The effects of the sympathetic nerves on lumbar radicular pain

Usefulness of digital infrared thermography video using the FLIR T560 in detecting hypothermia associated with lumbosacral radiculopathy following spinal stenosis: A CARE-compliant case report

RATIONALE

Here, we investigated the effectiveness of the FLIR T560 thermal imaging camera in detecting hypothermic changes associated with radiculopathy caused by spinal stenosis. This study aimed to determine whether the FLIR T560 could serve as a portable, efficient tool for diagnosing radiculopathy and its related sympathetic dysfunction in clinical practice.

PATIENT CONCERNS

A 77-year-old male had a 1-year history of neuropathic pain in the right distal lower leg, confirmed as L5 and S1 radiculopathy due to central stenosis at L4-5 and L5-S1, as shown by MRI and electrodiagnostic studies. The FLIR T560 recorded thermal images in an insulated room, revealing a significantly lower surface temperature (approximately 1.0°C difference) on the lateral and posterior right distal lower leg and right toes compared with the left side. By referencing the color map and scale, we estimated that the relative temperature difference between corresponding areas was approximately 1.0°C.

DIAGNOSES

L5 and S1 radiculopathy due to central stenosis at L4-5 and L5-S1.

INTERVENTIONS

A transforaminal epidural steroid injection targeting the right L5 and S1 nerve roots was conducted.

OUTCOMES

The patient's pain improved significantly.

LESSONS

The FLIR T560 camera offers a portable and convenient alternative to traditional digital infrared thermographic imaging, allowing real-time thermal imaging in a clinical setting without the need for additional equipment. Our case report suggests that the FLIR T560 is a valuable tool for detecting sympathetic dysfunction associated with radiculopathy. Further studies with larger patient populations are recommended to validate its clinical utility.

Expression of the noradrenaline transporter in the peripheral nervous system

The noradrenaline transporter (NAT) transfers noradrenaline released into the synaptic cleft back into the presynaptic terminal, thus terminating neurotransmission. Although the distribution of NAT within the central nervous system has been well-characterized, less is known about its distribution elsewhere in the peripheral nervous system and in organs such as the skin. To address this in the present study, NAT expression was investigated using immunohistochemistry in the hind paw skin and more proximally in the sciatic nerve, dorsal root ganglia and spinal cord of five male Wistar rats. It was hypothesised that NAT would be expressed exclusively on nerve fibres labelled by dopamine beta hydroxylase (DβH), an enzyme involved in the conversion of dopamine to noradrenaline. NAT co-localised with DβH in neurons in the spinal cord, dorsal root ganglia and sciatic nerve. Unexpectedly, however, NAT-like immunoreactivity was not observed in DβH immuno-reactive fibres that innervated dermal blood vessels, suggesting that a mechanism other than presynaptic re-uptake of noradrenaline through NAT regulates transmission at neurovascular junctions in the skin. Furthermore, a novel association between NAT-like immunoreactivity and the myelin marker myelin basic protein (MBP) was identified in peripheral nerves. Specifically, NAT and MBP appeared to congregate around primary afferent nerve fibres labelled by neurofilament 200, a marker of neurons with medium- and large-diameter axons. NAT-like immunoreactivity was also detected in cultured Schwann cells immunohistochemically and at the mRNA level. Together, these findings imply a hitherto unrecognised role of Schwann cells in clearance of noradrenaline in the peripheral nervous system.

Analgesic effects of calcitonin on radicular pain in male rats

Purpose

Radicular pain is a frequently observed symptom of lumbar disk herniation or lumbar spinal canal stenosis. Achieving radicular pain relief is difficult. This type of pain may progress to chronic neuropathic pain. Calcitonin (elcatonin [eCT]) has been used mainly for hypercalcemia and pain associated with osteoporosis. The purpose of this study was to investigate analgesic effects of repeated eCT administration on radicular pain in male rats and changes in mRNA-expression levels of voltage-dependent sodium channels in the dorsal root ganglion (DRG).

Methods

Seventy male Sprague-Dawley rats were used. A right L5 hemilaminectomy and an L5-L6 partial facetectomy were performed to expose the right L5 nerve root. Under a microscope, the right L5 spinal nerve root was tightly ligated extradurally with 8-0 nylon suture proximally to the DRG to cause radicular pain in rats. Mechanical hyperalgesia, thermal hyperalgesia, and analgesic effects of eCT were compared among rats with radicular pain that received eCT, those that received the vehicle, and sham rats that received the vehicle. Real-time reverse-transcription PCR was performed to measure mRNA-expression levels of tetrodotoxin-sensitive (Na_V1.3 and Na_V1.6) and tetrodotoxin-resistant (Na_V1.8 and Na_V1.9) sodium channels in the DRG.

