Intrathecal alpha 2-adrenergic agonists stimulate acetylcholine and norepinephrine release from the spinal cord dorsal horn in sheep. An in vivo microdialysis study

Targeted inactivation of spinal α2 adrenoceptors promotes paradoxical anti-nociception

Noradrenergic drive from the brainstem to the spinal cord varies in a context-dependent manner to regulate the patterns of sensory and motor transmission that govern perception and action. In sensory networks, it is traditionally assumed that activation of spinal α2 receptors is anti-nociceptive, while spinal α2 blockade is pro-nociceptive. Here, however, we demonstrate in vivo in rats that targeted blockade of spinal α2 receptors can promote anti-nociception. The anti-nociceptive effects are not contingent upon supraspinal actions, as they persist below a chronic spinal cord injury and are enhanced by direct spinal application of antagonist. They are also evident throughout sensory-dominant, sensorimotor integrative, and motor-dominant regions of the gray matter, and neither global changes in spinal neural excitability nor off-target activation of spinal α1 adrenoceptors or 5HT 1A receptors abolished the anti-nociception. Together, these findings challenge the current understanding of noradrenergic modulation of spinal nociceptive transmission.

Analgesic and Cardiopulmonary Effects of Epidural Romifidine and Morphine Combination in Horses

The study aim is to compare the effects of epidural administration of two different doses of romifidine combined with morphine in horses. A prospective crossover blinded experimental design was used. Five adult healthy horses two males and three females with a mean body weight of 380 ± 45 Kg (335-425 kg), were studied. Treatments consisted of romifidine 30 μg/kg (R30) or 60 μg/kg (R60) combined with morphine 0.1 mg/kg with a washout interval of 72 hours, administered through an epidural catheter placed at the first intercoccygeal space. Heart rate (HR) and respiratory rate (f_R), pH, blood gases, arterial blood pressures (mmHg), and threshold for electrical noxious stimulation was evaluated for 120 minutes and after 240 minutes of epidural injection. Data were collected before injections and every 15 minutes for 120 minutes, and at 240 minutes of epidural administration. Significant sedation occurred in both treatments with no statistically significant difference between them. There were significant changes in f_R and HR from baseline but no difference between treatments. Arterial blood pressures were significantly lower in R60 treatment from 75 up to 120 minutes post epidural injection. Analgesia was considered moderate for both treatments lasting longer with romifidine at 60 μg/kg. Epidurally administered romifidine and morphine combination in horses produces dose-dependent sedation, arterial hypotension, and antinociceptive effects.

Effect of dexmedetomidine on inflammation in patients with sepsis requiring mechanical ventilation: a sub-analysis of a multicenter randomized clinical trial

BACKGROUND

Administration of dexmedetomidine has been reported to improve inflammatory response in animals. We explored the effects of administering dexmedetomidine on the levels of C-reactive protein (CRP) and procalcitonin, and thus on inflammation, in patients with sepsis enrolled in a randomized clinical trial.

METHODS

The DESIRE trial was a multicenter randomized clinical trial in which adult patients with sepsis were sedated with (DEX group) or without (non-DEX group) dexmedetomidine while on mechanical ventilators. As a prespecified sub-analysis, we compared CRP and procalcitonin levels during the first 14 days of treatment between the two groups. The 14-day mortality rate, albumin level, and the number of patients with disseminated intravascular coagulation (DIC) were also assessed. We used generalized linear models to estimate the differences in these outcomes between groups. We also used the Kaplan-Meier method to estimate the 14-day mortality rate and the log-rank test to assess between-group differences.

RESULTS

Our study comprised 201 patients: 100 in the DEX group and 101 in the non-DEX group. CRP and procalcitonin levels were lower in the DEX vs. non-DEX group during the 14-day treatment period [CRP-range, 5.6-20.3 vs. 8.3-21.1 mg/dL (P = 0.03); procalcitonin-range, 1.2-37.4 vs. 1.7-52.9 ng/mL (P = 0.04)]. Albumin levels were higher in the DEX group (range, 2.3-2.6 g/dL) than in the non-DEX group (range, 2.1-2.7 g/dL; P = 0.01). The percentage of patients with DIC did not significantly differ between the groups (range, 21-59% and 17-56% for the DEX and non-DEX groups, respectively; P = 0.49). The 14-day mortality rates in the DEX and non-DEX groups were 13 and 21%, respectively (P = 0.16).

CONCLUSION

Sedation using dexmedetomidine reduced inflammation in patients with sepsis requiring mechanical ventilation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01760967 . Registered on 4 January 2013.

Intravenous dexmedetomidine versus intravenous clonidine for post spinal anesthesia shivering: a meta-analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine and clonidine are the most extensively studied drugs for shivering treatment, because α₂-adrenergic agonists can reduce the shivering threshold. The objective of this meta-analysis was to compare the efficacy and complications of dexmedetomidine with those of clonidine, when used for control of post spinal anesthesia shivering.

METHODS

Electronic databases were searched for randomized controlled trials (RCT) comparing the effect of dexmedetomidine versus clonidine for control of post spinal anesthesia shivering. The endpoints were effective rate of shivering treatment, time to cease shivering, recurrent rate of shivering and complications.

RESULTS

Six studies comprising 340 adult patients were included in this meta-analysis. Dexmedetomidine had higher effective rate of shivering treatment (odds ratio [OR]: 4.11, 95% confidence interval (CI): [1.53, 11.07], P = 0.005), shorter time to cease shivering (Mean differences (MD)=-1.91; 95% CI [-3.66, -0.15], P = 0.03), lower recurrent rate of shivering (OR = 0.30; 95% CI [0.12, 0.75], P = 0.01), compared to clonidine. Dexmedetomidine had a lower rate of hypotension and higher incidence of sedation than clonidine.

CONCLUSIONS

Dexmedetomidine is superior to clonidine when used for shivering treatment after spinal anesthesia, because of higher incidence of effective rate and sedation, faster control of shivering, lower incidence of recurrent rate and hypotention.

Evaluation of the neurotoxicity of intrathecal dexmedetomidine on rat spinal cord (electromicroscopic observations)

Background:

Spinal administration of dexmedetomidine has been proposed as an adjuvant in spinal anesthesia. However, there is limited information about its possible neurotoxic effect after its neuraxial administration. Potential spinal neurotoxicity should be investigated in animals before administering drugs through the spinal cord. Our aim was to investigate the neurotoxic effects of intrathecal dexmedetomidine in rats.

