted ranges. The development of these longitudinal patterns during earlier embryonic stages was followed from the time the afferents first reached the neural tube on day 4 of embryogenesis. The longitudinal axons lengthened as a single bundle up to day 10, with medial axons consistently longer than lateral axons. After day 10, the longitudinal axons were segregated into the dorsal funiculus and Lissauer's tract. Collaterals sprouted after about 2 days of longitudinal axon growth, by which time the axons had extended several segments in each direction. The segmental range over which collaterals were present reached a maximum of 20 segments at day 10. Collaterals to the different terminal areas differed in their segmental ranges already by this time. After day 10, the total segmental range of collaterals decreased to the stable level of about seven segments in each direction, which is characteristic of late-stage embryos.

Control of impulse conduction in long range branches of afferents by increases and decreases of primary afferent depolarization in the rat

It has been shown previously that impulses in axons of the descending branches of myelinated afferents in rat dorsal columns may suffer a blockade of transmission along their course in the dorsal columns. This paper tests the effect of the mechanism of primary afferent depolarization on the orthodromic movement of impulses in descending dorsal column primary afferent axons originating in the L1 dorsal root. Orthodromic impulses were recorded in the L5 and 6 dorsal columns after stimulation of the L1 dorsal root. Twenty-seven out of 82 axons (33%) suffered a temporary transmission block if primary afferent depolarization had been induced by L5 stimulation before the L1 stimulus. The tendency to block peaked at 10-15 ms and persisted for up to 30-40 ms. The number of single unit orthodromic impulses originating from the L1 root and recorded during a search of the dorsal columns 15 mm caudal to L1 increased by a factor of 3.1 after the systemic administration of bicuculline (1 mg/kg). The number of single unit orthodromic impulses originating from the L1 root and recorded in axons descending in the dorsal columns 20 mm caudal to the root increased by a factor of 8.7 after the systemic administration of picrotoxin (5 mg/kg). It is concluded that the transmission of impulses in the long range caudally running axons from dorsal roots to dorsal columns may be blocked during primary afferent depolarization and that conduction may be restored by the administration of GABA antagonists.

Long range afferents in rat spinal cord. III. Failure of impulse transmission in axons and relief of the failure after rhizotomy of dorsal roots

Dorsal root afferents entering the spinal cord form a T-junction with a caudal branch descending many segments and giving off side branches terminating in the dorsal horn. This anatomical finding contrasts with the physiological observation that the postsynaptic effects of arriving afferents in the dorsal horn are limited to a few segments on either side of the root carrying the input. This paper explores the possibility that one explanation for this paradox is that orthodromic impulse conduction fails to penetrate the long range parts of the caudal branch. The experiments show that when all roots are intact, very few fibres can be detected carrying orthodromic impulses as far as 20 mm caudal to the entry point. After section of neighbouring dorsal roots, however, large numbers of conducting fibres can be recorded at that point. Signs of orthodromic conduction begin 7 days after root section. These results were confirmed by another method which compared the relative refractory period of the membrane of the descending branch produced either after a local stimulus had evoked an action potential or after a rostral distant stimulus had produced an orthodromic action potential. Again, in the intact cord, the results indicate that impulses fail to penetrate long distances into the descending branches but that, as soon as 2 days after rhizotomy in the area of suspected conduction failure, orthodromic conduction is restored. It is proposed that the failure and release of conduction may depend on the control of membrane potential in the primary afferents, which would form a pre-presynaptic control mechanism.

Impulses in the rostral branch of primary afferents in rat dorsal columns travel faster than those in the caudal branch

Myelinated sensory afferents on entering the spinal cord form a junction in the dorsal columns and send a branch toward the head and another caudally. Recent experiments have shown that orthodromic impulses are reliably transmitted over the rostral branch but may suffer a transmission block in the caudal branch. This paper investigates a possible reason for the difference between rostral and caudal branches of the same axon by measuring the conduction velocities in each. Axons of either the ascending or descending branches of afferents in the L1 dorsal root of rat spinal cord were stimulated in the dorsal columns at various distances from the dorsal root. The resulting compound action potential or single unit spikes were recorded on the L1 dorsal root. The conduction velocity was found to be twice as fast in the rostral branch as in the caudal branch of the same axons.

Long-range afferents in the rat spinal cord. II. Arborizations that penetrate grey matter

1. The caudal extent of the collateral arborizations of entering sensory fibres in rat spinal cord was investigated by two methods: bulk labelling of peripheral nerves by injection of horseradish peroxidase conjugated to cholera toxin (B-HRP) and by antidromic stimulation using small currents from microelectrodes in the spinal cord while recording from single units in peripheral nerve or dorsal root. 2. The results show that injection of B-HRP into the sural or sciatic nerve labelled sural afferents in the grey matter three to four segments caudal to their root entry and sciatic nerve fibres were located in S4, the most caudal segment examined, four to six segments caudal to their root entry. 3. Detailed mapping with microelectrode stimulation showed that the parent descending fibres from filaments dissected from the L1 dorsal root coursed more than 20 mm, seven to eight segments caudal to the entry point in the dorsal columns and sent branches into the grey matter. Single units from the sural nerve were also followed caudally into the S2 and S3 spinal cord segments and also issued collateral branches into the grey matter. 4. The present results suggest that there is close agreement in the caudal penetration of long-ranging afferents by using complementary anatomical and electrophysiological methods.