Results

Mechanical and thermal hyperalgesic reactions occurring in rats with radicular pain significantly improved on days 5 and 9 of eCT administration, respectively. In rats with radicular pain, mRNA-expression levels of Na_V1.3, Na_V1.8, and Na_V1.9 increased. After repeated eCT administration, mRNA-expression levels of these sodium channels in rats with radicular pain improved to the same levels as in sham rats.

Conclusion

The present study demonstrated that repeated systemic eCT administration was effective for radicular pain. No serious side effects of eCT have been reported thus far. Therefore, calcitonin may be a preferred therapeutic option for patients with radicular pain or for those requiring long-term treatment.

Lumbar sympathectomy regulates vascular cell turnover in rat hindfoot plantar skin

BACKGROUND

Sympathetic denervation and impaired angiogenesis cause skin diseases. However, the relationship between the sympathetic nervous system and vascular cell turnover in normal skin remains unclear.

OBJECTIVE

To determine the effects of sympathetic denervation on vascular cell turnover in normal skin.

METHODS

Rats underwent bilateral L2-4 sympathetic trunk resection (sympathectomy group) or sham operation (control). Hindfoot plantar skin was analyzed 2 weeks and 3 months postoperatively.

RESULTS

Mural cell marker (α-smooth muscle actin; p < 0.001, and desmin; p = 0.047) expression decreased 2 weeks after sympathectomy, but recovered 3 months after sympathectomy (p > 0.05). CD31 levels were lower in the experimental group than in the control group at 2 weeks (p = 0.009), but not at 3 months. Von Willebrand factor, vascular endothelial growth factor, and angiopoietin-2 expression were not significantly different between the groups (p > 0.05). Angiopoietin-1 expression levels were higher in the experimental group than in the control group at 2 weeks (p = 0.035), but not at 3 months.

CONCLUSIONS

Lumbar sympathectomy regulates vascular cell turnover in rat hindfoot plantar skin by inhibiting mural cell proliferation and increasing angiopoietin-1 expression. Sympathetic nerves therefore play an important role in plantar skin vascular cell turnover.

Suppression of Sympathetic Nerve Sprouting by Local Administration of an α-antagonist Around the Dorsal Root Ganglion in a Lumbar Radiculopathy Model

STUDY DESIGN

Animal experimental study with intervention.

OBJECTIVE

The purpose of this study was to elucidate whether local administration of an α-antagonist around the dorsal root ganglion (DRG) suppressed sympathetic nerve sprouting, from the acute to the chronic pain development phase, in a lumbar radiculopathy model using immunohistochemical methods.

SUMMARY OF BACKGROUND DATA

The abnormal sympathetic-somatosensory interaction may underlie some forms of neuropathic pain. There were several reports suggesting α-antagonists are effective to treat neuropathic pain. However, its pathophysiological mechanisms remain obscure.

METHODS

We used 70 male Sprague-Dawley rats. After root constriction (RC), rats received a series of three local injections of the nonselective α-antagonist phentolamine around the DRG for 3 days. There were three groups of rats: those that were injected from the day of surgery and those injected from day 4 and third group injected from day 11. The control rats were subjected to RC but equal-volume normal saline injections, and the naïve rats were not subjected to any surgical procedures. At the 14th postoperative day, the left L5 DRG was removed, embedded in paraffin, and sectioned. Sections were then immunostained with antibodies to tyrosine hydroxylase (TH). To quantify the extent of the presence of sympathetic nerve fibers, we counted TH-immunoreactive fibers in the DRG using a light microscope equipped with a micrometer graticule. We counted the squares of the graticule, which contained TH-immunoreactive fibers for each of five randomly selected sections of the DRG.

RESULTS

In the naïve group, TH-immunoreactive fibers were scarce in the DRG. α-antagonist injections from postoperative day 0 and 4 suppressed sympathetic nerve sprouting compared with the control group. α-antagonist injections from postoperative day 11 had no suppressant effect compared with the control group.

CONCLUSION

The α-antagonist administered around the DRG could suppress neural plastic changes in the early phase after nerve injury.

LEVEL OF EVIDENCE

N/A.