Methods:

Two groups were performed: the dexmedetomidine (D) group (n = 10) received 10 μg (0.5 ml), whereas the control (C) group (n = 10) received 0.9% (0.5 ml) sodium chloride through indwelling intrathecal catheter. Seven days after the injection, the medulla spinalis was extracted. Samples were withdrawn from both groups for histologic, electron microscopic examination. The histologic examination was performed separately on each of the four sites. The findings were categorized as follows: 0 - normal neuron; 1 - intermediate neuron damage; and 2 - neurotoxicity.

Results:

Intrathecal administration of dexmedetomidine sensorial block was seen in the dexmedetomidine group and significant differences in the dexmedetomidine group than control group in 15^th and 30^th min (P < 0.05). Histological examination did not show evidence suggestive of neuronal body or axonal lesion, gliosis, or myelin sheath damage in any group. In all animals, there were observed changes compatible with unspecific inflammation at the tip of the needle location. On the four-area scoring histologic examination, the scores of both groups were 0–1, and no statistical difference was observed between the groups.

Conclusions:

A single dose of intrathecal dexmedetomidine did not produce histologic evidence of neurotoxicity.

A comparison between intrathecal clonidine and neostigmine as an adjuvant to bupivacaine in the subarachnoid block for elective abdominal hysterectomy operations: A prospective, double-blind and randomized controlled study

BACKGROUND AND AIMS

Adjuvant to the local anesthetic agent has proven benefits when used intrathecally. With regards to intrathecal bupivacaine as control, we have compared in this study the effects of clonidine and neostigmine when co-administered intrathecally with hyperbaric (0.5%) bupivacaine for abdominal hysterectomy.

MATERIALS AND METHODS

This prospective, randomized, double-blind study was conducted from May 2009 to June 2011. A total of 150 patients of American Society of Anaesthesiology grades I and II scheduled for abdominal hysterectomy under spinal anesthesia were randomly allocated into three groups. A volume of 3 ml of 0.5% hyperbaric bupivacaine was respectively added 1 ml solution containing 5% dextrose and 75 mcg of neostigmine in Group N, 1 ml containing 5% dextrose and 30 mcg of clonidine in Group C and 1 ml of 5% dextrose in Group D (control). We compared the sensory and motor block, the surgical condition, the duration of spinal analgesia and the side-effect profile.

RESULTS AND OBSERVATIONS

Sensory and motor blocks and duration of spinal analgesia were significantly increased in both Group C and Group N compared to Group D. More incidences of Nausea and vomiting were observed in Group N compared to other groups. The surgical condition was poorer in Group N compared to Group C.

CONCLUSION

Both intrathecal clonidine and neostigmine increase the bupivacaine-induced spinal block. However, clonidine provides better surgical condition and fewer incidences of nausea and vomiting.

Effect of dexmedetomidine on early postoperative cognitive dysfunction and peri-operative inflammation in elderly patients undergoing laparoscopic cholecystectomy

The use of intravenous dexmedetomidine during surgery has been shown to suppress inflammatory cytokines peri-operatively. It has also been demonstrated that dexmedetomidine may benefit cognitive function in elderly patients following surgery; however, it is not clear whether dexmedetomidine reduces postoperative cognitive dysfunction (POCD) via the suppression of inflammatory cytokines. The aim of the present study was to investigate the effects of dexmedetomidine on early POCD and inflammatory cytokines in elderly patients undergoing laparoscopic cholecystectomy (LC). The study comprised 120 elderly patients undergoing selective LC, who were randomly allocated to receive either dexmedetomidine intravenously (DEX group, n=60) or the same volume of normal saline (control group, n=60). Cognitive function was assessed by Mini-Mental State Examination (MMSE) scores 1 day prior to surgery, 6 h following surgery and postoperatively on days 1 and 2. Interleukin (IL)-1β, IL-6 and C-reactive protein (CRP) levels were also measured at these time-points. On the basis of whether the patients had POCD on the first day after surgery, patients were divided into a POCD group and a non-POCD group. Blood cytokine levels were compared between the patients with and without POCD. A total of 100 patients completed both pre- and postoperative MMSE tests. At 1 day following surgery, POCD occurred in 10/50 (20%) patients in the DEX group and in 21/50 (42%) patients in the control group (P=0.017). At 6 h following surgery, IL-1β, IL-6 and CRP levels showed significant increases (P<0.01) compared with the baseline levels in the two groups. Furthermore, in the control group, CRP levels showed a significant increase on day 1 (P<0.001) and day 2 (P=0.017) postoperatively. In the DEX group compared with the control group, IL-1β, IL-6 and CRP levels were markedly decreased at 6 h and 1 day after surgery (P<0.01). Concentrations of IL-1β, IL-6 and CRP were significantly higher in patients who developed POCD on day 1 following surgery than in the patients who did not develop POCD (P<0.05). The findings of the current study support the hypothesis that dexmedetomidine administration during anesthesia decreases the incidence of early POCD, most likely by the mechanism of reduction of the inflammatory response level.

Intrathecal administration of clonidine or yohimbine decreases the nociceptive behavior caused by formalin injection in the marsh terrapin (Pelomedusa subrufa)

BACKGROUND

The role of noradrenergic system in the control of nociception is documented in some vertebrate animals. However, there are no data showing the role of this system on nociception in the marsh terrapins.

METHODOLOGY

In this study, the antinociceptive action of intrathecal administration of the α 2-adrenoreceptor agonist clonidine and α 2-adrenoreceptor antagonist yohimbine was evaluated in the African marsh terrapin using the formalin test. The interaction of clonidine and yohimbine was also evaluated.

RESULTS

Intrathecal administration of clonidine (37.5 or 65 μg/kg) caused a significant reduction in the mean time spent in pain-related behavior. Yohimbine, at a dose of 25 μg/kg, significantly blocked the effect of clonidine (65 μg/kg). However, administration of yohimbine (40 or 53 μg/kg) caused a significant reduction in the mean time spent in pain-related behavior. Intrathecal administration of yohimbine (53 μg/kg) followed immediately by intrathecal injection of the serotonergic methysergide maleate (20 μg/kg) resulted in a significant reversal of the antinociceptive effect of yohimbine.

CONCLUSION

The present study documented the intrathecal administration of drugs in the marsh terrapin, a technique that can be applied in future studies on these animals. The data also suggest the involvement of both α 2-adrenoreceptors and 5HT receptors in the modulation of nociception in testudines.

