Morphine applied to the thalamic nucleus submedius produces a naloxone reversible antinociceptive effect in the rat

Development of a Modified Bayonet Forceps for Improving Steerability of Paddle Lead Electrodes During Spinal Cord Stimulator Surgery: A Technical Note

BACKGROUND AND OBJECTIVE

Despite recent advancements in spinal cord stimulation (SCS) technology, the surgical instrumentation for placement of SCS paddle leads remains suboptimal. Therefore, we developed a novel instrument to improve the steerability of SCS paddle leads during surgical placement.

METHODS

A review of existing literature was performed to analyze workflow deficiencies in the standard instrumentation of SCS paddle lead placement. After a period of adaptation and iterative feedback with a medical instrument company, a new instrument was developed, tested at benchtop, and successfully incorporated into the surgical routine.

RESULTS

A standard bayonet forceps was modified to include hooked ends and a ribbed surface, providing the surgeon with greater control over the paddle lead. The new instrument also included bilateral metal tubes starting approximately 4 cm proximal from the edge of the forceps. The bilateral metal tubes, through which the SCS paddle lead wires are passed, serve as anchors to keep the wires away from the incision site. In addition, it permitted the paddle lead to assume a bent configuration, reducing its overall size and allowing it to be placed through a smaller incision and laminectomy. The modified bayonet forceps was successfully used intraoperatively for placement of SCS paddle lead electrodes in several surgeries.

CONCLUSION

The proposed modified bayonet forceps increased steerability of the paddle lead, facilitating optimal midline placement. The bent configuration of the device facilitated a more minimally invasive surgical approach. Future studies are needed to validate our single-provider experience and evaluate the impact of this new instrument on operating room efficiency.

Enhancement of morphine-induced antinociception after electroconvulsive shock in mice

Electroconvulsive therapy (ECT) has been applied for chronic pain for decades. The amounts of opioids to treat pain are sometimes reduced after a series of ECT. The effect of ECT on morphine-induced analgesia and its mechanism underlying the reduction of morphine requirement has yet to be clarified. Therefore, we administered electroconvulsive shocks (ECS) to mice and investigated the antinociceptive effect of morphine in a hot plate test. We examined the expression level of µ-opioid receptor in the thalami of mice 25 h after administration of ECS compared to the thalami of mice without ECS administration using western blotting. ECS disturbed the development of a decrease in the percentage of maximal possible effect (%MPE), which was observed 24 h after a morphine injection, when ECS was applied 25, 23, 21, and 12 h before the second administration of morphine. We also examined the effect of ECS on the dose-response curve of %MPE to morphine-antinociception. Twenty-five hours after ECS, the dose-response curve was shifted to the left, and the EC50 of morphine given to ECS-pretreated mice decreased by 30.1% compared to the mice that were not pretreated with ECS. We also found that the expression level of µ-opioid receptors was significantly increased after ECS administration. These results confirm previous clinical reports showing that ECT decreased the required dose of opioids in neuropathic pain patients and suggest the hypothesis that this effect of ECT works through the thalamus.

Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action

Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.

Relationship between receptor occupancy and the antinociceptive effect of mu opioid receptor agonists in male rats

The analgesic mechanisms of mu opioid receptor (MOR) agonists, including receptor occupancy at the site of action, are not completely understood. The aims of the present study were to evaluate: (i) receptor occupancy in the rat brain after administration of MOR agonists; (ii) the relationship between occupancy and the antinociceptive effect. Morphine (2 or 4 mg/kg) or oxycodone (1 or 3 mg/kg) was subcutaneously administered to rats. The antinociceptive effect of these drugs was measured by the hot-plate test. MOR occupancy in the thalamus was assessed by conducting an ex vivo receptor binding assay using [³H] [D-Ala², N-MePhe⁴, Gly-ol]-enkephalin, followed by autoradiographic analysis. Both drugs produced antinociception in a dose-dependent manner, and these effects disappeared after the time point at which the maximal effect was elicited. Thalamic MOR occupancy was observed in a dose-dependent manner at the time point at which maximal antinociception was elicited, and relatively low occupancy was observed when the antinociceptive effect was decreasing. Good correlation between thalamic MOR occupancy and the antinociceptive effect was observed. These findings provide direct evidence for the receptor occupancy of MOR agonists at the site of action and its relationship with the analgesic effect.

