[Sacral neuromodulation in fecal continence disorders]

The therapeutic approaches to the impairments of the faecal continence not depending from organic lesions of the anal sphincters or the pelvic floor are often unsuccessful, particularly as far as long distance outcome is concerned. The direct setting to the sacral roots of a magnetic stimulation modulating the reflex activity of the Autonomic Nervous System, firstly applied successfully by the urologist in the bladder incontinence, could correct indefinitely the effects of such a defect implying also a social cost in terms of quality of life and linen clothes expenses. Here details of the Interstim, Medtronic devices are reported, discussing the instrumental and clinical indications and the steps of the protocol of its application, in agreement with the Italian Group of Sacral Neuromodulation (GINS), as well as the most recent data of the literature and the early results of our own experience in the treatment of faecal incontinence. It is stressed the aspect of "work in progress" peculiar to this technique, as clearly shows the difficulty to explain the pathway with which neuromodulation effects on anal sphincters and pelvic floor, and moreover on the colorectal motility, as some ongoing applications to patients with refractory constipation seems to evidence. Data of a long standing follow-up are not yet available but the early and intermediate results are in the main successfully in terms of complete recovery or improvement as clearly show both clinical evidence and subjective evaluation assessing the Quality of Life.

Neural control of the urethra

Coordination between the urinary bladder and the urethra is mediated by multiple reflex pathways organized in the brain and spinal cord. Some reflexes promote urine storage; whereas other reflexes facilitate voiding. During bladder filling, activation of mechanoreceptor afferent nerves in the bladder wall triggers firing in the cholinergic efferent pathways to the external urethral sphincter (EUS) and in sympathetic adrenergic pathways to the urethral smooth muscle. These storage reflexes are dependent upon interneuronal circuitry in the spinal cord. During voiding the spinal storage reflexes are inhibited by supraspinal mechanisms which originate in the pontine micturition center. Glutamatergic, serotonergic and alpha, adrenergic excitatory transmission as well as GABAergic/glycinergic inhibitory transmission have been implicated in the central control of sphincter reflexes. During voiding, a parasympathetic nitrergic inhibitory input to the urethral smooth is activated. This reflex mechanism which is triggered by bladder afferents persists in paraplegic rats and therefore must be mediated at least in part by spinal interneuronal circuitry. In female rats, the parasympathetic nitrergic pathway is prominent; but in male rats it is obscured by a dominant parasympathetic cholinergic excitatory input to the urethral smooth muscle. The function of the cholinergic pathway in voiding is uncertain. Stimulation of urethral afferents can also influence bladder activity. Contraction of the external urethral sphincter activates afferents that inhibit reflex bladder contractions; whereas infusion of fluid through the urethra facilitates bladder contractions. These reflexes are also organized in the spinal cord and presumably play a role in urine storage and elimination. Alterations in primitive bladder-to-urethra and urethra-to-bladder reflex mechanisms may contribute to neurogenic bladder dysfunction.

Spinal GABA(A) and GABA(B) receptor pharmacology in a rat model of neuropathic pain

BACKGROUND

This study tests the hypothesis that loss of spinal activity of gamma-aminobutyric acid (GABA) contributes to the allodynia and hyperalgesia observed after peripheral nerve injury.

METHODS

Intrathecal catheters were implanted in male Sprague-Dawley rats. Antinociception was assessed by measuring withdrawal latency to immersion of the tail in a 52 degrees C water bath. Nerve injury was produced by ligation of the L5 and L6 spinal nerves. Testing was performed 4-14 days after spinal nerve ligation, when tactile allodynia and thermal hyperalgesia were established. Tactile allodynia was quantitated using the threshold to withdrawal of the hind paw on probing with von Frey filaments. Thermal hyperalgesia was quantitated using the latency to withdrawal of the hind paw from radiant heat. Motor function was tested using a rotarod apparatus.

RESULTS

Spinal administration of the GABAA receptor antagonist bicuculline or the GABAB receptor antagonist phaclofen produced tactile allodynia and thermal hyperalgesia in normal rats. The GABAB receptor agonist baclofen, administered spinally, produced antinociception in the tail-flick test, whereas the GABAA receptor agonist isoguvacine did not. Isoguvacine and baclofen each reversed tactile allodynia and thermal hyperalgesia produced by spinal nerve ligation. Baclofen but not isoguvacine prolonged thermal withdrawal latency in nerve-injured rats beyond preoperative values. Baclofen but not isoguvacine impaired motor function.

CONCLUSIONS

Pharmacologic inhibition of intrinsic GABA tone in normal rats resulted in tactile allodynia and thermal hyperalgesia, consistent with the hypothesis being tested. Exogenous administration of GABA agonists reversed spinal nerve ligation-induced allodynia and hyperalgesia, also consistent with this hypothesis. Isoguvacine produced specific antihyperalgesic and antiallodynic effects, whereas assessment of the effects of baclofen was complicated by motor dysfunction. Spinal GABAA agonists may provide a specific therapy for neuropathic pain.

[Effects of electrical stimulation of the dorsal cutaneous branches of spinal nerves on the discharge activity of remote mechanoreceptive units in rats]

The method of isolating filaments of the dorsal cutaneous branches was used to observe the effects of antidromic electrical stimulation of the spinal nerves on the discharge of remote A delta and C mechanoreceptive units in rats. Seventy-nine mechanoreceptive units were recorded from the T12 nerve filaments after stimulation of the dorsal cutaneous branches of T9 spinal nerve. It was found that the discharge frequency of 59.3% (16/27) A delta-units and 71.2% (37/52) C-units significantly increased during 90-120 s after the stimulation. Sixty-four mechanoreceptive units were recorded from the T12 nerve filaments after stimulation of the dorsal cutaneous branches of T8 spinal nerves. The discharge frequency of 47.8% (11/23) A delta-units and 36.6% (15/41) C-units significantly increased during 120-150 s after the stimulation. In addition, the threshold of the majority of these mechanoreceptors (78.3%, 18/23) decreased after the stimulation. The results suggest that antidromic electrical stimulation of the dorsal cutaneous branches of spinal nerves leads to sensitization of A delta and C mechanoreceptive units of the remote peripheral nerve endings, which results in an increase in afferent discharge of these units.

Regulation of the respiratory central pattern generator by chloride-dependent inhibition during development in the bullfrog (Rana catesbeiana)

Isolated brainstem preparations from larval (tadpole) and adult Rana catesbeiana were used to examine inhibitory mechanisms for developmental regulation of the respiratory central pattern generator (CPG). Preparations were superfused at 20-22 °C with Cl--free artificial cerebrospinal fluid (aCSF) or with aCSF containing agonists/antagonists ofγ-aminobutyric acid (GABA) or glycine receptors. Respiratory motor output from the CPG, measured as neural activity from cranial nerve roots, was associated with fictive gill ventilation and lung ventilation in tadpoles and with fictive lung ventilation in adults. In tadpoles, fictive lung burst frequency was 0.8±0.2 min-1 and did not change significantly with Cl--free aCSF superfusion; however, lung burst amplitude increased by nearly 400 % (P<0.01). Fictive gill ventilation averaged 41.6±3.3 min-1 and was reversibly abolished by Cl--free aCSF. Superfusion with Cl--free aCSF abolished lung bursts in two of seven adult preparations, and overall lung burst frequency decreased from 3.1±0.7 to 0.4±0.03 min-1(P<0.01), but burst amplitude was unchanged. Low concentrations of GABA (0.5 mmol l-1) produced a significant increase in lung burst frequency followed by almost complete inhibition at 5.0 mmol l-1,accompanied by the abolition of gill ventilation at 2.5-5.0 mmol l-1. By contrast, fictive lung ventilation in adults was inhibited in a dose-dependent manner by glycine and GABA, and inhibition occurred at approximately 10-fold lower concentrations compared with tadpoles. The glycine receptor antagonist strychnine (2.5-25.0 μmol l-1) and the GABAA receptor antagonist bicuculline (1-10 μmol l-1)inhibited fictive gill ventilation and increased fictive lung ventilation in tadpoles. However, bicuculline and strychnine inhibited fictive lung ventilation in adults. These results suggest that lung ventilation in the tadpole brainstem may be driven by a pacemaker-like mechanism since Cl--free aCSF failed to abolish lung ventilation. Lung ventilation in adults and gill ventilation in tadpoles, however, appear to be dependent upon conventional Cl--mediated synaptic inhibition. Thus, there may be a developmental change in the fundamental process driving lung ventilation in amphibians. We hypothesize that maturation of the bullfrog respiratory CPG reflects developmental changes in glycinergic and/or GABAergic synaptic inhibitory mechanisms.

Possible involvement of a muscarinic receptor in the anti-allodynic action of a 5-HT2 receptor agonist in rats with nerve ligation injury

Intrathecal administration of 5-HT(2) receptor agonists produces an anti-allodynic effect in a rat model of neuropathic pain. Several non-serotonergic neurotransmitters have been implicated these anti-nociceptive effects. In the present study, intrathecal pre-treatment with the muscarinic receptor antagonist atropine (10 and 30 microg) and pirenzepine (10 microg) reversed the anti-allodynic effect of the 5-HT(2) receptor agonist alpha-methyl-5-hydroxytryptamine, unlike various other antagonists. Thus, muscarinic receptors may be involved in the anti-allodynic action of intrathecally injected 5-HT(2) receptor agonist.