Muscarinic pain pharmacology: realizing the promise of novel analgesics by overcoming old challenges

The antinociceptive and analgesic effects of muscarinic receptor ligands in human and nonhuman species have been evident for more than half a century. In this review, we describe the current understanding of the roles of different muscarinic subtypes in pain modulation and their mechanism of action along the pain signaling pathway, including peripheral nociception, spinal cord pain processing, and supraspinal analgesia. Extensive preclinical and clinical validation of these mechanisms points to the development of selective muscarinic agonists as one of the most exciting and promising avenues toward novel pain medications.

The antinociceptive activity of intrathecally administered amiloride and its interactions with morphine and clonidine in rats

In this study, we aimed to evaluate the antinociceptive interaction between intrathecally administered amiloride and morphine or clonidine. Using rats chronically implanted with lumbar intrathecal catheters, we examined the ability of intrathecal amiloride, morphine, clonidine, and mixtures of amiloride-morphine and amiloride-clonidine to alter tail-flick latency. To characterize any interactions, isobolographic analysis was performed. The effects of pretreatment with intrathecally administered naloxone or yohimbine were tested. Intrathecal administration of amiloride (25-150 μg), morphine (.25-10 μg), or clonidine (.5-10 μg) alone produced significant dose-dependent antinociception in the tail-flick test. The median effective dose (ED(50)) values for intrathecally administered amiloride, morphine, and clonidine were 120.5 μg, 5.0 μg, and 4.4 μg, respectively. Isobolographic analysis exhibited a synergistic interaction after coadministration of amiloride-morphine and amiloride-clonidine. Intrathecal pretreatment with naloxone (10 μg) completely blocked the antinociceptive effects of morphine and the amiloride-morphine mixture. Intrathecal pretreatment with yohimbine (20 μg) completely blocked the antinociceptive effect of clonidine and antagonized the effect of the amiloride-clonidine mixture. There was no motor dysfunction or significant change in blood pressure or heart rate after the intrathecal administration of amiloride, amiloride-morphine, and amiloride-clonidine. The synergistic effect observed after the coadministration of amiloride and morphine or clonidine suggests a functional interaction among calcium channels, μ-receptors and α(2)-receptors at the spinal cord level of the nociceptive processing system.

PERSPECTIVE

Although intrathecal morphine and clonidine produces pronounced analgesia, antinociceptive doses of intrathecal morphine and clonidine produce several side effects, including hypotension, bradycardia, sedation, and tolerance. This article presents antinociceptive synergistic interaction between amiloride and morphine, amiloride, and clonidine on thermal nociceptive tests in the rat.

A comparative study of the effect of clonidine and tramadol on post-spinal anaesthesia shivering

The aim of this study was to evaluate the efficacy, potency and side effects of clonidine as compared to tramadol in post–spinal anaesthesia shivering. In this prospective double-blind randomized controlled clinical trial, 80 American Society of Anaesthesiologists grade-l (ASAI) patients aged between 18 and 45 years scheduled for various surgical procedures under spinal anaesthesia, who developed shivering were selected.The patients were divided into two groups: Group C (n=40) comprised of patients who received clonidine 0.5mg/kg intravenously (IV) and group patients who received tramadol 0.5 mg/kg IV. Grade of shivering, disappearance of shivering, haemodynamics and side effects were observed at scheduled intervals. Disappearance of shivering was significantly earlier in group C (2.54±0.76) than in group T (5.01±1.02) (P=.0000001). Response rate to treatment in group C was higher (97.5%) than in group T (92.5%), but the difference was not significant. Nausea, vomiting and dizziness were found to be higher in group T (P=0.001, 0.005, 0.001, respectively), while the patients in group C were comparatively more sedated (sedation level, 2; group C, 25%). We conclude that clonidine gives better thermodynamics than tramadol, with fewer side effects.

The Effect of Dexmedetomidine on Agitation during Weaning of Mechanical Ventilation in Critically ill Patients

Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment, Dexmedetomidine infusion was commenced at 0.4 μg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 μg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P <0.001 for 6 and 12 vs 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.

Antinociceptive Synergistic Interaction Between Clonidine and Ouabain on Thermal Nociceptive Tests in the Rat

The antinociceptive effect produced by spinal injection of clonidine (an alpha(2)-adrenergic agonist) is mediated by a cholinergic mechanism. We aimed in the current study to evaluate the antinociceptive interaction between intrathecally administered ouabain, an inhibitor of Na(+), K(+)-ATPase, and clonidine. We used rats chronically implanted with lumbar intrathecal catheters to examine the ability of intrathecal clonidine and ouabain and the mixtures of clonidine-ouabain to alter tail-flick latency. To characterize the interaction, isobolographic analysis was performed. Intrathecal clonidine (0.5-10 microg) and ouabain (0.1-5 microg) produced significant dose- and time-dependent antinociception in the tail-flick tests. The median effective dose (ED(50)) values for intrathecally administered ouabain and clonidine were 2.3 microg and 4.7 microg, respectively. The experimental point for the ouabain-clonidine combination decreased significantly (P < .05) below the lines of additivity. Isobolographic analysis exhibited a synergistic interaction after the coadministration of ouabain and clonidine. No motor impairment was observed in the animals after intrathecal administration of the combination of ouabain and clonidine or clonidine alone. Intrathecal pretreatment with atropine but not yohimbine blocked the antinociceptive effect of ouabain and attenuated its interaction with spinal clonidine. These results suggest that the synergistic interaction of ouabain and clonidine were probably mediated, at least in part, via an enhancement of cholinergic transmission in the spinal nociceptive processing system.

PERSPECTIVE

Although intrathecal clonidine produces pronounced analgesia, antinociceptive doses of intrathecal clonidine produce several side effects, including hypotension, bradycardia, and sedation. This article presents antinociceptive synergistic interaction between clonidine and ouabain on thermal nociceptive tests in the rat.

Modulation of pain transmission by G-protein-coupled receptors

The heterotrimeric G-protein-coupled receptors (GPCR) represent the largest and most diverse family of cell surface receptors and proteins. GPCR are widely distributed in the peripheral and central nervous systems and are one of the most important therapeutic targets in pain medicine. GPCR are present on the plasma membrane of neurons and their terminals along the nociceptive pathways and are closely associated with the modulation of pain transmission. GPCR that can produce analgesia upon activation include opioid, cannabinoid, alpha2-adrenergic, muscarinic acetylcholine, gamma-aminobutyric acidB (GABAB), groups II and III metabotropic glutamate, and somatostatin receptors. Recent studies have led to a better understanding of the role of these GPCR in the regulation of pain transmission. Here, we review the current knowledge about the cellular and molecular mechanisms that underlie the analgesic actions of GPCR agonists, with a focus on their effects on ion channels expressed on nociceptive sensory neurons and on synaptic transmission at the spinal cord level.