Lumbar sympathectomy reduces vascular permeability, possibly through decreased adenosine receptor A2a expression in the hind plantar skin of rats

BACKGROUND

The effect of lumbar sympathectomy for the treatment of lower limb ischemia remains a matter of controversy.

METHODS

Sprague-Dawley rats were subjected to lumbar sympathectomy, after which Evans blue dye was injected into the hind plantar skin. Extravasation of dye was measured and compared with rats undergoing sham operation. Hind plantar skin was processed for HE staining, immunohistochemistry, and Western blot.

RESULTS

In sympathectomized rats, blue stained areas in hind plantar skin and concentrations of Evans blue were significantly less than that of sham sympathectomy (control) rats, both 2 weeks and 3 months after surgery. Expression of prostaglandin E2, bradykinin, bradykinin B2 receptor, and adenosine triphosphate were not significantly different between the sympathectomized and control groups. Adenosine receptor A2a expression was significantly reduced in the sympathectomized group both 2 weeks and 3 months after surgery.

CONCLUSION

Vascular permeability in the hind plantar skin of rats decreases following lumbar sympathectomy, possibly via reduced expression of adenosine receptor A2a.

Detailed Characterization of Sympathetic Chain Ganglia (SChG) Neurons Supplying the Skin of the Porcine Hindlimb

It is generally known that in the skin sympathetic fibers innervate various dermal structures, including sweat glands, blood vessels, arrectores pilorum muscles and hair follicles. However, there is a lack of data about the distribution and chemical phenotyping of the sympathetic chain ganglia (SChG) neurons projecting to the skin of the pig, a model that is physiologically and anatomically very representative for humans. Thus, the present study was designed to establish the origin of the sympathetic fibers supplying the porcine skin of the hind leg, and the pattern(s) of putative co-incidence of dopamine-β-hydroxylase (DβH) with pituitary adenylate cyclase-activating polypeptide (PACAP), somatostatin (SOM), neuronal nitric oxide synthase, substance P, vasoactive intestinal peptide, neuropeptide Y (NPY), leu5-enkephalin and galanin (GAL) using combined retrograde tracing and double-labeling immunohistochemistry. The Fast Blue-positive neurons were found in the L₂-S₂ ganglia. Most of them were small-sized and contained DβH with PACAP, SOM, NPY or GAL. The findings of the present study provide a detailed description of the distribution and chemical coding of the SChG neurons projecting to the skin of the porcine hind leg. Such data may be the basis for further studies concerning the plasticity of these ganglia under experimental or pathological conditions.

Sympathectomy and Sympathetic Blockade Reduce Pain Behavior Via Alpha-2 Adrenoceptor of the Dorsal Root Ganglion Neurons in a Lumbar Radiculopathy Model

STUDY DESIGN

Animal experimental study with intervention.

OBJECTIVE

We investigated whether sympathectomy and pharmacological sympathetic blockade reduced pain behavior and reversed adrenoceptor mRNA expression of the dorsal root ganglion (DRG) in a lumbar radiculopathy model.

SUMMARY OF BACKGROUND DATA

The abnormal sympathetic-somatosensory interaction may underlie some forms of neuropathic pain. There are several reports that sympathectomy and pharmacological sympathetic blockades are often effective to treat neuropathic pain. However, its pathophysiological mechanisms remain obscure.

METHODS

We used 91 male Sprague-Dawley rats. Just after root constriction (RC), the rats underwent sympathectomy or received 3 local injections of subtype-specific α-adrenergic receptor antagonists around the DRG. We evaluated the analgesic effects of sympathectomy and sympathetic blockade using behaviors indicative mechanical allodynia and thermal hyperalgesia. We estimated the mRNA expression levels of the DRG adrenoceptor subtypes using real time reverse transcription polymerase chain reaction.

RESULTS

Sympathectomy and α2-antagonist significantly reduced the mechanical allodynia and thermal hyperalgesia after RC. Real time reverse transcription polymerase chain reaction analysis indicated that sympathectomy possibly reversed α2A- and α2B-adrenoceptors mRNA overexpression in the DRG after RC.

CONCLUSION

We considered that pain behaviors of neuropathic pain are due, at least in part, to enhanced sympathetic noradrenergic transmission within the DRG. Suppression of sympathetic activity by reducing adrenergic release, α2-adrenoceptor stimulation, and/or α2-adrenoceptor upregulation in the DRG may relieve neuropathic pain.

LEVEL OF EVIDENCE

3.