The differential role of spinal MHC class II and cellular adhesion molecules in peripheral inflammatory versus neuropathic pain in rodents

The present study was designed to determine the role of central expression of immunoregulatory molecules in the development and maintenance of allodynia following a peripheral inflammatory insult or nerve transection. Differential spinal expression of major histocompatibility complex (MHC) class II, platelet-endothelial cellular adhesion molecule (PECAM), intercellular adhesion molecule (ICAM) and CD4 was observed in the two injury models. Intraplantar zymosan produced transient allodynia and only PECAM and ICAM immunoreactivity. In contrast, persistent mechanical allodynia and enhanced spinal PECAM, ICAM, MHC class II and CD4 immunoreactivity was observed following peripheral nerve transection. MHC class II knockout mice exhibited attenuated allodynia following spinal nerve transection as compared to wild-type control mice. These findings suggest that central neuroimmune activation may contribute to the maintenance of neuropathic pain following peripheral L5 spinal nerve transection but not following a peripheral inflammatory insult.

Assessment of motoneuron excitability using recurrent inhibition and paired reflex depression protocols: a test of reliability

Motor output may be regulated by both pre- and post-synaptic mechanisms. The purpose of this study was to investigate the reliability of two measurement protocols, which purport to examine spinal mechanisms responsible for gating motoneuron excitability. Nine subjects (aged 29 +/- 5 years) were tested using two soleus H-reflex protocols; 1) recurrent inhibition (RI) and 2) paired reflex depression (PRD). The dependent variable for each protocol was the peak-to-peak amplitude of the conditioned Hoffmann reflex (H-reflex). Seven trials were obtained for each subject under each condition as well as control values to assess test-retest reliability. After all trials were collected the subjects rested for at least five minutes after which the process was repeated. Each subject returned to the lab after a period of no less than 24 hours at which time the process was repeated. Protocol #1: Control reflexes (20% of maximal motor response) were obtained during quiet stance. After obtaining control trials two reflex responses were elicited which were separated by 10 ms on each trial to assess recurrent inhibition (Pierrot-Deseilligny et al., 1976; Bussel and Pierrot-Deseilligny, 1977). Protocol #2: Again a double-pulse technique was used to assess reflex activation history on motoneuron pool output (Trimble et al., 2000). This protocol utilized two reflex stimuli of the same intensity separated by 80 ms. The peak-to-peak amplitude of the control, RI conditioned and PRD conditioned H-reflexes exhibited intraclass reliability estimates of .97, .97 and .93 respectively. To achieve a reliability of rI > or = .80, it is recommended that a minimum of 2 trials be used for the RI protocol and that 4 trials be used for the PRD protocol. The results indicate that both techniques provide a means to objectively and reliably measure spinal mechanisms for gating motoneuron pool output.

A combination of gabapentin and morphine mediates enhanced inhibitory effects on dorsal horn neuronal responses in a rat model of neuropathy

BACKGROUND

Peripheral nerve damage can result in severe, long-lasting pain accompanied by sensory deficits. This neuropathic pain remains a clinical problem, and effective morphine analgesia is often limited by intolerable side effects. The antiepileptic gabapentin has recently emerged as an alternative chronic pain treatment. Improved management of the diverse symptoms and mechanisms of neuropathic pain may arise from combination therapy, based on multiple pharmacologic targets and low drug doses.

METHODS

The authors used the Kim and Chung rodent model of neuropathy to induce mechanical and cold allodynia in the ipsilateral hind paw. In vivo electrophysiologic techniques were subsequently used to record evoked dorsal horn neuronal responses in which the effects of systemic morphine and gabapentin were investigated, both individually and in combination.

RESULTS

Morphine (1 and 4 mg/kg) inhibited neuronal responses of control rats but not after neuropathy. Gabapentin (10 and 20 mg/kg) inhibited neuronal responses in nerve injured rats and to a lesser extent in sham rats but not in naive rats. In the presence of gabapentin (ineffective low dose of 10 mg/kg), morphine (1 and 3 mg/kg) mediated significant inhibitory effects in all experimental groups, with the greatest inhibitions observed in spinal nerve-ligated and sham-operated rats. After neuropathy, inhibitions mediated by morphine were significantly increased in the presence of gabapentin compared with morphine alone.

CONCLUSIONS

After spinal nerve ligation, the inhibitory effects of systemic morphine on evoked dorsal horn neuronal responses are reduced compared with control, whereas the effectiveness of systemic gabapentin is enhanced. In combination with low-dose gabapentin, significant improvement in the effectiveness of morphine is observed, which demonstrates a clinical potential for the use of morphine and gabapentin combinational treatment for neuropathic pain.

L-Dopa decreases cutaneous nociceptive inhibition of motor activity in Parkinson's disease

OBJECTIVES

To estimate changes in motor inhibitory mechanisms at the spinal level in Parkinson's disease (PD) patients by measuring cutaneous silent responses to nociceptive stimuli in the course of L-Dopa therapy.

MATERIALS AND METHODS

Fourteen patients with idiopathic PD (Group 1) and 13 patients with other forms of parkinsonism (Group 2) participated in the study. The cutaneous silent period (CSP) from the hand and clinical scores (UPDRS, part III) were measured "off" therapy (T0), after a single dose of L-Dopa (T1) and 3 months after the beginning of L-Dopa daily therapy (T2).

RESULTS

At T0 the duration of the CSP was significantly prolonged in Group 1 and Group 2. At T1 and T2 the mean duration of the CSP significantly decreased in Group 1 (P < 0.05) and a significant correlation was found between the shortening of the CSP and the improvement of rigidity and bradikynesia in the upper limb.

CONCLUSIONS

Our findings show that L-Dopa decreases the cutaneous nociceptive inhibition of motor activity in PD patients. CSP may be useful to assess L-Dopa responsiveness during the clinical course of PD.

Neuroendocrine control of urine-marking behavior in male rats

Sexually experienced Wistar male rats were used to investigate (a) urine voiding in the presence of nearby estrous females and the control of such voiding by (b) steroid hormones and (c) peripheral nerves supplying the genitourinary system. The first experiment showed that males always have a low rate of urine voiding that is significantly increased when a receptive female is around. Thus, it is suggested that an airborne scent from the female stimulates the olfactory system of males, triggering urine emission to transmit sex-related messages, i.e., male rats display the well-known urine-marking behavior of mammals. The number of urine marks and sniffing to females decreased after castration, and were restored after exogenous treatment with testosterone or estradiol. The proposed hypothesis is that airborne scents from the female activate the aromatization process in nuclei of the olfactory pathway of the male, evoking a cascade of neuronal responses that finish in urine marking. Peripheral nerves supplying the genitourinary system are the viscerocutaneous branch of the pelvic nerve (Vc) and the hypogastric (Hg). Data showed that both nerves are important for the central control of urine storage and voiding. Transection of Vc almost blocked urine marking, while Hg lesion increased the number of marks. Thus, it is discussed that Vc is the most important nerve in charge of voiding the bladder, and that Hg is important for continence.

Electrophysiologic evidence for an intersegmental reflex pathway between lumbar paraspinal tissues

STUDY DESIGN

Electrophysiologic recordings were obtained from a lumbar paraspinal nerve or muscle in the anesthetized cat while electrically stimulating a paraspinal nerve or facet capsule in an adjacent lumbar segment. A variety of approaches were used to demonstrate the reflex nature of both the nerve and the muscle response.

OBJECTIVE

The primary purpose of this study was to seek electrophysiologic evidence for the presence of intersegmental reflexes between adjacent lumbar vertebral segments. A second purpose of this study was to confirm a previous procedure used to evoke paraspinal reflexes. This previous work had shown that electrical stimulation of the L1-L2 facet joint capsule elicits electromyographic activity from multifidus muscle one to two vertebral segments caudal to the stimulated facet in a porcine preparation.

SUMMARY OF BACKGROUND DATA

Biomechanical approaches have stressed the need for spinal stability to avoid conditions that could give rise to low back dysfunction. It seems reasonable to believe that reflex interactions between vertebral segments contribute to the sensorimotor integration of lumbar paraspinal tissues. It also seems reasonable to believe that alterations or abnormal elicitation of these reflexes could contribute to biomechanical changes associated with low back pain and paraspinal muscle spasm.