Progress in shivering control

Hypothermia is a potent neuroprotectant and induced hypothermia holds great promise as a therapy for acute neuronal injury. Thermoregulatory responses, most notably shivering, present major obstacles to therapeutic temperature management. A review of thermoregulatory physiology and strategies aimed at controlling physiologic responses to hypothermia is presented.

Acetylcholine release from fetal tissue homotopically grafted to the motoneuron-depleted lumbar spinal cord. An in vivo microdialysis study in the awake rat

Grafts of spinal cord (SC) tissue can survive and develop into the severed SC, but no conclusive data are available concerning the functional activity of transplanted neurons. In the present study, suspensions of prelabeled embryonic ventral SC tissue were grafted to the lumbar SC of rats with motoneuron loss induced by perinatal injection of volkensin. Eight to ten months post-grafting, acetylcholine (ACh) release was measured by microdialysis in awake rats, under either basal or stimulated conditions. In normal animals, baseline ACh output averaged 1.6 pmol/30 microl, it exhibited a 4-fold increase after KCl-induced depolarization or handling, and it was completely inhibited by tetrodotoxin administration. Moreover, ACh levels did not change following acute SC transection performed under anesthesia during ongoing dialysis, suggesting an intrinsic source for spinal ACh. Treatment with volkensin produced a severe (>85%) motoneuronal loss accompanied by a similar reduction in baseline ACh release and almost completely abolished effects of depolarization or handling. In transplanted animals, many motoneuron-like labeled cells were found within and just outside the graft area, but apparently in no case were they able to extend fibers towards the denervated muscle. However, the grafts restored baseline ACh output up to near-normal levels and responded with significantly increased release to depolarization, but not to handling. The present findings indicate that spinal neuroblasts can survive and develop within the motoneuron-depleted SC and release ACh in a near-normal, but apparently non-regulated, manner. This may be of importance for future studies involving intraspinal stem cell grafts.

Noradrenergic pain modulation

Norepinephrine is involved in intrinsic control of pain. Main sources of norepinephrine are sympathetic nerves peripherally and noradrenergic brainstem nuclei A1-A7 centrally. Peripheral norepinephrine has little influence on pain in healthy tissues, whereas in injured tissues it has variable effects, including aggravation of pain. Its peripheral pronociceptive effect has been associated with injury-induced expression of novel noradrenergic receptors, sprouting of sympathetic nerve fibers, and pronociceptive changes in the ionic channel properties of primary afferent nociceptors, while an interaction with the immune system may contribute in part to peripheral antinociception induced by norepinephrine. In the spinal cord, norepinephrine released from descending pathways suppresses pain by inhibitory action on alpha-2A-adrenoceptors on central terminals of primary afferent nociceptors (presynaptic inhibition), by direct alpha-2-adrenergic action on pain-relay neurons (postsynaptic inhibition), and by alpha-1-adrenoceptor-mediated activation of inhibitory interneurons. Additionally, alpha-2C-adrenoceptors on axon terminals of excitatory interneurons of the spinal dorsal horn possibly contribute to spinal control of pain. At supraspinal levels, the pain modulatory effect by norepinephrine and noradrenergic receptors has varied depending on many factors such as the supraspinal site, the type of the adrenoceptor, the duration of the pain and pathophysiological condition. While in baseline conditions the noradrenergic system may have little effect, sustained pain induces noradrenergic feedback inhibition of pain. Noradrenergic systems may also contribute to top-down control of pain, such as induced by a change in the behavioral state. Following injury or inflammation, the central as well as peripheral noradrenergic system is subject to various plastic changes that influence its antinociceptive efficacy.

Clonidine depresses LTP of C-fiber evoked field potentials in spinal dorsal horn via NO-cGMP pathway

Clonidine, a specific alpha2-adrenergic receptor agonist, has been found to be effective for the treatment of neuropathic pain, the mechanism underlying the effect is, however, not well understood. Here, the effect of clonidine on long-term potentiation (LTP) of C-fiber evoked field potentials in spinal dorsal horn, which is a synaptic model of injury-induced hyperalgesia, was investigated. LTP of C-fiber evoked field potentials was recorded in the superficial layers of spinal dorsal horn in anesthetized adult Sprague-Dawley rats. Clonidine and other substances were applied locally at the recording spinal segments before or after LTP induction by tetanic stimulation. We found that (1) Clonidine completely blocked LTP induction, when applied 30 min before tetanic stimulation and depressed spinal LTP, when applied 30 min and 3 h after LTP induction. (2) The inhibitory effect of clonidine on spinal LTP had two phases: a fast phase lasting for about 3.5 h and a slow phase persisting for the rest time of experiments (up to 8 h after drug). (3) Spinal clonidine at low dose (10.7 micro g/100 micro l) depressed spinal LTP but not C-fiber baseline response and at higher dose (107 micro g/100 micro l) depressed both of them. (4) Pretreatment with alpha2-adrenergic receptor antagonist yohimbine completely blocked the inhibitory effect of clonidine. (5) Pretreatment with muscarinic receptor antagonist atropine, nitric oxide synthesis inhibitor l-NNA or cGMP inhibitor ODQ depressed the fast phase inhibition significantly and abolished the slow phase inhibition completely. These results suggest that clonidine may exert analgesic effect by depressing the synaptic plasticity in spinal dorsal horn, via activation of muscarinic receptor-NO-cGMP pathway.

Intrathecal clonidine reduces the incidence of ischemia-provoked ventricular arrhythmias in a canine postinfarction heart failure model

BACKGROUND

Intrathecal clonidine (ITC) is used clinically to manage neuropathic pain but frequently causes hypotension and bradycardia due to centrally mediated sympatholytic effects.

OBJECTIVES

The purpose of this study was to evaluate the cardiac electrophysiologic effects of thoracic ITC and its effects on ischemia-provoked ventricular arrhythmias.