Transient receptor potential ankyrin 1 in spinal cord dorsal horn is involved in neuropathic pain in nerve root constriction rats

Background

Lumbar radicular pain is categorized as a type of neuropathic pain, but its pathophysiological mechanisms are not fully understood. The substantia gelatinosa (SG) in the spinal cord dorsal horn receives primary afferent inputs and is considered to be a therapeutic target for treating neuropathic pain. In vivo patch-clamp recording is a useful procedure for analyzing the functional properties of synaptic transmission in SG neurons. Transient receptor potential ankyrin 1 (TRPA1) has been widely identified in the central and peripheral nervous systems, such as in the peripheral nociceptor, dorsal root ganglion, and spinal cord dorsal horn and is involved in synaptic transmission of pain. However, its functional role and mechanism of pain transmission in the spinal cord dorsal horn are not well understood. The purpose of this study was to use in vivo patch-clamp analysis to examine changes in the excitatory synaptic transmission of SG neurons treated with TRPA1 antagonist and to clarify the potential role of TRPA1 in the rat spinal cord dorsal horn.

Results

The rats with root constriction (RC) showed mechanical hypersensitivity, hyperalgesia, and thermal hyperalgesia. In addition, pin pricks elicited pain-related behavior even in the sham and naïve rats. These pain-related behaviors were significantly attenuated by intrathecal injection of a TRPA1 antagonist. The degrees of intrathecal injection efficacy were equivalent among the 3 groups (RC, sham, and naïve groups). In an electrophysiological study, the frequencies and amplitudes of excitatory postsynaptic currents (EPSCs) were significantly increased in the RC rats compared with those in the sham and naïve rats. Spontaneous EPSCs and evoked-EPSCs by non-noxious and noxious stimuli were significantly decreased by TRPA1 antagonist. As in the behavioral study, there were no statistically significant differences among the 3 groups.

Conclusion

These data showed that the TRPA1 antagonist had an inhibitory effect on mechanical hypersensitivity and hyperalgesia as well as on physiological pain transmission in the spinal cord dorsal horn. This suggests that TRPA1 is consistently involved in excitatory synaptic transmission even in the physiological state and has a role in coordinating pain transmission.

Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report

Thoracolumbar junction syndrome is characterized by referred pain which may originate at the thoracolumbar junction, which extends from 12th thoracic vertebra to 2nd lumbar vertebra, due to functional abnormalities. Clinical manifestations include back pain, pseudo-visceral pain and pseudo-pain on the posterior iliac crest, as well as irritable bowel symptoms. During clinical examination, pain can be demonstrated by applying pressure on the facet joints or to the sides of the spinous processes. Radiological studies show only mild and insignificant degenerative changes in most cases. We report a 42-year-old female patient with osteogenesis imperfecta who suffered from chronic low back pain. Under the diagnosis of thoracolumbar junction syndrome, she was treated with an epidural block and a sympathetic nerve block, which improved her symptoms.

Sympathectomy attenuates excitability of dorsal root ganglion neurons and pain behaviour in a lumbar radiculopathy model

Objectives

In order to elucidate the influence of sympathetic nerves on lumbar radiculopathy, we investigated whether sympathectomy attenuated pain behaviour and altered the electrical properties of the dorsal root ganglion (DRG) neurons in a rat model of lumbar root constriction.

Methods

Sprague-Dawley rats were divided into three experimental groups. In the root constriction group, the left L5 spinal nerve root was ligated proximal to the DRG as a lumbar radiculopathy model. In the root constriction + sympathectomy group, sympathectomy was performed after the root constriction procedure. In the control group, no procedures were performed. In order to evaluate the pain relief effect of sympathectomy, behavioural analysis using mechanical and thermal stimulation was performed. In order to evaluate the excitability of the DRG neurons, we recorded action potentials of the isolated single DRG neuron by the whole-cell patch-clamp method.

Results

In behavioural analysis, sympathectomy attenuated the mechanical allodynia and thermal hyperalgesia caused by lumbar root constriction. In electrophysiological analysis, single isolated DRG neurons with root constriction exhibited lower threshold current, more depolarised resting membrane potential, prolonged action potential duration, and more depolarisation frequency. These hyperexcitable alterations caused by root constriction were significantly attenuated in rats treated with surgical sympathectomy.

Conclusion

The present results suggest that sympathectomy attenuates lumbar radicular pain resulting from root constriction by altering the electrical property of the DRG neuron itself. Thus, the sympathetic nervous system was closely associated with lumbar radicular pain, and suppressing the activity of the sympathetic nervous system may therefore lead to pain relief.