METHODS

Experiments were performed on 23 alpha-chloralose anesthetized adult cats. In eight cats the L3, L4, and L5 medial branch from each dorsal ramus was exposed and placed on a bipolar hook electrode. In six cats the L4 medial branch was stimulated and a compound action potential was recorded from the L3 medial branch. In three of the six cats the L5 medial branch was stimulated and a compound action potential was recorded from the L3 medial branch. In one cat the L4 medial branch was stimulated and a compound action potential was recorded from the L5 medial branch. In one cat the L3 medial branch was stimulated and a compound action potential was recorded from the L5 medial branch. At the end of each protocol the medial branch was cut just proximal to the stimulating electrode to confirm that the compound action potential was reflexive in nature and not initiated by volume conduction. In 15 cats three approaches were used to confirm that multifidus electromyographic activity evoked by electrical stimulation of a lumbar facet capsule was reflexive in nature: 1) by anesthetizing the site of the sensory endings, i.e., the facet capsule, 2) by injecting lidocaine intrathecally to block neural conduction centrally, i.e., within the spinal canal, or 3) by cutting the afferent pathway, i.e., the medial branch of the dorsal ramus.

RESULTS

Electrical stimulation of the medial branch of the dorsal ramus innervating the medial-most lumbar paraspinal tissues evoked a compound action potential in the medial branch innervating the medial-most paraspinal tissues one and two segments away. Stimulating voltages between 2 and 70 V were necessary to evoke the compound action potential. Each compound action potential was reflexive in nature because cutting the lumbar medial branch proximal to its contact with the stimulating electrode abolished each compound action potential. The conduction velocity of the reflex ranged from 3.5 to 6.1 m/sec. Electrical stimulation of a lumbar facet capsule evoked lumbar multifidus muscle electromyographic activity. However, injecting lidocaine intrathecally or transecting the medial branch of the dorsal ramus had no effect on electromyographic activity. Injecting lidocaine into the facet or into the multifidus muscle around the facet joint (near the stimulating electrode) significantly decreased the magnitude of the multifidus electromyography.

CONCLUSION

These results indicate that afferent impulses conveyed by the medial branch of the dorsal ramus reflexly altered efferent activity to an adjacent lumbar segment. This intersegmental paraspinal reflex may span at least one or two vertebral segments. The data suggest that electrical stimulation of the facet joint capsule may not have reflexly elicited multifidus activity because neither chemical interruption (intrathecal lidocaine) nor physical interruption (nerve transection) of the presumed reflex pathway diminished or abolished the electromyographic response. Volume conduction of the stimulating currents likely elicited multifidus activity during electrical stimulation of the facet capsule. When using electrical stimulation of neural paraspinal tissues to evoke reflex muscle activity, appropriate control experiments must be performed to clearly demonstrate the reflexive nature of the response.

The bilateral reflex control of the trapezius muscle in humans

Abstract. Electromyographic recordings were made from the trapezius muscle in 18 healthy subjects using surface electrodes placed bilaterally. A mechanical tap applied to the insertion of the lower fibres of trapezius evoked a reflex at 11.9 +/- 1.4 ms (mean plus minus SD) in the ipsilateral trapezius muscle. In addition and surprisingly, short latency, facilitatory reflexes were also seen on the contralateral side at a latency of 14.3 +/- 1.7 ms. Electrical stimulation of the afferent nerve to trapezius, the cervical nerve of C3/4, also evoked short latency, facilitatory reflexes from both the ipsilateral and contralateral muscles. Since this nerve carries the Ia fibres from trapezius, this reflex would appear to be the equivalent of the H reflex seen in the soleus muscle. The latency of this reflex was 10.9 +/- 1.4 ms ipsilaterally and 11.9 +/- 1.5 ms contralaterally, the difference being only 1.0 +/- 0.7 ms. Voluntary activity of the ipsilateral trapezius increased the amplitude of both mechanically and electrically evoked ipsilateral and crossed reflexes, and vibration of the ipsilateral trapezius decreased the amplitude of both reflexes. These results together suggest that the earliest parts of both ipsilateral and crossed reflexes are monosynaptic in origin. If the crossed reflex is, in part, due to a common Ia presynaptic input, correlation of bilateral trapezius activity should produce a peak in the cross-correlogram. Indeed, cross-correlation of the bilateral trapezius activity during elevation of the arms produced a short duration peak. Moreover, this was significantly larger when compared to that constructed from activity of the upper and lower fibres of trapezius from one side. These results imply that muscle spindle afferents from the ipsilateral trapezius monosynaptically activate motoneurones contralaterally.

Spinal cord injury repair research: a new combination treatment strategy

The optimism that a cure will soon be found for paraplegia and quadriplegia is strongly founded on the series of discoveries in the last two decades which showed that adult mammalian spinal cord axons can be made to regenerate given appropriate conditions and microenvironment. But then, why no cure yet in sight? Why is the delay? Spinal cord scientists are encountering a newfound obstacle in regeneration research. While axons do regenerate up and down through a graft/transplant placed at the injury site, they fail to regenerate further on once they reach healthy cord tissue beyond the injury zone. Research from our laboratory since the 1980s found that the principal reason for this failure of long distance regeneration is that the neural circuitry these axons have to traverse through are in a well-stabilized state which is unreceptive and refractory to new growth. Successful long distance regeneration is possible only within labilized (destabilized) neural tissues. We have shown simple and reliable methods of inducing labile state in adult spinal cord neural circuitry. This is achieved by inducing polyneuronal spinal motor control in the paralyzed limb muscles. We had predicted (Krishnan, 1991, 1983) two outcomes of inductive lability in paraplegia. One is partial revival of functions in the paralyzed limbs. The second outcome addresses effective relinking of the severed cord ends. Our preliminary results from adult paraplegic frogs convince us that inductive lability in these animals is capable of generating new growth and new connections in the distal isolated cord. Locomotor rhythm and function reappeared in the hind limbs, which enabled these animals to swim and progress on surface for long periods of observation up to 120 days. Based on these results we now recommend that inductive lability should be included as an essential component in the treatment strategy for spinal cord injury repair for effective relinking of the severed cord ends.

Intrathecal adenosine following spinal nerve ligation in rat: short residence time in cerebrospinal fluid and no change in A(1) receptor binding

BACKGROUND

Intrathecal adenosine produces a remarkably prolonged effect to relieve mechanical hypersensitivity after peripheral nerve injury in animals. The purpose of the current study was to investigate whether this reflected an alteration in kinetics of adenosine in cerebrospinal fluid or in the number of spinal A1 adenosine receptors after nerve injury.

METHODS

Male rats were anesthetized, and the left L5 and L6 spinal nerves were ligated. Two weeks later, a lumbar intrathecal catheter and intrathecal space microdialysis catheter were inserted. Adenosine, 20 microg, was injected intrathecally in these and in normal rats, and microdialysates of the intrathecal space were obtained. Radioligand binding studies of adenosine A1 receptors were determined in spinal cord tissue from other normal and spinal nerve-ligated rats.

RESULTS

Adenosine disappeared from rat cerebrospinal fluid within 30 min after intrathecal injection, with no difference between normal and spinal nerve-ligated animals. A1 adenosine receptor binding sites in the spinal cord were increased after spinal nerve ligation. This increase disappeared when adenosine deaminase was added to the membrane homogenates, suggestive of decreased endogenous adenosine in the membranes of nerve-ligated animals.

CONCLUSION

These data show that prolonged alleviation of hypersensitivity observed with intrathecal adenosine in this animal model of neuropathic pain is not due to prolonged residence in cerebrospinal fluid, although pharmacokinetics in tissues are unknown. Similarly, there is no evidence for up-regulation in spinal A1 adenosine receptors after spinal nerve ligation, and the adenosine deaminase experiment is consistent with a depletion of adenosine in spinal cord tissue after spinal nerve ligation.

Functional changes in the inhibitory effect of spinal cannabinoid (CB) receptor activation in nerve injured rats

Recent interest has focused on the potential of cannabinoids as novel analgesics. The aim of the present study was to investigate the effect of a potent cannabinoid agonist, HU210, on somatosensory transmission in a model of neuropathic pain. Here, the effects of spinal versus systemic administration of HU210 on noxious and innocuous evoked responses of spinal neurones of nerve injured (selective ligation of spinal nerves L5-L6) and sham operated rats were compared 14-17 days post-surgical intervention. Spinal administration of HU210 (0.5-500 ng/50 microl) significantly reduced the C-fibre mediated post-discharge response of spinal neurones in sham operated, but not nerve injured rats. By contrast, spinal HU210 significantly reduced Adelta-fibre evoked responses of spinal neurones in both sham operated and nerve injured rats.Systemic administration of HU210 (6-60 microg/kg) significantly reduced C- and Adelta-fibre evoked responses of spinal neurones in sham operated rats. HU210 (60 microg/kg) inhibited the overall C-fibre evoked response (54+/-8% of control, p<0.01), post-discharge response (28+/-12% of control, p<0.01), and Adelta-fibre evoked (48+/-5% of control p<0.01) responses of spinal neurones. In nerve injured rats, systemic administration of HU210 did not significantly reduce C- or Abeta-fibre evoked responses of spinal neurones. This study demonstrates plasticity of the spinal cannabinoid receptor system following peripheral nerve injury.