METHODS

Twelve mongrel dogs with healed myocardial infarctions and heart failure were evaluated. ITC was delivered locally via catheter to the T2-T4 spinal segments and was dosed to reduce heart rate (HR) by >20% to 25%. Electrophysiologic testing was performed before and after ITC. Transient (4-minute) myocardial ischemia was induced via left circumflex coronary artery occlusion on two separate occasions to provoke ventricular arrhythmias (ventricular tachycardia [VT]/ventricular fibrillation [VF]). Ischemic episodes were separated by 1 to 2 days, and dogs were randomly assigned to receive ITC or intrathecal saline flush (control) prior to the first or the second ischemic episode.

RESULTS

ITC produced significant decrease in HR (31%) and increases in PR interval (22%), Wenckebach cycle length (122%), and atrial and ventricular effective refractory periods (19% and 9%, respectively) but had no significant effect on systemic blood pressure. The occurrence of VT/VF was reduced from 9 of 12 to 3 of 12 dogs when ITC was administered prior to transient myocardial ischemia (P = .04). ITC also blunted ischemia-induced HR increase by 74%.

CONCLUSION

ITC reduced ischemia-induced VT/VF in a canine model of healed myocardial infarction with superimposed heart failure and acute ischemia. Results from electrophysiologic testing were consistent with a clonidine-induced reduction in cardiac sympathetic activity from the spinal cord. These data suggest that ITC administration may be a novel approach to treating ventricular arrhythmias.

Involvement of spinal GABA receptors in the regulation of intraspinal acetylcholine release

It has been shown that analgesics such as morphine, lidocaine and clonidine increase the release of spinal acetylcholine. Acetylcholine may therefore play an important role in the regulation of spinal pain threshold. Since behavioral as well as in vitro studies have shown a clear involvement of GABA (gamma-amino butyric acid) receptors in the regulation of spinal nociceptive mechanisms, the present study focused on the role of GABA receptors for spinal acetylcholine release control. GABA receptor agonists and antagonists were infused via a spinal microdialysis probe and acetylcholine release was measured. The GABA(A) receptor agonist muscimol decreased acetylcholine release and the antagonist bicuculline increased acetylcholine release. The GABA(B) receptor agonist baclofen decreased acetylcholine release whereas the antagonist saclofen did not change acetylcholine release. The results suggest that both GABA receptor subtypes have an inhibitory role on spinal dorsal horn acetylcholine release and that the GABA(A) receptors are tonically regulating acetylcholine release.

The effects of chemical or surgical deafferentation on [3H]-acetylcholine release from rat spinal cord

Cholinergic modulation of nociceptive transmission through both nicotinic and muscarinic receptors in the spinal cord represents an important mechanism in pain signaling. However, what neuronal elements release acetylcholine and how release might change in response to deafferentation are unclear. The present studies demonstrated Ca++- and K+-dependent release of [3H]-acetylcholine from slices of regional areas of rat spinal cord. That [3H]-acetylcholine was synthesized from [3H]-choline was demonstrated by the lack of [3H]-acetylcholine release following incubation with either the choline uptake inhibitor hemicholinium or the choline acetyltransferase inhibitor bromoacetylcholine. Rats treated neonatally with capsaicin or with spinal nerve ligation as adults showed a significantly decreased K+-stimulated release of [3H]-acetylcholine from dorsal horn but not ventral horn lumbar spinal cord slices. In rats subjected to dorsal rhizotomy, while basal release from lumbar dorsal spinal cord slices was reduced, K+-stimulated [3H]-acetylcholine release, while decreased, was not significantly different compared with controls. The data presented here show that there are regional differences in the release of acetylcholine from spinal cord and that this release can be modulated by chemical or surgical deafferentation. These results also indicate that the source of acetylcholine in the dorsal cord originates mainly from resident somata and their collaterals, interneurons and/or descending terminals, with only very minor contributions coming from primary afferents. The present data help to further elucidate the role of acetylcholine in spinal signaling, particularly with respect to the effects of nerve injury and nociceptive neurotransmission.

Involvement of spinal serotonin receptors in the regulation of intraspinal acetylcholine release

Stimulation of spinal serotonin (5-HT) receptors results in analgesia and release of acetylcholine. We investigated the involvement of 5-HT1, 5-HT2, and 5-HT3 receptor subtypes in the regulation of spinal acetylcholine release. A spinal microdialysis probe was placed dorsally at about the C5 level in anaesthetized rats. The selective serotonin reuptake inhibitor citalopram was found to increase acetylcholine release when infused via the microdialysis probe. Several doses of the 5-HT receptor agonists 8-hydroxy-2-(di-n-propylamino)tetraline (8-OH-DPAT, 5-HT1A), 1,4-dihydro-3-(1,2,3,6-tetrahydro-4-pyridinyl)-5H-pyrrolo[3,2-b]pyridin-5-one dihydrochloride (CP93129, 5-HT1B), alpha-methyl-5-hydroxytryptamine maleate (m5-HT, 5-HT2), 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI, 5-HT2C), and 1-(m-chlorophenyl)-biguanide (5-HT3) were subsequently infused via the microdialysis probe. Only 8-OH-DPAT, CP93129, and m5-HT increased acetylcholine release dose dependently. The 5-HT1A receptor selective antagonist (S)-N-tert-butyl-3-(4-(2-methoxyphenyl)piperazine-1-yl)-2-phenylpropanamide hydrochloride and the 5-HT2A receptor selective antagonist ketanserin tartrate inhibited the 8-OH-DPAT and the m5-HT induced acetylcholine release. The results suggest that 5-HT1A and the 5-HT2A receptors are involved in the regulation of acetylcholine release in the spinal cord.

The combination of epidural clonidine and S(+)-ketamine did not enhance analgesic efficacy beyond that for each individual drug in adult orthopedic surgery

STUDY OBJECTIVES

To evaluate the benefit of epidural clonidine and S(+)-ketamine combination through the epidural route in adult orthopedic surgery.

DESIGN

Randomized double-blinded study.

SETTING

Teaching hospital.

PATIENTS

Scheduled to undergo knee surgery, 56 American Society of Anesthesiologists physical status 1 and 2 adult patients.

INTERVENTIONS

Patients were randomized to 1 of 4 groups to receive the combined epidural-intrathecal technique. A 10-mL epidural injection of either study drug or normal saline was first administered to all patients. Intrathecal anesthesia was performed with 15 mg of bupivacaine. The control group (CG) received epidural saline. The 0.1-mg/kg S(+)-ketamine epidural group received 0.1 mg/kg epidural S(+)-ketamine. The 0.5-microg/kg clonidine epidural group received 0.5 microg/kg epidural clonidine. The S(+)-ketamine/clonidine group received 0.1 mg/kg epidural S(+)-ketamine plus 0.5 microg/kg epidural clonidine.