A neuroanatomical framework for the central modulation of respiratory sensory processing and cough by the periaqueductal grey

Sensory information arising from the airways is processed in a distributed brain network that encodes for the discriminative and affective components of the resultant sensations. These higher brain networks in turn regulate descending motor control circuits that can both promote or suppress behavioural responses. Here we explore the existence of possible descending neural control pathways that regulate airway afferent processing in the brainstem, analogous to the endogenous descending analgesia system described for noxious somatosensation processing and placebo analgesia. A key component of this circuitry is the midbrain periaqueductal grey, a region of the brainstem recently highlighted for its altered activity in patients with chronic cough. Understanding the nature and plasticity of descending neural control may help identify novel central therapeutic targets to alleviate the neuronal hypersensitivity underpinning many symptoms of respiratory disease.

Connection changes in somatosensory cortex induced by different doses of propofol

BACKGROUND

The mechanism by which general anesthetics, widely used in clinical practice for over 160 years, effects on sensory responsiveness has been unclear until now. In the present study, the authors sought to explore the effect of different doses of propofol on somatosensory cortex by whisker stimulation in rats.

METHODS

In a fixed cage, rats were anesthetized with propofol 80 mg/kg intraperitoneally and then cathetered tail vein with 23-gauge metal needle connected with a pump. Two holes (2 mm diameter) were drilled and recording electrodes implantated in the primary somatosensory cortex barrel field (S1BF) and secondary somatosensory cortex (S2). The extracellular (20 rats) and intracellular (8 rats) recordings were used to test the neuron activity in both cortices at different doses of propofol (20, 40 and 80 mg/kg/h) through tail vein by pump. Meantime, vibrissal, olfactory, corneal responses (VOCR, sedation), and tail-pinch response (TRP, analgesia) were tested every 10 min during the doses of propofol 20, 40 and 80 mg/kg/h.

RESULTS

VOCR and TRP were depressed by propofol in a dose-dependent manner. The amplitude by whisker stimulation in S1BF was stronger and the peak latency was shorter compared with that of in S2. The response latency of S1BF and S2 was increased by raising infusion rate of propofol with the response latency in S2 being longer than that in S1BF at the same doses of propofol. The cross-correlation between S1BF and S2 decreased as the propofol infusion rate increased. The input resistance was higher by increasing infusion rate of propofol.

CONCLUSION

The sedation and analgesia effects of propofol were dose-dependent. Both the connectivity and instinctive oscillation between S1BF and S2 were proportionally modulated by the different doses of propofol.

Synergistic analgesic effects between neuronostatin and morphine at the supraspinal level

Neuronostatin, a 13-amino acid peptide, is encoded in the somatostatin pro-hormone. I.c.v. administration of neuronostatin produces a significant antinociceptive effect in the mouse tail-flick test, which is mediated by endogenous opioid receptor. However, the direct functional interaction between morphine and neuronostatin has not been characterized. In the present study, effect of neuronostatin on morphine analgesia was investigated in the tail-flick test. Our findings showed that i.c.v. administration of neuronostatin (0.3nmol/mouse i.c.v.) significantly enhanced the antinociceptive effect of morphine (2.5, 5 or 10μg/kg) at the supraspinal level. Results of antagonism experiments suggested that the synergistic analgesia induced by morphine and neuronostatin was mediated by μ- and к-opioid receptors not δ-opioid receptor. In conclusion, there may be a cascade amplification phenomenon when morphine and neuronostatin were co-administered in acute pain model. The above results provide evidence for the potential use of neuronostatin in combination with morphine to control pain and addiction.