The changes in expression of three subtypes of TTX sensitive sodium channels in sensory neurons after spinal nerve ligation

Our previous studies showed that the ectopic discharges in injured sensory neurons and mechanical allodynia that developed after spinal nerve ligation were significantly reduced by application of a low concentration of tetrodotoxin (TTX) to the corresponding dorsal root ganglion (DRG) of the ligated spinal nerve. Based on these data, we hypothesized that expression of TTX-sensitive sodium channels is up-regulated in the injured sensory neurons and that such up-regulation plays an important role in the generation of ectopic discharges and thus pain behaviors in spinal nerve ligated neuropathic rats. To test this hypothesis, the present study examined the changes in three subtypes of TTX-sensitive sodium channels in the DRG after spinal nerve ligation. The changes in the total amount of mRNA for alpha-subunits of sodium channel brain type I (type I), brain type II (type II) and brain type III (type III) were determined by RNase protection assays (RPA). The population of DRG neurons expressing type III sodium channel protein was examined by an immunohistochemical method with antibodies to type III sodium channels. In the normal DRG, the level of mRNA for the type I sodium channel is high while that for type II and type III is very low. After spinal nerve ligation, the expression of type III mRNA was significantly increased at 16-h postoperatively (PO), doubled by 3 days PO and then was maintained at this high level until the end of the experiment (7 days PO). By contrast, the amount of mRNA for type I and type II sodium channels started to decrease at 1 day PO and were reduced to 25-50% of the normal control levels by 7 days after nerve ligation. Neurons showing positive immunostaining for type III sodium channels were rare ( approximately 3.2% of total population) in the normal DRG but increased after nerve ligation to 21% and 15% of the total neuronal population by 1 day and 7 days PO, respectively. Type III immunoreactivity was found preferentially in medium to large sized neurons. Thus the majority of neurons with cell bodies having diameters > or =40 microm became type III-positive after nerve ligation. The data indicate that the increased expression of type III sodium channels in axotomized sensory neurons may be the critical factor for the TTX sensitivity of ectopic discharges in injured sensory neurons and thus the generation of ectopic discharges and neuropathic pain behaviors in spinal nerve ligated rats.

Peripheral effects of morphine in neuropathic rats: role of sympathetic postganglionic nerve fibers

We studied the contribution of peripheral opioid receptors to the morphine-induced antinociception in rats with a spinal nerve ligation-induced neuropathy. Intraplantar (i.pl.) injection of morphine produced a stronger suppression of nociceptive reflex responses of the neuropathic limb following ipsilateral, than contralateral, administration, whereas the morphine-induced effect on the control limb was independent of the injection side. Antinociception induced by systemically administered morphine was significantly attenuated by i.pl. injection of a peripherally acting opioid receptor antagonist in neuropathic but not in sham-operated rats. Following chemical sympathectomy with 6-hydroxydopamine, antinociception was achieved at a lower dose ipsilaterally, than contralaterally, following i.pl. administration of morphine, and the morphine-induced antinociception was attenuated by a peripherally acting opioid receptor antagonist. These results indicate that peripheral opioid receptors may contribute to the morphine-induced antinociception in the spinal nerve ligation-induced model of neuropathy. Sympathectomy of the neuropathic limb may underlie, at least partly, the increased peripheral efficacy of morphine in neuropathy.

[How I explore ... lumbar paraspinal muscle electromyography in the assessment of radiculopathy]

Lumbar paraspinal muscles examination is an interesting part of the electrodiagnostic evaluation of patients with suspected lumbosacral radiculopathy. However, many electromyographers hesitate to routinely include that technique in their study of lower limbs. The purpose of this paper is to specify the anatomy and electrophysiologic data of multifidus lumbar paraspinal muscle. Previous anatomic studies indicate that the medial lumbar multifidus and lumbar interspinalis muscles share unisegmental innervation by the dorsal ram of the spinal nerve. Electromyography of these muscles can improve the sensitivity of lumbosacral radiculopathy detection. Multi-MUP analysis of quantitative electromyographic parameters in lumbar paraspinal muscles, in a population of 75 healthy subjects without back pain, allowed to set up normal values for the L5 myotome.

Optical imaging of spreading depolarization waves triggered by spinal nerve stimulation in the chick embryo: possible mechanisms for large-scale coactivation of the central nervous system

Using a multiple-site optical recording technique with a voltage-sensitive dye, we found that widely spreading depolarization waves were evoked by dorsal root stimulation in embryonic chick spinal cords. Spatiotemporal maps of the depolarization waves showed that the signals were mainly distributed in the ventral half of the slice, with the highest activity in the ventrolateral area. The propagation velocity of the waves was estimated to be in the order of mm/s. Depolarization waves were evoked in the ventral root-cut preparation, but not in the dorsal root-cut preparation, suggesting that the wave was triggered by synaptic inputs from the primary afferents, and that activation of the motoneurons was not essential for wave generation. In intact spinal cord-brain preparations, the depolarization wave propagated rostrally and caudally for a distance of several spinal segments in normal Ringer's solution. In a Mg(2+)-free solution, the amplitude and extent of the signals were markedly enhanced, and the depolarization wave triggered in the cervical spinal cord propagated to the brainstem and the cerebellum. The depolarization wave demonstrated here had many similarities with the vagus nerve-evoked depolarization wave reported previously. The results suggest that functional cell-to-cell communication systems mediated by the depolarization wave are widely generated in the embryonic central nervous system, and could play a role in large-scale coactivation of the neurons in the spinal cord and brain.

Allosteric adenosine modulation to reduce allodynia

BACKGROUND

Adenosine and adenosine agonists reduce hypersensitivity following inflammation and peripheral nerve injury models of chronic pain. Because inhibitors of adenosine reuptake or metabolism are also effective at reducing hypersensitivity, it is likely that there is a tonic release of spinal adenosine in these models. One approach to avoid adverse effects from direct agonists is to enhance the effect of the endogenous ligand by administering a positive allosteric modulator of its receptor.

METHODS

Rats with mechanical hypersensitivity after spinal nerve ligation received intrathecal injections of adenosine, the allosteric adenosine receptor modulator T62, or their combination, or received systemic T62 alone or with intrathecal injection of a specific A1 adenosine antagonist.

RESULTS

Both adenosine and T62 reduced hypersensitivity alone, with 50% maximal doses (ED50) of 14+/-5.9 and 3.7+/-0.8 microg, respectively. They interacted in an additive manner as determined by isobolography. T62 also reduced mechanical hypersensitivity after systemic administration (15 mg/kg), and this effect was blocked by intrathecal injection of 9 microg of the A1-specific adenosine receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine.

CONCLUSIONS

These results add to previous studies that suggest ongoing spinal release of adenosine, which is antiallodynic, in this animal model of neuropathic pain. Positive allosteric modulation of the adenosine receptor reduces hypersensitivity by a spinal mechanism involving A1 adenosine receptor stimulation. Although obvious adverse effects were not observed in this investigation, further study is required to determine the feasibility of the use of such modulators in the treatment of chronic pain associated with hyperalgesia and allodynia.

The central loop of H-reflex in the S1 spinal nerve: normal values and constitutional influencing factors

OBJECTIVE

To investigate the central loop of H reflex in the S1 nerve and the constitutional influencing factors in normal healthy individuals.

MATERIALS AND METHODS

The study was performed on 39 apparently healthy volunteers. To obtain central H-reflex, the cathode electrode was inserted at a point 1 cm medial to the posterior superior iliac spine, perpendicular to the frontal plane. After the needle touched the sacrum, it was slightly retracted to avoid direct contract to the sacrum. The anode electrode was placed over the anterior iliac spine. The active pick-up electrode was placed at the middle of the line connecting the popliteal crease to the medial malleolus. The reference electrode was placed 2 cm distal to it. The ground eletrode was placed near the active pick-up electrode over the calf muscles.

RESULTS

Mean +/- SD for minimum necessary stimulation to obtain central H-reflex was 23 +/- 13 mA. This was significantly higher than the minimum necessary stimulation to obtain peripheral H reflex (p < 0.0001 using paired t test). Mean central loop of H reflex was 6.9 msec with SD of 0.4 msec. There were no significant differences between the two sides. Mean amplitude of M-wave was 2.2 mV with SD of 1.5 in central loop study. Mean amplitude of H-wave was 2.4 mV with SD of 1.5 in central loop study. The Mean time interval between the onset of M-wave and the end of H-wave (M-H duration) was 18.5 msec with SD of 2.3. After stepwise reduction of variables, considering the correlation between leg length and other variables, the leg length was the only variable strongly correlating with central loop of H-reflex.

CONCLUSION

Lack of major influencing factors after correction for leg length, elimination of a major fraction of the afferent segment of the loop, and its ability to differentiate peripheral from central lesions make central H-reflex studies an invaluable diagnostic tool.