MEASUREMENTS AND MAIN RESULTS

Pain and adverse effects were evaluated by visual analog scale. Rescue analgesics were available to patients. The groups were demographically similar. Sensory level to pinprick, surgical and anesthetic time, and visual analog scale scores for pain at first rescue medication were similar among the groups. The time to first rescue analgesic (minute) was lowest in CG (P < .005). The CG required more rescue analgesics in 24 hours than any of the other groups (P < .0005). Patients who received either epidural clonidine, S(+)-ketamine, or both displayed similar analgesia. The frequency of adverse effects was similar among groups (P > .05).

CONCLUSIONS

The association of epidural clonidine or S(+)-ketamine did not result in a greater analgesic effect in the model of acute postoperative pain studied, although the interaction of epidural clonidine and S(+)-ketamine is not attributable to sharing of a common second messenger system.

The spinal muscarinic receptor subtypes contribute to the morphine-induced antinociceptive effects in thermal stimulation in mice

The present study was undertaken to clarify how spinal muscarinic receptors can be involved in the antinociceptive effects induced by morphine in thermal stimulation. The morphine-induced antinociceptive effects (26.6 micromol/kg, s.c.) was inhibited by an intrathecal (i.t.) injection of the muscarinic antagonist (M) atropine and the M(1)/M(4) antagonist pirenzepine in a dose-dependent manner. In contrast, the M(2) antagonist methoctramine and the M(3) antagonist 4-DAMP did not inhibit the morphine-induced antinociceptive effects. Injection (i.t.) of the putative M(1) agonist McN-A-343 resulted in dose-dependent antinociceptive effects in thermal stimuli. In addition, antinociceptive effects induced by the i.t. injection of morphine were not inhibited by the M(1)/M(4) antagonist pirenzepine, although pirenzepine did inhibit the intracerebroventricular (i.c.v.) injection of morphine-induced antinociceptive effects. These results suggest that the morphine-induced antinociceptive effects in thermal stimuli are regulated by the M(1) or M(4) receptor in the spinal cord.

INVOLVEMENT OF NITRIC OXIDE IN CLONIDINE-INDUCED SPINAL ANALGESIA

BACKGROUND

The chronic pain relieving effects following spinal administration of clonidine are probably connected to alpha2-adrenoreceptor-induced augmented synthesis of nitric oxide (NO) in the spinal cord. In contrast, when acute pain is considered, the possible role of NO is still speculative. The aim of the present study was to explore the role of NO in acute pain relief following intraspinal administration of clonidine.

METHODS

We used the mouse tail-flick model of acute pain. Spinal injections of the following agents and their combinations were administered: clonidine, L-arginine (NO precursor), the NO production inhibitor nitro-L-arginine-methyl ester (L-NAME), the NO antagonist methylene blue (MB) and nitroglycerine (NO releasing agent).

RESULTS

A 95% analgesic response was achieved with 2.0 microg clonidine. L-Arginine produced analgesia, and L-arginine administration followed by clonidine resulted in a pronounced synergistic analgesic effect. This synergistic effect was attenuated by L-NAME. Pre-treatment with MB decreased and nitroglycerine administration did not affect the clonidine-induced analgesia.

CONCLUSIONS

NO may be involved in the mediation of the acute pain relieving effects of intraspinally administered clonidine. Further research is warranted to establish the potential benefits and possibility for incorporation of NO promoting agents in therapeutic regional pain regimens.

Intrathecal clonidine inhibits mechanical allodynia via activation of the spinal muscarinic M1 receptor in streptozotocin-induced diabetic mice

We examined the involvement of the spinal muscarinic receptors in the clonidine-induced antiallodynic effects. Mechanical sensitivity was assessed by stimulating the hind paw with von Frey filaments. In streptozotocin-treated (200 mg/kg, i.v.) diabetic mice, hypersensitivity to mechanical stimulation appeared 3 days after streptozotocin administration, and persisted for 11 days. This mechanical hypersensitivity (allodynia) was inhibited by the intrathecal (i.t.) injection of clonidine. The muscarinic receptor antagonist atropine (i.t.) and alpha2-adrenoreceptor antagonist yohimbine (i.t. or subcutaneous injection) abolished the antiallodynic effect of clonidine. The effect was mimicked by the muscarinic M1 receptor antagonist pirenzepine, but not by the muscarinic M2 receptor antagonist methoctoramine or the muscarinic M3 receptor antagonist 4-DAMP (4-diphenyl-acetoxy-N-methylpiperidine methiodide). In addition, the mechanical hypersensitivity in diabetic mice was reduced by the selective muscarinic M1 receptor agonist McN-A-343 (4-(m-chlorophenyl-carbamoyloxy)-2-butynyltrimethylammonium chloride) (i.t.). These results suggest that spinal muscarinic M1 receptors participate in the antiallodynic effect of clonidine in diabetic mice.

Characteristic of Interactions Between Intrathecal Gabapentin and Either Clonidine or Neostigmine in the Formalin Test

Intrathecal gabapentin is effective for phase 2 of the formalin response but not for acute pain. Unlike gabapentin, intrathecal clonidine and neostigmine attenuate both acute pain and phase 2 of the formalin response. We evaluated gabapentin's interactions with either clonidine or neostigmine in the formalin test. Male Sprague-Dawley rats were used. For the formalin test, 50 microL of 5% formalin solution was injected into the hindpaw. The interaction of drugs was investigated by a fixed-dose analysis or an isobolographic analysis. Intrathecal gabapentin produced a suppression of the phase 2 flinching response, but not the phase 1 response, in the formalin test. Intrathecal clonidine and neostigmine resulted in a reduction of the pain behavior in both phases. A fixed-dose analysis in phase 1 showed that gabapentin potentiated the antinociceptive effect of clonidine and neostigmine. An isobolographic analysis in phase 2 revealed a synergistic interaction after intrathecal administration of gabapentin-clonidine or gabapentin-neostigmine mixture. We conclude that the combination of gabapentin with either clonidine or neostigmine at the level of the spinal cord could play a major role not only in acute pain, but also in phase 2 of the formalin response.

IMPLICATIONS

We determined the pharmacological properties of gabapentin combined with either clonidine or neostigmine in the formalin test. Spinal gabapentin reinforced the effects of clonidine and neostigmine in the formalin test. The hitherto unreported action of gabapentin on acute nociceptive stimulus could be of considerable significance.