Microinjection of morphine into thalamic nucleus submedius depresses bee venom-induced inflammatory pain in the rat

Previous studies have provided evidence of the existence of a pain modulatory feedback pathway consisting of thalamic nucleus submedius (Sm)–ventrolateral orbital cortex-periaqueductal grey pathway, which is activated during acute pain and leads to depression of transmission of nociceptive information in the spinal dorsal horn. The aim of this study was to test the hypothesis that morphine microinjection into the Sm decreased spontaneous pain and bilateral thermal hyperalgesia, as well as ipsilateral mechanical allodynia, induced by subcutaneous injections of bee venom into the rat hind paw. Morphine (1.0, 2.5 or 5.0 m̀g in 0.5 μL) injected into the Sm, contralateral to the bee venominjected paw, depressed spontaneous nociceptive behaviour in a dose-dependent manner. Furthermore, morphine significantly decreased bilateral thermal hyperalgesia and ipsilateral mechanical allodynia 2 h after bee venom injection. These morphine-induced effects were antagonized by 1.0 μg naloxone (an opioid antagonist) microinjected into the Sm 5 min before morphine administration. The results provided further support for the important role of the Sm and Sm-opioid receptors in inhibiting nociceptive behaviour and indicated for the first time that Sm opioid receptors were also effective in inhibiting the hypersensitivity provoked by bee venom-induced inflammation.

The effects of microinjection of morphine into thalamic nucleus submedius on formalin-evoked nociceptive responses of neurons in the rat spinal dorsal horn

Previous studies have indicated that the thalamic nucleus submedius (Sm), as an ascending component, is involved in an endogenous analgesic system consisting of spinal cord-Sm-ventrolateral orbital cortex (VLO)-periaqueductal gray (PAG)-spinal cord loop. To investigate the action of opioid in this antinociception pathway, the effects of microinjection of morphine and naloxone into the Sm on the formalin-induced nociceptive responses of neurons in the spinal dorsal horn were determined in the anesthetized rat. Formalin (5%, 50 microl) subcutaneously injected into unilateral hindpaw produced a biphasic nociceptive response which was similar to that obtained from assessing the nociceptive behavior either in the relative magnitude of response or the time course. A unilateral microinjection of morphine (5 microg, 0.5 microl) into the Sm 15 min after formalin injection significantly depressed the second phasic responses of neurons induced by formalin, and this effect was significantly attenuated by pre-microinjection of opioid receptor antagonist naloxone (1 microg, 0.5 microl) into the same site. The results suggest that the Sm is involved in opioid receptor-mediated antinociceptive effect on the persistent nociception through depression of the nociceptive transmission at the spinal cord level.

μ- but not δ- and κ-opioid receptor mediates the nucleus submedius interferon-α-evoked antinociception in the rat

Previous studies have indicated that interferon-alpha (IFN-alpha) can bind to opioid receptors and exerts an antinociceptive effect in both peripheral and central nervous systems. The current study investigated the antinociceptive effect of IFN-alpha unilaterally microinjected into the thalamic nucleus submedius (Sm) of rats on noxious thermal stimulus, and the roles of different subtypes of opioid receptors in mediating the Sm IFN-alpha-evoked antinociception. The results indicated that unilateral microinjection of IFN-alpha (4, 8, 16 pmol) into the Sm dose-dependently increased the hind paw withdrawal latency from the noxious heat stimulus, and this effect was reversed by pretreatment with non-selective opioid receptor antagonist naloxone (200 pmol) and specific mu-opioid receptor antagonist beta-FNA (1 nmol) into the same sites, whereas delta-opioid receptor antagonist ICI174,864 (1 nmol) and kappa-opioid receptor antagonist nor-BNI (1 nmol) failed to alter the effect of IFN-alpha. These results suggest that Sm is involved in IFN-alpha-evoked antinociception and mu- but not delta- and kappa-opioid receptor mediates the Sm IFN-alpha-evoked antinociception.

