Dorsolateral funiculus-lesions unmask inhibitory or disfacilitatory mechanisms which modulate the effects of innocuous mechanical stimulation on spinal Fos expression after inflammation

c-Fos and pERK, which is a better marker for neuronal activation and central sensitization after noxious stimulation and tissue injury?

c-Fos, the protein of the protooncogene c-fos, has been extensively used as a marker for the activation of nociceptive neurons in the spinal cord for more than twenty years since Hunt et al. first reported that peripheral noxious stimulation to a hind paw of rats leads to a marked induction of c-Fos in superficial and deep dorsal horn neurons in 1987. In 1999, Ji et al. reported that phosphorylated extracellular signal-regulated kinase (pERK) is specifically induced by noxious stimulation in superficial dorsal horn neurons. Accumulating evidence indicates that pERK induction or ERK activation in dorsal horn neurons is essential for the development of central sensitization, increased sensitivity of dorsal horn neurons that is responsible for the generation of persistent pain. Further, molecular mechanisms underlying ERK-mediated central sensitization have been revealed. In contrast, direct evidence for c-Fos-mediated central sensitization is not sufficient. After a noxious stimulus (e.g., capsaicin injection) or tissue injury, c-Fos begins to be induced after 30-60 minutes, whereas pERK can be induced within a minute, which can correlate well with the development of pain hypersensitivity. While c-Fos is often induced in the nuclei of neurons, pERK can be induced in different subcellular structures of neurons such as nuclei, cytoplasma, axons, and dendrites. pERK can even be induced in spinal cord microglia and astrocytes after nerve injury. In summary, both c-Fos and pERK can be used as markers for neuronal activation following noxious stimulation and tissue injury, but pERK is much more dynamic and appears to be a better marker for central sensitization.

Spinal NK-1 receptor expressing neurons mediate opioid-induced hyperalgesia and antinociceptive tolerance via activation of descending pathways

Opioids can induce hyperalgesia in humans and in animals. Mechanisms of opiate-induced hyperalgesia and possibly of spinal antinociceptive tolerance may be linked to pronociceptive adaptations occurring at multiple levels of the nervous system including activation of descending facilitatory influences from the brainstem, spinal neuroplasticity, and changes in primary afferent fibers. Here, the role of NK-1 receptor expressing cells in the spinal dorsal horn in morphine-induced hyperalgesia and spinal antinociceptive tolerance was assessed by ablating these cells with intrathecal injection of SP-saporin (SP-SAP). Ablation of NK-1 receptor expressing cells prevented (a) morphine-induced thermal and mechanical hypersensitivity, (b) increased touch-evoked spinal FOS expression, (c) upregulation of spinal dynorphin content and (d) the rightward displacement of the spinal morphine antinociceptive dose-response curve (i.e., tolerance). Morphine-induced hyperalgesia and antinociceptive tolerance were also blocked by spinal administration of ondansetron, a serotonergic receptor antagonist. Thus, NK-1 receptor expressing neurons play a critical role in sustained morphine-induced neuroplastic changes which underlie spinal excitability reflected as thermal and tactile hypersensitivity to peripheral stimuli, and to reduced antinociceptive actions of spinal morphine (i.e., antinociceptive tolerance). Ablation of these cells likely eliminates the ascending limb of a spinal-bulbospinal loop that engages descending facilitation and elicits subsequent spinal neuroplasticity. The data may provide a basis for understanding mechanisms of prolonged pain which can occur in the absence of tissue injury.

Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome

In addition to the debilitating fatigue, the majority of patients with chronic fatigue syndrome (CFS) experience chronic widespread pain. These pain complaints show the greatest overlap between CFS and fibromyalgia (FM). Although the literature provides evidence for central sensitization as cause for the musculoskeletal pain in FM, in CFS this evidence is currently lacking, despite the observed similarities in both diseases. The knowledge concerning the physiological mechanism of central sensitization, the pathophysiology and the pain processing in FM, and the knowledge on the pathophysiology of CFS lead to the hypothesis that central sensitization is also responsible for the sustaining pain complaints in CFS. This hypothesis is based on the hyperalgesia and allodynia reported in CFS, on the elevated concentrations of nitric oxide presented in the blood of CFS patients, on the typical personality styles seen in CFS and on the brain abnormalities shown on brain images. To examine the present hypothesis more research is required. Further investigations could use similar protocols to those already used in studies on pain in FM like, for example, studies on temporal summation, spatial summation, the role of psychosocial aspects in chronic pain, etc.