Intrathecal clonidine and bupivacaine have synergistic analgesia for acute thermally or inflammatory-induced pain in rats

We investigated the interaction between spinally administered bupivacaine and clonidine using an animal model of acute and inflammatory pain. Rats implanted with lumbar intrathecal catheters were injected intrathecally with saline (control), bupivacaine (1 to 100 microg), or clonidine (0.1 to 3 microg) and tested for their responses to thermal stimulation to the tail (tail flick test) and subcutaneous formalin injection into the hindpaw (formalin test). The effects of the combination of bupivacaine and clonidine on both stimuli were tested by isobolographic analysis. General behavior and motor function were examined as side effects. The 50% effective doses of bupivacaine and clonidine were significantly smaller when combined compared with each single drug in both the tail flick test (2.82 and 0.11 microg versus 7.1 and 0.29 microg, respectively) and phase 1 (0.24 and 0.009 microg versus 5.7 and 0.15 microg) and phase 2 (0.31 and 0.012 microg versus 3.2 and 0.16 microg) of the formalin test. Side effects were decreased by the combination. These results suggest a favorable combination of intrathecal bupivacaine and clonidine in the management of acute and inflammatory pain.

IMPLICATIONS

The analgesic interaction between intrathecally administered bupivacaine and clonidine was examined during acute thermal and inflammatory-induced pain in rats. The analgesia produced by the combination of these two drugs was synergistic in both acute thermal and inflammatory induced pain, with a decrease in behavioral side effects.

The Effects of the alpha2-Adrenergic Receptor Agonists Clonidine and Rilmenidine, and Antagonists Yohimbine and Efaroxan, on the Spinal Cholinergic Receptor System in the Rat

Cholinergic agonists produce spinal antinociception via mechanisms involving an increased release of intraspinal acetylcholine. The cholinergic receptor system interacts with several other receptor types, such as alpha2-adrenergic receptors. To fully understand these interactions, the effects of various receptor ligands on the cholinergic system must be investigated in detail. This study was initiated to investigate the effects of the alpha2-adrenergic receptor agonists clonidine and rilmenidine and the alpha2-adrenergic receptor antagonists yohimbine and efaroxan on spinal cholinergic receptors in the rat. Spinal microdialysis was used to measure in vivo changes of acetylcholine after administration of the ligands, with or without nicotinic receptor blockade. In addition, in vitro binding properties of the ligands on muscarinic and nicotinic receptors were investigated. It was found that clonidine and rilmenidine increased, while yohimbine decreased spinal acetylcholine release. Efaroxan affected acetylcholine release differently depending on concentration. Nicotinic receptor blockade attenuated the effect of all ligands. All ligands showed poor binding affinity for muscarinic receptors. On the other hand, all ligands possessed affinity for nicotinic receptors. Clonidine and yohimbine binding was best fit to a one site binding curve and rilmenidine and efaroxan to a two site binding curve. The present study demonstrates that the tested alpha2-adrenergic receptor ligands affect intraspinal acetylcholine release in the rat evoked by nicotinic receptor mechanisms in vivo, and that they possess binding affinity to nicotinic receptors in vitro. The binding of alpha2-adrenergic receptor ligands to nicotinic receptors might affect the intraspinal release of acetylcholine.

Effect of Oral Tizanidine on Local-anesthetic Infiltration Pain during Epidural Catheterization

PURPOSE

Tizanidine is a clonidine derivative and has the same effects, such as sedation, anxiolysis and analgesic response. We evaluated the effect of tizanidine on infiltration pain during epidural catheterization.

METHODS

Forty patients scheduled to undergo epidural anesthesia in elective surgery were randomly allocated into two groups. The control group received placebo 60 minutes before arrival in the operating room, and the tizanidine group received 3 mg of oral tizanidine as premedication 60 minutes before arrival in the operating room. Every patient was measured heart rate and blood pressure before receiving placebo or premedication and after arrival in the operating room. After an epidural catheter was indwelled, the patients were questioned about the infiltrating pain of local anesthetic, and the degree was assessed by means of visual analog scale score (VAS score, 0 to approximately 100 mm).

RESULTS

Blood pressure in the operating room was significantly attenuated in the tizanidine group compared to the control group (148 +/- 21 mmHg vs 130 +/- 15 mmHg). Heart rate was not significantly different between the two groups. Rate-pressure product was significantly lower in the tizanidine group (11282 +/- 2960 vs 9592 +/- 2632). VAS score in the tizanidine group was significantly lower than that in the control group (P <0.001).

CONCLUSION

It was possible to reduce the infiltration pain of local anesthetic during epidural catheterization by oral administration of 3 mg of tizanidine as premedication. Blood pressure and rate-pressure product in the operating room were also attenuated by receiving tizanidine. Therefore, we recommend premedication with tizanidine for patients undergoing epidural catheterization.

The effect of intrathecal medetomidine on small bowel transit in the rat

BACKGROUND AND OBJECTIVE

Gastrointestinal motility is influenced by abdominal trauma, laparotomy and particularly by intestinal ischaemia. The reflex inhibition of gastrointestinal motility is mediated mainly by the sympathetic nervous system. There are reports on the effects of systemically applied alpha2-adrenoceptor agonists on gastric emptying and recovery of bowel motility, but the effect of spinally applied alpha2-adrenoceptor agonists on intestinal motility has not been studied. The aim of this study was to investigate the effects of intrathecal medetomidine on gastrointestinal transit in rats after transient intestinal ischaemia.

METHODS

Forty rats were randomly assigned to four groups of 10 each. Intrathecal catheter insertion and laparotomy were performed on each rat. Saline (10 microL) was injected intrathecally in Groups A and B. Medetomidine (10 microg in 10 microL) was injected intrathecally in Groups C and D. Intestinal ischaemia was induced in Groups B and D. Gastrointestinal transit was determined by measuring the length that a standardized marker meal of activated charcoal had travelled. Intrathecal medetomidine was compared to intrathecal saline in their effect on intestinal motility after 30 min period of bowel ischaemia.

RESULTS

Laparotomy and intestinal ischaemia slowed gastrointestinal transit. Intrathecal medetomidine accelerated transit in both ischaemia and non-ischaemia groups.

CONCLUSION

Intrathecal medetomidine markedly accelerated small intestinal transit and may also hasten the recovery from post-ischaemic paralytic ileus.