Long-term changes in the distribution of galanin in dorsal root ganglia after sciatic or spinal nerve transection in rats

The neuropeptide galanin is upregulated in primary afferent and sympathetic neurones and might be involved in the development of sympathetic perineuronal baskets ("rings") following nerve injury. Galanin, calcitonin gene-related peptide and tyrosine hydroxylase have been examined immunohistochemically in dorsal root ganglia and associated roots at times up to one year after transection of either sciatic or L5 spinal nerves in adult rats. Small diameter somata containing calcitonin gene-related peptide (with or without galanin) were reduced in number, whereas galanin (and, at later times, calcitonin gene-related peptide) appeared in medium to large diameter cells after both types of lesion. Galanin also appeared in axons in grey rami and somata in lumbar paravertebral ganglia. Within dorsal root ganglia, galanin-positive axons formed perineuronal rings of two types: (i) smooth coiled axons surrounded small (< 30 microm diameter) somata from which they probably arose; these were rare after 12 weeks, particularly after a spinal nerve lesion; and (ii) varicose terminals encircled medium to large galanin-positive somata; some arose from brightly immunofluorescent somata nearby and took nearly a year to disappear. About 30% of varicose galanin-positive rings had associated calcitonin gene-related peptide-positive terminals (partly colocalized) whereas nearly 45% had associated tyrosine hydroxylase-positive terminals (partly colocalized). Synaptophysin was present in swollen axons and in some varicosities of all types. We conclude that, after peripheral nerve lesions, varicose perineuronal rings around large diameter dorsal root ganglion cells may be formed by axotomized primary afferent neurones (some containing calcitonin gene-related peptide) and sympathetic neurones, both of which contain upregulated galanin. Exocytosis from the varicosities may modify the excitability of mechanosensitive somata. Small galanin-positive somata disappear over several months after both lesions as calcitonin gene-related peptide reappears in medium to large neurones.

Propentofylline, a glial modulating agent, exhibits antiallodynic properties in a rat model of neuropathic pain

The present study was undertaken to determine whether propentofylline, a glial modulating agent, could both prevent the induction of mechanical allodynia and attenuate existing mechanical allodynia in a rodent L5 spinal nerve transection model of neuropathic pain. In a preventative paradigm, propentofylline (1 and 10 mg/kg intraperitoneally) was administered systemically daily, beginning 1 day prior to nerve transection. This regimen produced a dose-dependent decrease in mechanical allodynia (p < 0.01). In another preventative paradigm, propentofylline (0.1, 1, or 10 microg) was administered daily intrathecally via direct lumbar puncture. Intrathecal administration of propentofylline was more effective than systemic administration at dose dependently reducing mechanical allodynia (p < 0.01). The effect of systemic propentofylline on existing allodynia was examined with 0.1-, 1-, and 10-mg/kg intraperitoneal administration initiated on day 4 post L5 spinal nerve transection. Systemic propentofylline was found to be equally effective in the attenuation of existing allodynia (p < 0.01) as in the prevention of allodynia in this rodent model of neuropathic pain. Spinal cords (L4-L6 segments) were removed for immunohistochemical analysis on day 10 or 20 post-transection. Microglial and astrocytic activation was decreased by both peripheral and central administration of propentofylline in both preventative and existing allodynia paradigms. This research supports a growing body of literature highlighting the importance of glial activation in the development of persistent neuropathic pain states, and the potential to therapeutically modulate glial activation in the treatment of neuropathic pain.

[Anatomy and basic knowledge of the spinal cord]

Basic knowledge of macroscopic anatomy is needed to understand the clinical signs and distinct syndromes resulting from the disturbed function of the tracks, segments and roots of the spinal cord. The cord is contained within the vertebral canal, continuing the medulla down to the conus medullaris. Descending tracks are motor (corticospinal and extrapyramidal), and ascending tracks are sensory (spinothalamic and lemniscal). Spinal cord involvement must be considered when a sensorimotor spinal tract and a radicular spinal syndromes are combined. Syringomyelia, Brown-Séquard syndrome and subacute combined degeneration of the spinal cord must also be familiar to clinicians, as well as how to differentiate a conus medullaris from a cauda equina syndrome.

P75-expressing elements are necessary for anti-allodynic effects of spinal clonidine and neostigmine

Cells expressing nerve growth factor are implicated in development of hypersensitivity following nerve injury and cholinergic neurons are implicated in reduction of such hypersensitivity by alpha2-adrenergic agonists. Intrathecal injection of the cell toxin, saporin, linked to an antibody to the low-affinity nerve growth factor, p75 (192-IgG saporin), an agent which destroys cholinergic neurons in the brain, was used in the current study to further elucidate these mechanisms. Mechanical hypersensitivity was established in rats by ligation of the L5 and L6 spinal nerves. Animals were pretreated with intrathecal saline or 192-IgG saporin, and one week later received intrathecal clonidine or neostigmine. Spinal cords were removed for acetylcholine and norepinephrine analysis and for cholinergic and p75 immunohistochemistry. Treatment with 192-IgG saporin had no effect on mechanical hypersensitivity following spinal nerve ligation, but blocked the anti-hypersensitivity effects of intrathecal clonidine and neostigmine. Destruction of p75-expressing fibers in the superficial dorsal horn by 192-IgG saporin was not accompanied by changes in acetylcholine or norepinephrine content or by reduction in cholinergic neuronal number in the spinal cord dorsal horn. Unlike in the brain, 192-IgG saporin does not destroy cholinergic neurons in the spinal cord dorsal horn and cannot be used as a tool for this purpose. P75-expressing elements are not necessary for the maintenance of mechanical hyperalgesia in this model of neuropathic pain, but their destruction disrupts the targets or circuitry activated by alpha2-adrenergic and cholinergic agents to reduce hypersensitivity.

Origin and pathway of sensory nerve fibers to the ventral and dorsal sides of the sacroiliac joint in rats

The purpose of this study is to clarify sensory innervation in the ventral and dorsal sides of the sacroiliac joint. Fluoro-gold, a neural tracer, was injected into the left sacroiliac joint of adult rats from the dorsal side after denervation of the dorsal side, and the bilateral dorsal root ganglia (DRGs) from T13 to S4 were examined by fluorescence microscopy five days after injection. In another rat group, the DRGs were examined using the same methods after injection of fluoro-gold from the ventral side. In the case of dorsal denervation (ventral nerve supply), labeled neurons were mainly located in the ipsilateral DRGs from L1 to S2. On the other hand, in the case of ventral denervation (dorsal nerve supply), labeled neurons were noted in the ipsilateral DRGs from L4 to S2. The sacroiliac joint in rats is innervated differently on the ventral and dorsal sides: the sensory nerve fibers to the dorsal side of the sacroiliac joint were derived from the DRGs of lower lumbar and sacral levels (from L4 to S2); and those to the ventral side from the DRGs of upper lumbar, lower lumbar, and sacral levels (from L1 to S2).

Corticospinal responses to motor training revealed by transcranial magnetic stimulation

Transcranial magnetic stimulation was recently used to investigate the nature of adaptations that occur in the central nervous system in response to motor training. In this report, we provide a brief description of trancranial magnetic stimulation and discuss its potential as a tool for identifying corticospinal response to exercise.

Spontaneous spike activity of spinoreticular tract neurons during sleep and wakefulness

Sleep mentation studies infer that pain sensation in humans may be reduced during active REM sleep. However, to provide a mechanistic explanation for this phenomenon, few, if any neurophysiological studies have been performed at the lumbar level from neurons comprising classical pain pathways during sleep and wakefulness. The spinoreticular tract is one such classical pathway that has been implicated in the rostral transmission of nociceptive information. The present study was performed to determine if the activity of spinoreticular tract (SRT) neurons is dependent upon behavioral state. Accordingly, extracellular recording techniques were used to monitor the activity of identified SRT neurons in unanesthetized chronic cats during sleep and wakefulness. The ongoing spike activity of SRT neurons was found to be relatively uniform when the states of quiet wakefulness and quiet sleep were compared. However, during active sleep, the majority of the SRT neurons sampled underwent a sustained reduction in spike activity. Marked facilitation of SRT cell activity occurred in a few instances. These data provide the first unitary evidence supporting earlier evoked potential, psychophysical and clinical studies that ascending sensory information in a classical pain pathway is regulated in a state-dependent fashion.