Does norepinephrine influence pain behavior mediated by dorsal root ganglia?: a pilot study

BACKGROUND

Postganglionic neurons in the sympathetic nervous system reportedly are involved in lumbar radicular pain and release norepinephrine (NE), a neurotransmitter. Increased numbers of sympathetic nerve fibers have been found in dorsal root ganglion (DRG) neurons in a root constriction model. Whether this is a reasonable model for pain, however, is unclear

QUESTIONS/PURPOSES

We asked whether: (1) painful behaviors occurred in the root constriction model; (2) NE enhanced the excitability of DRG neurons in the root constriction model; and (3) which adrenoceptors were related to the mediation of the NE effects.

METHODS

The L5 root was sutured proximal to the DRG as the root constriction model. Behavioral tests were performed until 28 days after surgery. At 10 to 14 days after the root constriction, DRG neurons were quickly excised and digested with collagenase for electrophysiologic studies. Action potentials were recorded from single DRG neurons using a whole-cell patch clamp technique. NE (10 μmol/L) was directly applied to the DRG neurons. The adrenergic sensitivity was examined in combination with antagonists.

RESULTS

The rats with root constriction exhibited painful behavior. NE increased the excitability of DRG neurons in the root constriction model. The effects of NE were inhibited by pretreatment with an α-antagonist and α(2)-antagonist but not an α(1)-antagonist.

CONCLUSIONS

Our observations suggest NE plays an important role in generating lumbar radicular pain mainly via α(2)-adrenoceptors.

CLINICAL RELEVANCE

An α(2)-antagonist may be an appropriate agent for trials to treat lumbar radicular pain.

Changes in synaptic transmission of substantia gelatinosa neurons in a rat model of lumbar radicular pain revealed by in vivo patch-clamp recording

Little is known about the pathophysiological mechanisms of radicular pain. We investigated changes in synaptic transmission of substantia gelatinosa (SG) neurons after an injury to the L5 nerve root using in vivo patch-clamp recording. A total of 141 SG neurons were recorded at L4 and L5 segmental levels of the spinal cord in root constriction rats and sham-operated control rats. At L4 and L5 segmental levels, SG neurons without a receptive field were observed only in root constriction rats, and the frequencies of spontaneous action potential firings in SG neurons were higher in the root constriction group than in the control group. At the L5 segmental level, the frequencies and amplitudes of spontaneous excitatory postsynaptic currents (EPSCs) as well as the proportion of multireceptive neurons among SG neurons was higher in the root constriction group than in the control group. At the L4 segmental level, the frequencies and amplitudes of spontaneous EPSCs were increased in the root constriction group, but the proportions of cell types did not change. The mean amplitudes of EPSCs evoked by mechanical stimuli at L4 and L5 segmental levels were larger in the root constriction group than in the control group. The results indicated that injuring the nerve root led to characteristic excitatory synaptic transmission in SG neurons at each segmental level and changed sensory processing in SG neurons at the segment to which the injured nerve projected. These changes could lead to spontaneous pain, mechanical allodynia, and hyperalgesia contributing to the pathogenesis of radicular pain.

Periganglionic inflammation elicits a distally radiating pain hypersensitivity by promoting COX-2 induction in the dorsal root ganglion

We have developed a model in which inflammation contiguous to and within a dorsal root ganglion (DRG) was generated by local application of complete Freund's adjuvant (CFA) to the L4 lumbar spinal nerve as it exits from the intervertebral foramen. The periganglionic inflammation (PGI) elicited a marked reduction in withdrawal threshold to mechanical stimuli and an increase in heat pain sensitivity in the ipsilateral hindpaw in the absence of any hindpaw inflammation. The pain sensitivity appeared within hours and lasted for a week. The PGI also induced a prominent increase in IL-1beta and TNF-alpha levels in the DRG and of cyclooxygenase-2 (COX-2) expression in neurons and satellite cells. A selective COX-2 inhibitor reduced the PGI-induced hyperalgesia. We also show that IL-1beta induces COX-2 expression and prostaglandin release in DRG neurons in vitro in a MAP kinase-dependent fashion. The COX-2 induction was prevented by ERK and p38 inhibitors. We conclude that periganglionic inflammation increases cytokine levels, including IL-1beta, leading to the transcription of COX-2 and prostaglandin production in the affected DRG, and thereby to the development of a dermatomally distributed pain hypersensitivity.