Descending facilitation from the rostral ventromedial medulla maintains nerve injury-induced central sensitization

Nerve injury can produce hypersensitivity to noxious and normally innocuous stimulation. Injury-induced central (i.e. spinal) sensitization is thought to arise from enhanced afferent input to the spinal cord and to be critical for expression of behavioral hypersensitivity. Descending facilitatory influences from the rostral ventromedial medulla have been suggested to also be critical for the maintenance, though not the initiation, of experimental neuropathic pain. The possibility that descending facilitation from the rostral ventromedial medulla is required for the maintenance of central sensitization was examined by determining whether ablation of mu-opioid receptor-expressing cells within the rostral ventromedial medulla prevented the enhanced expression of repetitive touch-evoked FOS within the spinal cord of animals with spinal nerve ligation injury as well as nerve injury-induced behavioral hypersensitivity. Rats received a single microinjection of vehicle, saporin, dermorphin or dermorphin-saporin into the rostral ventromedial medulla and 28 days later, underwent either sham or spinal nerve ligation procedures. Animals receiving rostral ventromedial medulla pretreatment with vehicle, dermorphin or saporin that were subjected to spinal nerve ligation demonstrated both thermal and tactile hypersensitivity, and showed significantly increased expression of touch-evoked FOS in the dorsal horn ipsilateral to nerve injury compared with sham-operated controls at days 3, 5 or 10 post-spinal nerve ligation. In contrast, nerve-injured animals pretreated with dermorphin-saporin showed enhanced behaviors and touch-evoked FOS expression in the spinal dorsal horn at day 3, but not days 5 and 10, post-spinal nerve ligation when compared with sham-operated controls. These results indicate the presence of nerve injury-induced behavioral hypersensitivity associated with nerve injury-induced central sensitization. Further, the results demonstrate the novel concept that once initiated, maintenance of nerve injury-induced central sensitization in the spinal dorsal horn requires descending pain facilitation mechanisms arising from the rostral ventromedial medulla.

Why do restless legs occur at rest?—pathophysiology of neuronal structures in RLS. Neurophysiology of RLS (part 2)

Restless legs syndrome (RLS) is a heterogeneous disorder encompassing genetically caused types with early onset and acquired varieties occurring later in life. Genetic studies in the near future will most likely discover more than one causative gene. The acquired cases too have different etiologies ranging from idiopathic types to secondary forms with uremia, iron depletion, polyneuropathy and others. Here we aim to correlate typical RLS symptoms, such as the sensory symptoms at rest, the reduction of the complaint in response to movement or other physical stimuli, the dominant involvement of the legs, pain, circadian rhythm, and the responsiveness to dopaminergic drugs with neurophysiological features of the central nervous system. We outline the complexity of the neural structures involved and their connections. A diversity of hypothetical affections of different neuronal levels might lead to various combinations of RLS symptomatology. No single pathophysiological explanation has yet been developed that covers all clinical features.

Pain in a Balance: Noxious Events Engage Opposing Processes That Concurrently Modulate Nociceptive Reactivity

Studies have shown that noxious cutaneous stimulation engages physiologically different antinociceptive systems to inhibit a spinal reflex, tail withdrawal from radiant heat. Two experiments are reported that examine the relationship between the inhibition of the tail-flick response and brain-mediated responses to nociception. The induction of a spinally mediated antinociception was accompanied by an increase in latency to vocalize to a noxious thermal stimulus, suggesting pain inhibition. Physiological manipulations that eliminated the inhibition of the tail-flick reflex restored vocalization to thermal stimulation and revealed a concurrent sensitization that generally heightened behavioral reactivity. The results suggest that net pain is regulated by 2 opposing processes, a selective inhibition of nociceptive signals within the spinal cord and a general sensitization that heightens stimulus processing.

Long-lasting changes in rostral ventral medulla neuronal activity after inflammation

Activity-dependent synaptic plasticity occurs in many regions of the central nervous system. It is known that spinal sensory transmission undergoes long-lasting changes after tissue injury and inflammation, but much less is known about descending modulation. In the present study, we demonstrate that tissue injury causes long-lasting changes within the rostral ventral medulla, a region critical for descending modulation of spinal sensory transmission. Subcutaneous formalin injections induced changes in the activity of rostral ventral medulla neurons, particularly during phase 2 (10 to 55 minutes after injection). The activity of neutral cells, which showed no response to acute noxious stimuli, was significantly decreased after formalin injection. Furthermore, 2 "silent" cells became active after the formalin injection. To demonstrate directly that descending biphasic modulation from the rostral ventral medulla was affected after the inflammation, we investigated descending modulation of a spinal nociceptive reflex produced by focal electrical stimulation in the rostral ventral medulla and found that both facilitation and inhibition were significantly decreased. These data suggest that rostral ventral medulla circuits modulating spinal sensory transmission undergo profound and long-lasting changes after tissue injury and inflammation. This may contribute to the pathological modification of nociceptive processing in chronic pain states.

Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for MT

Manual therapy (MT-) is moving beyond its empirical origins and into an era of evidence-based practice. Mechanisms for the appearance of clinically observed symptoms and signs are beng incorporated into its clinical reasoning process. The recent, but well-documented phenomenon, central sensitization, is recognized as being one such mechanism. Anatomical, physiological, behavioural and clinical evidence demonstrate that, in addition to input from the periphery, central sensitization can be enhanced or maintained by supraspinal processes involving cognitions, attention ('focussing') and emotions. These forebrain products may, therefore, make a significant contribution to the symptoms and signs of common musculoskeletal presentations such as 'non-specific' back pain and fibromyalgia. The evidence can also be interpreted to provide MT with an acceptable role in the management of these patients.