Nerve injury-induced tactile allodynia is mediated via ascending spinal dorsal column projections

Peripheral nerve injury produces signs of neuropathic pain including tactile allodynia and thermal hyperalgesia, sensory modalities which may be associated with different neuronal pathways. Studies of spinally-transected, nerve-injured rats have led to suggestions that thermal hyperalgesia may be mediated predominately through local spinal circuitry whereas ascending input to supraspinal sites is critical to the manifestation of tactile allodynia. Here, the nature of ascending spinal input mediating tactile allodynia was explored using selective spinal lesions. Male Sprague-Dawley rats received L(5)/L(6) spinal nerve ligation (SNL) and ipsilateral or contralateral (relative to the SNL side) lesions including spinal hemisections and bilateral and unilateral dorsal column lesions. The rats were maintained in a sling and monitored for tactile allodynia by measuring withdrawal thresholds to probing with von Frey filaments 24 h after the hemisection. Rats receiving dorsal column lesions demonstrated no motor deficits while rats receiving spinal hemisection showed paralysis of the paw which nevertheless responded to strong noxious stimulation. Spinal hemisection ipsilateral, but not contralateral, to SNL completely abolished tactile allodynia while maintaining spinal nocifensive reflexes to noxious pinch. Bilateral and ipsilateral dorsal column lesions blocked tactile allodynia while contralateral dorsal column lesions did not. Administration of lidocaine into the nucleus gracilis ipsilateral to SNL also blocked tactile allodynia, but did not alter thermal hyperalgesia in SNL rats or increase thermal nociceptive responses in sham-operated rats. Lidocaine microinjected into the contralateral nucleus gracilis produced no changes in responses to tactile or thermal stimuli in either group. These results indicate that tactile allodynia after peripheral nerve injury is dependent upon inputs to supraspinal sites. Furthermore, it is apparent that afferent signals interpreted as tactile allodynia course through the ipsilateral dorsal columns and are relayed through the nucleus gracilis. This neuronal pathway is consistent with the interpretation that tactile allodynia pursuant to peripheral nerve injury is transmitted to the central nervous system by means of large diameter, myelinated fibers.

Effects of sleep on spinal nociceptive reflexes in humans

Controversy continues to surround the monosynaptic and polysynaptic spinal reflexes during the different stages of sleep. In animal studies both of these reflexes were found to be depressed during desynchronized sleep. In humans, the H reflex was unchanged whereas the second component of the nociceptive flexion reflex was increased. However, abolition of the H reflex and F waves during REM sleep has also been reported. The aim of this investigation was to examine the effects of different sleep stages on the polysynaptic nociceptive flexion reflex. Six healthy volunteers were studied. The RIII reflex was studied according to Willer's method (1977) during the different stages of NREM and REM sleep. The RIII reflex threshold was found to increase during stage 2 of NREM sleep. It remained higher during stages 3 and 4. During REM sleep a further increase in the reflex threshold was observed. The reflex latency was prolonged during stage 4 of NREM sleep. There was evidence of further latency prolongation during REM sleep. It was also during REM sleep that the maximum increase in the amplitude and duration of the reflex were recorded.

Randomized controlled trial of percutaneous intradiscal radiofrequency thermocoagulation for chronic discogenic back pain: lack of effect from a 90-second 70 C lesion

STUDY DESIGN

A prospective double-blind randomized trial in 28 patients.

OBJECTIVES

To assess the clinical effect of percutaneous intradiscal radiofrequency thermocoagulation for reducing pain, functional disability, and physical impairment in patients with chronic discogenic low back pain.

SUMMARY OF BACKGROUND DATA

Chronic discogenic low back pain is a challenging problem in western countries. A treatment option is radiofrequency heating of the affected disc. Its clinical efficacy has never been formally tested in a controlled trial.

METHODS

Twenty-eight patients with a history of at least 1 year of chronic low back pain were selected on the basis of a diagnostic anesthetization of the lower intervertebral discs. Only patients with one putative painful level were selected and randomly assigned to one of two treatment groups. Each patient in the radiofrequency treatment group (n = 13) received a 90-second 70 C lesion of the intervertebral disc. Patients in the control group (n = 15) underwent the same procedure, but without use of radiofrequency current. Both the treating physician and the patients were blinded to the group assignment. Before treatment, physical impairment, rating of pain, the degree of disability, and quality of life were assessed by a blinded investigator.

RESULTS

Eight weeks after treatment, there was one success in the radiofrequency group (n = 13) and two in the control group (n = 15). The adjusted and unadjusted odds ratio was 0.5 and 1.1, respectively (not significant). Also, visual analog scores for pain, global perceived effect, and the Oswestry disability scale showed no differences between the two groups.

CONCLUSIONS

Percutaneous intradiscal radiofrequency thermocoagulation (90 seconds, 70 C) is not effective in reducing chronic discogenic low back pain.

Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation

PURPOSE

We investigate the efficacy of sacral neurostimulation in patients with idiopathic urinary retention in a prospective, randomized multicenter trial.

MATERIALS AND METHODS

A total of 177 patients with urinary retention refractory to standard therapy were enrolled in the study. Greater than 50% improvement in baseline voiding symptoms during a 3 to 7-day percutaneous test stimulation qualified a patient for surgical implantation of an InterStim parallel system. Of the patients who qualified for implantation 37 were randomly assigned to a treatment and 31 to a control group. Patients in the treatment group underwent early surgical implantation of the sacral nerve stimulation system, while implantation was delayed in the control group for 6 months. Followup evaluations, including voiding diary analysis and temporary deactivation of the stimulator at 6 months, were conducted at 1, 3, 6, 12 and 18 months after implantation in the treatment group, and after 3 and 6 months in the control group.

RESULTS

Compared to the control group, patients implanted with the InterStim system had statistically and clinically significant reductions in the catheter volume per catheterization (p <0.0001). Of the patients treated with implants 69% eliminated catheterization at 6 months and an additional 14% had a 50% or greater reduction in catheter volume per catheterization. Therefore, successful results were achieved in 83% of the implant group with retention compared to 9% of the control group at 6 months. Temporary inactivation of sacral nerve stimulation therapy resulted in a significant increase in residual volumes (p <0.0001) but effectiveness of sacral nerve stimulation was sustained through 18 months after implant.

CONCLUSIONS

Results of this prospective, randomized clinical study demonstrate that sacral nerve stimulation is effective for restoring voiding in patients with retention who are refractory to other forms of treatment.

Participation of angiotensin II in pressor response and norepinephrine release to spinal nerve stimulation in pithed rats

Experiments were carried out to examine whether endogenous angiotensin II (A-II) is involved in the regulation of release of norepinephrine (NE) elicited by the stimulation of spinal sympathetic nerves in pithed rats. It was assessed in terms of the alterations in concentrations of arterial blood plasma A-II and NE elicited by nerve stimulation (5 Hz, 50 V, 1 msec for 45 s) in pithed rats under vehicle or captopril (3 mg/kg, i.v.) treatment. Comparative study with pentobarbital anesthetized rats showed that pithing rats have the characteristics of lower basal blood pressure and lower NE level, whereas they have higher basal A-II level. In pithed rats treated with vehicle, pressor response to nerve stimulation was accompanied by increases in both A-II and NE level. In rats treated with captopril, the nerve stimulation caused about 40% lower increases in pressor response and NE level than those observed in rats treated with vehicle. These results suggest that the sympathetic nerve-induced NE release is facilitated by endogenous A-II in pithed rats, and that captopril exerts its inhibitory effect on the pressor response to nerve stimulation through the suppression of this interaction.

Regulation of sympathetic tone and arterial pressure by rostral ventrolateral medulla after depletion of C1 cells in rat

1. In this study we examined whether the rostral ventrolateral medulla (RVLM) maintains resting sympathetic vasomotor tone and activates sympathetic nerve activity (SNA) after the depletion of bulbospinal C1 adrenergic neurones. 2. Bulbospinal C1 cells were destroyed ( approximately 84% loss) by bilateral microinjections (spinal segments T2-T3) of an anti-dopamine-beta-hydroxylase antibody conjugated to the ribosomal toxin saporin (anti-DH-SAP). 3. Extracellular recording and juxtacellular labelling of bulbospinal barosensitive neurones in the RVLM revealed that treatment with anti-DH-SAP spared the lightly myelinated neurones with no tyrosine hydroxylase immunoreactivity. 4. In rats treated with anti-DH-SAP, inhibition of RVLM neurones by bilateral microinjection of muscimol eliminated splanchnic SNA and produced the same degree of hypotension as in control rats. 5. Following treatment with anti-DH-SAP the sympathoexcitatory (splanchnic nerve) and pressor responses to electrical stimulation of the RVLM were reduced. 6. Treatment with anti-DH-SAP also eliminated the majority of A5 noradrenergic neurones. However, rats with selective lesion of A5 cells by microinjection of 6-hydroxydopamine into the pons showed no deficits to stimulation of the RVLM. 7. In summary, the loss of 84% of bulbospinal adrenergic neurones does not alter the ability of RVLM to maintain SNA and arterial pressure at rest in anaesthetized rats, but this loss reduces the sympathoexcitatory and pressor responses evoked by RVLM stimulation. The data suggest sympathoexcitatory roles for both the C1 cells and non-C1 cells of the RVLM and further suggest the C1 cells are critical for the full expression of sympathoexcitatory responses generated by the RVLM.

Isolation and characterization of a novel conus peptide with apparent antinociceptive activity

Cone snails are tropical marine mollusks that envenomate prey with a complex mixture of neuropharmacologically active compounds. We report the discovery and biochemical characterization of a structurally unique peptide isolated from the venom of Conus marmoreus. The new peptide, mr10a, potently increased withdrawal latency in a hot plate assay (a test of analgesia) at intrathecal doses that do not produce motor impairment as measured by rotarod test. The sequence of mr10a is NGVCCGYKLCHOC, where O is 4-trans-hydroxyproline. This sequence is highly divergent from all other known conotoxins. Analysis of a cDNA clone encoding the toxin, however, indicates that it is a member of the recently described T-superfamily. Total chemical synthesis of the three possible disulfide arrangements of mr10a was achieved, and elution studies indicate that the native form has a disulfide connectivity of Cys1-Cys4 and Cys2-Cys3. This disulfide linkage is unprecedented among conotoxins and defines a new family of Conus peptides.