The roles of different subtypes of opioid receptors in mediating the nucleus submedius opioid-evoked antiallodynia in a neuropathic pain model of rats

Previous studies have indicated that thalamic nucleus submedius is involved in opioid-mediated antinociception in tail flick test and formalin test. The current study examined the effects of opioids microinjected into the thalamic nucleus submedius on the allodynia developed in neuropathic pain model rats, and determined the roles of different subtypes of opioid receptors in the thalamic nucleus submedius opioid-evoked antiallodynia. The allodynic behaviors induced by L5/L6 spinal nerve ligation were assessed by mechanical (von Frey filaments) and cold (4 degrees C plate) stimuli. Morphine (1.0, 2.5, and 5.0 microg) microinjected into the thalamic nucleus submedius contralateral to the nerve injury paw produced a dose-dependent inhibition of the mechanical and cold allodynia, and these effects were reversed by microinjection of the non-selective opioid receptor antagonist naloxone (1.0 microg) into the same site. Microinjection of endomorphin-1 (5.0 microg), a highly selective mu-opioid receptor agonist, and [D-Ala2, D-Leu5]-enkephalin (10 microg), a delta-/mu-opioid receptor agonist, also inhibited the allodynic behaviors, and these effects were blocked by selective mu-opioid receptor antagonist beta-funaltrexamine hydrochloride (3.75 microg). However, the [D-Ala2, D-Leu5]-enkephalin-evoked antiallodynic effects were not influenced by the selective delta-opioid receptor antagonist naltrindole (5.0 microg). Microinjection of the selective kappa-receptor agonist spiradoline mesylate salt (100 microg) into the thalamic nucleus submedius failed to alter the allodynia induced by spinal nerve ligation. These results suggest that the thalamic nucleus submedius is involved in opioid-evoked antiallodynia which is mediated by mu- but not delta- and kappa-opioid receptor in the neuropathic pain model rats.

Thalamic nucleus submedius receives GABAergic projection from thalamic reticular nucleus in the rat

GABAergic projection from thalamic reticular nucleus to thalamic nucleus submedius in the medial thalamus of the rat was studied by using immunohistochemistry for GABA, retrograde labeling with Fluoro-Gold combined with immunohistochemistry for GABA, and anterograde labeling with biotinylated dextranamine. Immunohistochemistry displayed that only GABA immunoreactive terminals were observed in the thalamic nucleus submedius, while GABA immunoreactive neuronal cell bodies were located in the thalamic reticular nucleus and lateral geniculate nucleus. Injection of Fluoro-Gold into the thalamic nucleus submedius resulted in massive retrogradely labeled neuronal cell bodies in the rostroventral portion of the ipsilateral thalamic reticular nucleus and a few in the contralateral thalamic reticular nucleus, and most of these cell bodies showed GABA immunopositive staining. Many biotinylated dextranamine anterogradely labeled fibers and terminals in the thalamic nucleus submedius were observed after injection of biotinylated dextranamine into the thalamic reticular nucleus. The present results provide a morphological evidence for a hypothesis that a disinhibitory effect on output neurons elicited by opioid or 5-hydroxytryptamine inhibiting a GABAergic terminal in the thalamic nucleus submedius may lead to activation of the descending inhibitory system and depression of the nociceptive inputs at the spinal cord level.

Involvement of GABAergic modulation of the nucleus submedius (Sm) morphine-induced antinociception