Colonic inflammation induces fos expression in the thoracolumbar spinal cord increasing activity in the spinoparabrachial pathway

The descending colon and rectum are innervated by primary afferent fibers projecting to the lumbosacral and thoracolumbar spinal cord segments. Previous work from this laboratory has suggested that afferent input and sensory processing in the lumbosacral spinal cord is necessary and sufficient to mediate reflex responses to transient colorectal stimulation while processing in both the lumbosacral and thoracolumbar spinal cord segments contribute to visceral hyperalgesia. In the rat, repetitive noxious colorectal distention (CRD) induces >200 Fos labeled cells per section in the lumbosacral segments, but few in the thoracolumbar segments, further suggesting that transient colonic nociceptive input is transduced primarily in the lumbosacral spinal cord. The laminar distribution of this CRD-induced Fos suggests some of these neurons project to the parabrachial nucleus (PBn), an important relay for visceroceptive input from the spinal cord to higher order centers for nociceptive processing. In this study, two hypotheses were tested: first, inflammation of the colon prior to CRD would induce Fos expression in neurons in the thoracolumbar spinal cord segments and increase the number of neurons in the lumbosacral spinal cord segments that express Fos in response to noxious CRD; and second, the inflammation-induced increase in Fos expression in the spinal cord would be partially manifest as an increase in the number of spinoparabrachial projection neurons that respond to CRD. The retrograde tracer Fluorogold (FG) was injected unilaterally into the PBn of male Sprague-Dawley rats. Ten to 14 days later the rat's colon was either distended or inflamed and distended. Sections from the T13-L2 and L6-S2 spinal cord segments were double labeled using antibodies directed against FG and Fos protein. The results show that: (1) colonic inflammation plus distention induced Fos expression in the thoracolumbar spinal cord and increased Fos expression in the lumbosacral spinal cord compared to distention alone. In the lumbosacral cord, the increase in Fos expression was localized primarily to the superficial dorsal horn (SDH). In the thoracolumbar spinal segments, Fos was induced primarily in the SDH and the area around the central canal. (2) Injection of FG into the PBn produced dense retrograde labeling in the SDH, the lateral deeper gray matter and the area around the central canal at the lumbosacral and thoracolumbar levels. (3) In the lumbosacral spinal cord, 30-40% of the FG labeled cells double labeled for Fos. Colonic inflammation plus CRD did not significantly increase the percentage of spinoparabrachial neurons that were labeled for Fos compared to distention alone. (4) In the thoracolumbar spinal cord less than 10% of the FG labeled neurons were double labeled for Fos following CRD, but 25% of the FG labeled neurons in the SDH were double labeled following colonic inflammation. These data support the hypothesis that colonic inflammation activates viscerosensory processing in the thoracolumbar spinal cord and further suggests that this information is relayed to the PBn. The increase in information reaching the PBn over these parallel pathways may contribute to the affective-motivational component of the pain experience.

Effects of acute and chronic midthoracic spinal cord injury on neural circuits for male sexual function. II. Descending pathways

In normal animals, microstimulation of the medullary reticular formation (MRF) has two effects on efferent neurons in the motor branch of the pudendal nerve (PudM). MRF microstimulation depresses motoneuron reflex discharges (RD) elicited by dorsal nerve of the penis (DNP) stimulation and produces long latency sympathetic fiber responses (SFR). The midthoracic spinal location of these descending MRF-PudM projections was studied electrophysiologically using a variety of acute and chronic lesions. Chronic lesions, in 27 mature male rats, included dorsal (DHx) or lateral (LHx) hemisections or moderate/severe contusions (Cx) at spinal level T(8). Behavioral data (sexual reflex latency, bladder voiding) obtained throughout the recovery period revealed a significant impairment of urogenital function for the DHx and severe Cx groups of animals. Microstimulation-induced PudM-RDs and PudM-SFRs, obtained in terminal electrophysiological experiments 30 days postinjury in the same 27 rats (urethan-anesthetized), were tested for a combined total of 1,404 bilateral MRF sites. PudM-RD was obtained for LHx and moderate Cx groups of animals but not for DHx or severe Cx groups. PudM-SFRs were obtained for LHx, DHx (although significantly weakened) and moderate Cx groups but not for those having received either an over-DHx or a severe Cx injury. PudM responses also were tested for 6 MRF sites in six intact control rats both before and after various select acute spinal cord lesions. For MRF sites producing a robust PudM-RD and PudM-SFR, acute bilateral lesions confined to the dorsolateral quadrant (DLQ) eliminated the PudM-RD but failed to eliminate PudM-SFRs. A deeper lesion encompassing additional white matter located dorsally in the ventrolateral quadrant (VLQ) was necessary to eliminate PudM-SFRs. Overall, these electrophysiological results provide evidence for descending projections conveying information between MRF and the lower thoracic/lumbosacral male urogenital circuitry within the DLQ and the dorsal-most aspect of VLQ at the midthoracic level of spinal cord. The alterations of supraspinal projections observed after chronic injury are likely of important clinical significance for functional recovery in cases of clinically incomplete spinal cord injury at midthoracic spinal cord.