Intrathecal anti-IL-6 antibody and IgG attenuates peripheral nerve injury-induced mechanical allodynia in the rat: possible immune modulation in neuropathic pain

Interleukin-6 (IL-6) is a pleiotrophic cytokine with a diverse range of actions including the modulation of the peripheral and central nervous system. We have previously shown significant IL-6 protein and messenger RNA elevation in rat spinal cord following peripheral nerve injury that results in pain behaviors suggestive of neuropathic pain. These spinal IL-6 levels correlated directly with the mechanical allodynia intensity following nerve injury. In the current study, we sought to determine whether it is possible to attenuate mechanical allodynia and/or alter spinal glial activation resulting from peripheral nerve injury by specific manipulation of IL-6 with neutralizing antibodies or by global immune modulation utilizing immunogamma-globulin (IgG). Effects of peripheral administration of normal goat IgG and intrathecal (i.t.) administration of IL-6 neutralizing antibody, normal goat or normal rat IgG on mechanical allodynia associated with L5 spinal nerve transection were compared. Spinal glial activation was assessed at day 10 post surgery by immunohistochemistry. Low dose (0.01-0.001 microg) goat anti-rat IL-6 i.t. administration (P=0.025) significantly decreased allodynia and trended towards significance at the higher dose (0.08 microg to 0.008 microg, P=0.062). Low doses (0.01-0.001 microg) i.t. normal goat and rat IgG significantly attenuated mechanical allodynia, but not at higher doses (0.08-0.008 microg; P=0.001 for both goat and rat IgG). Peripherally administered normal goat IgG (30 or 100 mg/kg) did not attenuate mechanical allodynia. Spinal glial activation was unaltered by any treatment. These data provide further evidence for the role of central IL-6 and neuroimmune modulation in the etiology of mechanical allodynia following peripheral nerve injury.

Downregulation of TrkA expression in primary sensory neurons after unilateral lumbar spinal nerve transection and some rescuing effects of nerve growth factor infusion

Peripheral nerve injury results in sprouting of sympathetic and sensory nerve terminals around large diameter neurons in the dorsal root ganglia (DRG), but the underlying mechanism is not clear. Current study sought to examine changes of the nerve growth factor (NGF) receptor TrkA in DRG and spinal cord after a spinal nerve transection by an immunohistochemical technique and to investigate effects of NGF on the expression of TrkA protein in the same animal model. In the control rat, TrkA immunoreactivity was localized to about 55 +/ -1% of total neurons in DRG and to laminae I and II of the spinal cord. The percentage of TrkA immunoreactive neurons in DRG and TrkA staining intensity of spinal cord were reduced 1 week after the nerve lesion. The changes became maximal 2 weeks, but recovered partially 4 weeks after the lesion. The size of TrkA immunoreactive neurons dramatically shifted to smaller sizes, becoming more remarkable 4 weeks after the lesion. In the contralateral DRG, the percentage of TrkA immunoreactive neurons also decreased significantly. Exogenous NGF delivered to DRG for 2 weeks partially reversed the reduction of TrkA expression as well as atrophy of TrkA immunoreactive neurons. No TrkA immunoreactive basket was found around neuronal somata. Our data show that unilateral peripheral nerve injury results in dynamic downregulation of TrkA in sensory neurons in bilateral DRG and spinal cord, and that TrkA expression in sensory neurons is partially regulated by target-derived NGF.

Neurophysiologic response to intraoperative lumbosacral spinal manipulation

BACKGROUND

Although the mechanisms of spinal manipulation are poorly understood, the clinical effects are thought to be related to mechanical, neurophysiologic, and reflexogenic processes. Animal studies have identified mechanosensitive afferents in animals, and clinical studies in human beings have measured neuromuscular responses to spinal manipulation. Few, if any, studies have identified the basic neurophysiologic mechanisms of spinal manipulation in human beings or animals.

OBJECTIVES

The purpose of this clinical investigation was to determine the feasibility of obtaining intraoperative neurophysiologic recordings and to quantify mixed-nerve root action potentials in response to lumbosacral spinal manipulation in a human subject undergoing lumbar spinal surgery.

METHODS

An L4-L5 laminectomy was performed in a 62-year-old man. Short-duration (<0.1 ms) mechanical force, manually assisted spinal manipulative thrusts (150 N) were delivered to the lumbosacral spine with an Activator II Adjusting Instrument. With the spine exposed, spinal manipulative thrusts were delivered internally to the L5 mammillary process, L5-S1 joint, and the sacral base with various force vectors. This protocol was repeated by contacting the skin overlying respective anatomic landmarks. Mixed-nerve root recordings were obtained from gas-sterilized platinum bipolar hooked electrodes attached to the S1 nerve root at the level of the dorsal root ganglion during the spinal manipulative thrusts and during a 30-second baseline period during which no spinal manipulative thrusts were applied.

RESULTS

During the active trials, mixed-nerve root action potentials were observed in response to both internal and external spinal manipulative thrusts. Differences in the amplitude and discharge frequency were noted in response to varying segmental contact points and force vectors, and similarities were noted for internally and externally applied spinal manipulative thrusts. Amplitudes of mixed-nerve root action potentials ranged from 200 to 2600 mV for internal thrusts and 800 to 3500 mV for external thrusts.

CONCLUSIONS

Monitoring mixed-nerve root discharges in response to spinal manipulative thrusts in vivo in human subjects undergoing lumbar surgery is feasible. Neurophysiologic responses appeared sensitive to the contact point and applied force vector of the spinal manipulative thrust. Further study of the neurophysiologic mechanisms of spinal manipulation in humans and animals is needed to more precisely identify the mechanisms and neural pathways involved.

Sympathetic-sensory coupling after L5 spinal nerve lesion in the rat and its relation to changes in dorsal root ganglion blood flow

Transection of the L5 spinal nerve in rats results in allodynia- and hyperalgesia-like behavior to mechanical stimulation which are thought to be mediated by ectopic activity arising in lesioned afferent neurons mainly in the dorsal root ganglion (DRG). It has been suggested that the neuropathic pain behavior is dependent on the sympathetic nervous system. In rats 3-56 days after L5 spinal nerve lesion, we tested responses of axotomized afferent fibers recorded in the dorsal root of the lesioned segment to norepinephrine (NE, 0.5 microg/kg) injected intravenously and to selective electrical stimulation of the lumbar sympathetic trunk (LST). In some experiments we measured blood flow in the DRG by laser Doppler flowmetry. The majority of lesioned afferent fibers with spontaneous activity responded to neither LST stimulation (82.4%) nor NE (71.4%). In those which did react to LST stimulation, responses occurred only at high stimulation frequencies (likely to be above the physiological range), and they could be mimicked by non-adrenergic vasoconstrictor drugs (angiotensin II, vasopressin). Excitatory responses to LST stimulation were closely correlated with the stimulation-induced phasic vasoconstrictions in the DRG. We therefore hypothesized that the activation of lesioned afferents might be brought about indirectly by an impaired blood supply to the DRG. To test this hypothesis we induced a strong and sustained baseline vasoconstriction in the DRG by blocking endothelial nitric oxide synthesis with N(G)-nitro-L-arginine methyl ester (L-NAME) applied systemically. L-NAME enhanced baseline vascular resistance in the DRG about threefold and also increased stimulation-induced vasoconstrictions. After L-NAME, the majority of axotomized neurons with spontaneous activity were activated by LST stimulation (76%) or NE (75%). Again, activations closely followed stimulation-induced phasic vasoconstrictions in the DRG provided that a critical level of vasoconstriction was exceeded. In the present study, inhibitory responses to LST stimulation were generally rare and could be reversed to activation by prolonged stimulation or after L-NAME. These results show that sympathetic-sensory coupling occurs only in a minority of axotomized afferents after L5 spinal nerve injury. Like previous studies, they cast doubt on the notion that the L5 spinal nerve lesion is a good model for sympathetically maintained pain. Since responses of lesioned afferent neurons to LST stimulation and NE could be provoked with high reliability after inducing vasoconstriction in the DRG, and since they mirrored stimulation-induced vasoconstrictions in the DRG, it appears that in this model the association of sympathetic activity with afferent discharge occurs mainly when perfusion of the DRG is impaired.

Control of digits via C3-C4 propriospinal neurones in cats; recovery after lesions

C3-C4 propriospinal neurones (C3-C4 PNs) transmit the command for forelimb target-reaching in cats, while the command for food-taking is mediated by interneurones in the forelimb segments. The ability of the C3-C4 PNs to control digits has now been reinvestigated with combined lesions in dorsal C5 (transecting the cortico- and rubrospinal tracts) and ventral C2 (transecting reticulospinal tracts) leaving the C3-C4 PNs in sole control of the forelimb. Components of food-taking like flexion in the proximal interphalangeal joints were found in half of the cats. Supination and terminal flexion of the metacarpophalangeal joints by which normal cats bring the morsel of food to the mouth were lacking in all cats.