Previous studies have shown that microinjection of morphine into the nucleus submedius (Sm) of the thalamus produces antinociception. The aim of the current study was to examine whether gamma-aminobutyric acid (GABA)ergic terminals in the Sm were involved in this antinociception. Under light anesthesia, the GABA(A) receptor antagonist bicuculline or agonist muscimol was microinjected into the Sm of the thalamus in Sm non-morphine-treated (control) or Sm morphine-treated (microinjection into the Sm in the thalamus) rats. Tail flick latencies (TFL) were measured in each of these groups of rats every 5 min. Bicuculline (100, 200, 500 ng in 0.5 microL) depressed the TF reflex in a dose-dependent fashion, and this effect was blocked by microinjection of the opioid receptor antagonist naloxone (0.5 microg) into the same Sm site. A small dose (100 ng) of bicuculline microinjected into Sm significantly enhanced the morphine-evoked inhibition of TF reflex. In contrast, administration of muscimol (250 ng) did not significantly influence the TF reflex in Sm non-morphine-treated rats, but it significantly attenuated the morphine-induced antinociception in the Sm morphine-treated rats. These results suggest that locally released GABA acting at GABA(A) receptors is involved in the modulation of Sm morphine-induced antinociception, and support the hypothesis that a disinhibitory effect elicited by morphine on GABAergic terminals in Sm may lead to activation of the Sm-ventrolateral orbital cortex (VLO)-perioqueductal gray (PAG) brainstem descending inhibitory system and depression of the nociceptive inputs at the spinal cord level.

Differential rostral projections of caudal brainstem neurons receiving trigeminal input after masseter inflammation

To understand the functional significance of orofacial injury-induced neuronal activation, this study examined the rostral projection of caudal brainstem neurons that were activated by masseteric inflammation. Rats were injected with a retrograde tracer, Fluorogold, into the nucleus submedius of the thalamus (Sm), parabrachial nucleus (PB), lateral hypothalamus (LH), or medial ventroposterior thalamic nucleus (VPM) 7 days before injection of an inflammatory agent, complete Freund's adjuvant (CFA), into the masseter muscle. Rats were perfused at 2 hours after inflammation, and brainstem tissues were processed for Fos-Fluorogold double immunocytochemistry. Although there was no difference in Fos expression among the four groups (n=4 per site), the rostral projection of Fos-positive neurons showed dramatic differences. In the ventral portion of the trigeminal subnuclei interpolaris/caudalis (Vi/Vc) transition zone, the percentage of Fos-positive neurons projecting to the Sm (39.7%) was significantly higher than that projecting to the LH (5.4%) or VPM (5.6%; P<.001). The anesthesia alone also induced Fos expression in ventral Vi/Vc neurons, but these neurons did not project to Sm. In the caudal laminated Vc and dorsal Vi/Vc, the PB was the major site of rostral projection of Fos-positive neurons. In the caudal ventrolateral medulla and nucleus tractus solitarius, Fos-positive neurons projected to the Sm, PB, and LH. Most VPM-projecting neurons examined did not show Fos-like immunoreactivity after masseter inflammation. These findings emphasize the importance of the trigeminal Vi/Vc transition zone in response to orofacial deep tissue injury. Furthermore, the results differentiate the ventral and dorsal portions of the Vi/Vc transition zone, in that the Sm received projection mainly from activated neurons in the ventral Vi/Vc. The activation of Vi/Vc neurons and associated ascending pathways may facilitate somatoautonomic and somatovisceral integration and descending pain modulation after orofacial deep tissue injury.

Pain activation of human supraspinal opioid pathways as demonstrated by [11C]-carfentanil and positron emission tomography (PET)

The role of the supraspinal endogenous opioid system in pain processing has been investigated in this study using positron emission tomography imaging of [11C]-carfentanil, a synthetic, highly specific mu opioid receptor (mu-OR) agonist. Eight healthy volunteers were studied during a baseline imaging session and during a session in which subjects experienced pain induced by applying capsaicin topically to the dorsal aspect of the left hand. A pain-related decrease in brain mu-OR binding was observed in the contralateral thalamus consistent with competitive binding between [11C]-carfentanil and acutely released endogenous opioid peptides. This decrease varied directly with ratings of pain intensity. These results suggest that the supraspinal mu-opioid system is activated by acute pain and thus may play a substantial role in pain processing and modulation in pain syndromes.