The orthodox view of brain sexual differentiation

The standard view of sexual differentiation of the brain, derived primarily from work with mammals, is that the same steroidal signal which permanently masculinizes the body early in life, androgen, also permanently masculinizes the nervous system. This oversimplified view overlooks the rich diversity of mechanisms produced by natural selection. We review the mechanisms underlying sexual differentiation of what may be the simplest mammalian model, the spinal nucleus of the bulbocavernosus (SNB), a system that is intimately associated with sexual differentiation of the periphery. Indeed, in many instances, early androgen can permanently masculinize the SNB system but, surprisingly, these early influences may depend to some extent on social mediating factors. Furthermore, in adulthood, androgen continues to affect the SNB system in diverse ways, acting on several different loci, indicating a life-long plasticity in even this simple system. Finally, there is evidence that adult androgens interact with social experience in order to affect the SNB system. Thus the SNB system displays a far richer array of interactions than the standard view of sexual differentiation would predict. Examination of other systems and other species, as depicted in the following reports, reveals a far more complicated, and far more interesting perspective on how the brains and behaviors of males and females diverge.

Transcutaneous sacral neurostimulation for irritative voiding dysfunction

OBJECTIVE

Patients with irritative voiding dysfunction are often unresponsive to standard clinical treatment. We evaluated the response of such individuals to transcutaneous electrical stimulation of the third sacral nerve.

METHODS

32 patients with refractory irritative voiding dysfunction (31 female and 1 male; mean age 47 years) were recruited to the study. Ambulatory transcutaneous electrical neurostimulation was applied bilaterally to the third sacral dermatomes for 1 week. Symptoms of frequency, nocturia, urgency, and bladder pain were scored by each patient throughout and up to 6 months following treatment.

RESULTS

The mean daytime frequency was reduced from 11.3 to 7.96 (p = 0.01). Nocturia episodes were reduced from a mean of 2.6 to 1.8 (p = 0.01). Urgency and bladder pain mean symptom scores were reduced from 5.97 to 4.89 and from 1.48 to 0.64, respectively. After stopping therapy, symptoms returned to pretreatment levels within 2 weeks in 40% of the patients and within 6 months in 100%. Three patients who continued with neurostimulation remained satisfied with this treatment modality at 6 months.

CONCLUSIONS

Transcutaneous third sacral nerve stimulation may be an effective and noninvasive ambulatory technique for the treatment of patients with refractory irritative voiding dysfunction. Following an initial response, patients may successfully apply this treatment themselves to ensure long-term relief.

Dorsal root section elicits signs of neuropathic pain rather than reversing them in rats with L5 spinal nerve injury

Mechanical allodynia- and hyperalgesia-like behavior which develops in rats after L5 spinal nerve lesion has been suggested to be due to ectopic activity in the lesioned afferent neurons originating at the lesion site and/or in the dorsal root ganglion because it is eliminated by section of the dorsal root. Here we reevaluated the effect of a dorsal rhizotomy in rats after L5 spinal nerve lesion. Using calibrated von Frey hairs, paw withdrawal threshold to single stimuli and paw withdrawal incidence to repetitive stimulation were tested before and after nerve section. Neuropathic pain behavior of similar time course and magnitude also developed after cutting the L5 dorsal root, and L5 spinal nerve lesion-induced abnormal behavior could not be reversed by dorsal rhizotomy. The neuropathic pain behavior elicited by dorsal root section also developed when impulse conduction in the dorsal root axons was blocked during rhizotomy by a local anesthetic, i.e. when the immediate injury discharge was prevented from reaching the spinal cord. These results challenge the widely accepted idea that neuropathic pain behavior developing after spinal nerve lesion is dependent on ectopic activity in the lesioned afferent neurons. However, the present results do not rule out the possibility that after the two nerve lesions the mechanisms generating neuropathic pain behavior are different. After dorsal rhizotomy neuropathic pain behavior may be related to deafferentation whereas after spinal nerve lesion it may be caused by ectopic activity.

Areas of operation of interneurons mediating presynaptic inhibition in sacral spinal segments

Sources of primary afferent depolarization (PAD) of skin afferents in the sural (Sur) nerve and of group-II muscle afferents in the posterior biceps and semitendinosus (PBST) nerve were compared at several sites, about 2 mm apart, within the L7-S2 segments in order to define areas of projection of sacral interneurons mediating PAD of these afferents. Just rostral to the pudendal nucleus, strong PAD of Sur afferents was evoked by stimulation of skin nerves, while stimulation of muscle nerves had only marginal effects. This indicates that sacral PAD interneurons co-excited by skin and muscle afferents operate primarily within the regions overlying the pudendal nucleus. Furthermore, PAD evoked by muscle afferents was weaker over the rostral part of the pudendal nucleus than over the caudal part of this nucleus, where hamstring afferents became its main source, both in Sur and in PBST group-II afferents. By correlating the relative strength of PAD at the levels of the rostral and caudal parts of the pudendal nucleus with the previously established input from muscle and cutaneous afferents to interneurons at these levels, it is therefore proposed that sacral PAD interneurons operate over shorter distances than indicated by previous experiments: over either rostral or caudal parts of the pudendal nucleus, i.e., about 2 mm, rather than over the whole length of this nucleus, i.e., 4-5 mm. Sacral PAD interneurons may, thus, modulate synaptic transmission to even more spatially restricted neuronal populations than previously proposed.

Different increase in C-fibre evoked responses after nociceptive conditioning stimulation in sham-operated and neuropathic rats

Mechanisms of neuropathic pain are not clear. Recently we showed long-term potentiation (LTP) of wide dynamic range (WDR) neurones after electrical conditioning stimulation of the sciatic nerve in normal rats. In this study we investigated the effects of the same conditioning on both the evoked responses of WDR cells and on vital signs in neuropathic rats. Nerve injury was produced by tight ligation of the L5 and L6 spinal nerves and a control group received sham surgery. The electrical conditioning gave a significantly smaller LTP in neuropathic rats as compared to controls. Despite giving a smaller LTP in neuropathic rats, the rise in mean arterial blood pressure and heart rate induced by the conditioning was exactly the same as in the control group. The threshold for activating C-fibres was significantly lower and the baseline tended to be higher in neuropathic rats. Thus, it is suggested that the nerve injury itself is likely to induce an LTP-like state in the neurones studied. Further studies using the LTP-inducing model can provide new information on the mechanisms of neuropathic pain.

Spinal nerve injury enhances subthreshold membrane potential oscillations in DRG neurons: relation to neuropathic pain

Primary sensory neurons with myelinated axons were examined in vitro in excised whole lumbar dorsal root ganglia (DRGs) taken from adult rats up to 9 days after tight ligation and transection of the L(5) spinal nerve (Chung model of neuropathic pain). Properties of subthreshold membrane potential oscillations, and of repetitive spike discharge, were examined. About 5% of the DRG neurons sampled in control DRGs exhibited high-frequency, subthreshold sinusoidal oscillations in their membrane potential at rest (V(r)), and an additional 4.4% developed such oscillations on depolarization. Virtually all had noninflected action potentials (A(0) neurons). Amplitude and frequency of subthreshold oscillations were voltage sensitive. A(0) neurons with oscillations at V(r) appear to constitute a population distinct from A(0) neurons that oscillate only on depolarization. Axotomy triggered a significant increase in the proportion of neurons exhibiting subthreshold oscillations both at V(r) and on depolarization. This change occurred within a narrow time window 16-24 h postoperative. Axotomy also shifted the membrane potential at which oscillation amplitude was maximal to more negative (hyperpolarized) values, and lowered oscillation frequency at any given membrane potential. Most neurons that had oscillations at V(r), or that developed them on depolarization, began to fire repetitively when further depolarized. Spikes were triggered by the depolarizing phase of oscillatory sinusoids. Neurons that did not develop subthreshold oscillations never discharged repetitively and rarely fired more than a single spike or a short burst, on step depolarization. The most prominent spike waveform parameters distinguishing neurons capable of generating subthreshold oscillations, and hence repetitive firing, was their brief postspike afterhyperpolarization (AHP) and their low single-spike threshold. Neurons that oscillated at V(r) tended to have a more prolonged spike, with slower rise- and fall-time kinetics, and lower spike threshold, than cells that oscillated only on depolarization. The main effects of axotomy were to increase spike duration, slow rise- and fall-time kinetics, and reduce single-spike threshold. Tactile allodynia following spinal nerve injury is thought to result from central amplification ("central sensitization") of afferent signals entering the spinal cord from residual intact afferents. The central sensitization, in turn, is thought to be triggered and maintained in the Chung model by ectopic firing originating in the axotomized afferent neurons. Axotomy by spinal nerve injury enhances subthreshold membrane potential oscillations in DRG neurons, augments ectopic discharge, and hence precipitates neuropathic pain.