Naloxone increases pain induced by topical capsaicin in healthy human volunteers

Opioid receptors occur in locations of strategic importance within the central nervous system for modulation of pain. Is pain reduced by ongoing inhibition mediated by activation of these receptors? Experiments to date in which the opioid-receptor antagonist, naloxone, is administered during a painful event have yielded unclear results. Topically applied capsaicin can be used to induce tonic pain of moderate to severe intensity without tissue injury and is an ideal stimulus for studying acute pain modulation. We therefore conducted a placebo-controlled double-blind crossover study to investigate the effects of naloxone on capsaicin-induced pain (five men, four women, aged 29 +/- 5 years). Capsaicin (10%) was applied topically and subjects rated pain every 2 min. The subjects were told that any drug given to them could increase, decrease, or not change their pain sensation. Pain plateaued after 20 min. At 26 min subjects received either naloxone or placebo in double-blind fashion. At 56 min subjects received the alternative (placebo or naloxone). In a second session the order of presentation was reversed. The naloxone induced a significant increase in pain compared both to baseline (P < 0.01) and placebo (P < 0.01). The peak effect, reached at 12-20 min after naloxone delivery, was 59% greater than placebo. This experiment suggests that acute pain is actively suppressed by endogenous opioid-receptor activation.

Response of neurons in the thalamic nucleus submedius (Sm) to noxious stimulation and electrophysiological identification of on- and off-cells in rats

Previous studies have indicated that thalamic nucleus submedius (Sm) is involved in nociceptive modulation and plays an important role in an endogenous analgesic system (a feedback loop) consisting of spinal cord (Sc)-Sm-ventrolateral orbital cortex-periaqueductal gray-Sc. However, the function of different types of Sm neurons in nociceptive modulation is unclear. For this reason, on the basis of further studies of properties of the Sm neurons responding to noxious stimuli, the different effects of systemic morphine on the Sm neurons were examined and two classes of nociceptive modulatory neurons, named as off- and on-cells, in this region were identified in lightly anesthetized rats. The results showed that (1) most (84%, 132/157) of the Sm neurons responded to peripheral noxious stimuli. Of these neurons, 66% (n = 87) were inhibited, 34% (n = 45) excited. All neurons had very large and bilateral, even all body receptive fields. No neuron was found to be responsive to innocuous stimulation; (2) systemic morphine increased the firing rate of neurons inhibited by noxious stimulation, but decreased that of neurons excited by the same stimulation. Furthermore, the effects of morphine could be reversed by systemic naloxone; (3) 45 of Sm neurons examined could be divided into three different classes: off-cells that decreased the firing rate from tail heating just prior to occurrence of the tail-flick (TF) reflex (3140 +/- 167 ms, n = 27), on-cells that increased the firing rate just before the TF reflex (1720 +/- 240 ms, n = 8), and neutral-cells that did not respond to any stimuli and neuronal activities were not related to the TF reflex (n = 10). Findings of this study provided electrophysiological evidence for involvement of Sm neurons, as those in the rostral ventromedial medulla, in the opioid-receptor-mediated descending nociceptive modulation.

Morphine microinjections into the rat nucleus submedius depress nociceptive behavior in the formalin test

Our previous studies have indicated that the thalamic nucleus submedius (Sm) is involved in modulation of nociception and plays an important role in an endogenous analgesic system (a feedback loop) consisting of spinal cord-Sm-ventrolateral orbital cortex-periaqueductal gray-spinal cord. To investigate whether opioids are involved in this antinociception pathway, the effects of microinjection of morphine and naloxone into the Sm on the nociceptive behavior (agitation) evoked in the formalin test were investigated in the awake rat using an automated movement detection system. The results indicate that a unilateral microinjection of morphine (5 micro g, 0.5 microl) into the Sm suppresses the formalin-induced agitation response, but does not influence spontaneous motor activity, and that the morphine-induced depression can be reversed by microinjection of the opioid receptor antagonist naloxone (1.0 micro g, 0.5 microl) into the same Sm site. The results suggest that opioid receptors in the Sm may be involved in the Sm-mediated depression of persistent inflammatory pain.