Nicotinic Acetylcholinergic Receptors Regulate the Intraspinal Release of Acetylcholine in Male Rats

Activation of cholinergic receptors in the spinal cord increases the intraspinal release of acetylcholine (ACh) and produces potent analgesia. The mechanisms that regulate the release of spinal ACh are not fully known. In the present study, we investigated the role of nicotinic ACh receptors in the regulation of intraspinal ACh release. Using an in vivo intraspinal microdialysis technique, nicotine was administered alone and in combination with the nicotinic antagonists mecamylamine (50 microM), dihydro-beta-erythroidine (DbetaE) (500 microM) and methyllycaconitine (MLA) (40 nM). Administration of nicotine (1 microM-1 mM) produced a dose dependent increase of intraspinal ACh release, while 10 mM nicotine resulted in dramatic increase in ACh release followed by a decrease to baseline. Administration of mecamylamine or DbetaE also induced an increased ACh release while MLA caused a decreased release. Mecamylamine and DbetaE, but not MLA pretreatment attenuated the stimulatory effect of 100 microM nicotine on intraspinal ACh release. It is suggested that spinal ACh release is regulated by different nicotinic ACh receptors. These receptors may tonically regulate spinal ACh release either directly or indirectly via inhibitory interneurones. Some of these receptors may be desensitised by high nicotine concentrations leading to a reduction of ACh release.

Cross-tolerance between spinal neostigmine and morphine in the rat

BACKGROUND

Direct or indirect acting cholinergic muscarinic agonists such as neostigmine, are potent antinociceptives when administered intrathecally (i.t.). This study examines whether spinal neostigmine tolerance and cross-tolerance to spinal morphine occurs.

METHODS

Rats (32/group) were implanted with miniosmotic pumps delivering either i.t. saline 1 microl h(-1) (S), morphine 10 nmol microl(-1) h(-1) (M), or neostigmine 3 nmol microl(-1) h(-1) (N). Latencies (infrared thermal withdrawal rear paw) were measured daily for 6 days after which four animals from each group were given one i.t. challenge dose of morphine (m) 0.1, 1, 10, or 100 nmol, or neostigmine (n) 0.3, 3, 10, or 30 nmol.

RESULTS

Neostigmine and morphine-infused animals both developed tolerance to spinal neostigmine, but neostigmine-infused animals showed no significant cross-tolerance to spinal morphine; mean ED(50) nmol (CI 95%) dose-response values were Sn 2.6 (1.9-3.5), Mn 15.6 (9.9-24.6)*, Nn 18.7 (11.7-29.8)*, Sm 0.7 (0.4-1.1), Nm 1.2 (0.8-2.0), Mm 152 (50-461)* (*significance vs saline infused control group).

CONCLUSION

Thus, unidirectional cross-tolerance from morphine to neostigmine was evident. Previous studies suggest morphine has a cholinergic mechanism of action partially accounting for its antinociceptive effect, which may explain this observed unidirectional cross-tolerance.

The role of spinal muscarinic acetylcholine receptors in clonidine-induced anti-nociceptive effects in rats

We have examined the effects of intrathecal (i.t.) injection of the muscarinic acetylcholine receptor antagonist atropine on the clonidine-induced nociceptive effect in formalin-induced nociception in rats. The injection of 5% formalin into the hind paw caused biphasic nociceptive responses, and i.t. injection of clonidine inhibited both phases of the nociceptive response in a dose-dependent manner. Pretreatment with atropine (i.t.) only partially inhibited the nociceptive effect of clonidine. These results suggest that the nociceptive effect of clonidine in the rat formalin model may be at least partly mediated by muscarinic acetylcholine receptors in the spinal cord.

[Neostigmine added to bupivacaine in axillary plexus block: which benefit?]

INTRODUCTION

Recent study showed that neostigmine (500 microg) by intra-articular produces postoperative analgesia without adverse effect. The author's goal was to determine whether 500 microg of neostigmine added to bupivacaine in axillary plexus block could prolonged postoperative analgesia without increasing the incidence of side effects.

METHODS

Ninety patients scheduled for orthopedic or plastic surgery with axillary plexus block were randomly assigned to one of 3 groups : group 1 (TGr n = 30) received saline solution (1 ml) in the axillary plexus, group 2 (NAGr n = 30) received 500 microg (1 ml) neostigmine in the axillary plexus and group 3.500 microg neostigmine subcutaneously (NSGr n = 30). We evaluated visual analog pain scores (VAS), the consumption of the ketoprofene, nausea and vomiting incidence during the first 24 h. ANOVA, Kruskall Wallis and Fisher tests were used for statistical analysis. A p value of <0.05 was considered significant.

RESULTS

The VAS score was lower in NAGr (21 +/- 18) vs NSGr (31 +/- 14) and control group TGr (45 +/- 2) (p < 0.05). The consumption of the ketoprofene is 127 +/- 65 mg in NAGr vs 150 +/- 53 mg in NSGr and 200 +/- 50 mg in group TGr (p = 0.02). Incidence of nausea and vomiting was 3.5% in NAGr vs 6.8% in NSGr and 0% for TGr.

CONCLUSION

Neostigmine combined to a mixture of lidocaine and bupivacaine prolongs postoperative analgesia after axillary plexus block.

Spinal norepinephrine release from nitric oxide species is not increased following peripheral nerve injury in rats

Alpha(2)-Adrenergic agonists increase the synthesis of nitric oxide (NO) in the spinal cord in both in vitro slice perfusion and in vivo microdialysis. In the normal condition, inhibition of NO synthase (NOS) has little effect on antinociception from alpha(2)-adrenergic agonists. However, following peripheral nerve injury, NOS inhibitors completely block the antihypersensitivity effects of alpha(2)-adrenergic agonists. It is possible that this increased reliance on NO may reflect a positive feedback release of norepinephrine (NE) stimulated by NO conjugates. For example, both S-nitroso-l-cysteine (SNC) and 6-NO(2)-norepinephrine (6-NO(2)-NE) release NE in rat spinal synaptosomes in a concentration-dependent manner and both are formed in spinal cord in vivo. In the current study, we tested whether SNC and 6-NO(2)-NE induced spinal NE release is increased in animals with peripheral nerve injury compared to normals. Crude spinal cord synaptosomes were prepared from nerve ligated and normal rats, loaded with [(3)H]NE and incubated with SNC or 6-NO(2)-NE. In a separate experiment, spinal cords from both groups were sonicated and the amount of NE measured using HPLC. NE release stimulated by SNC or 6-NO(2)-NE in lumbar dorsal spinal cord tissue did not differ between normal and nerve ligated groups. This suggests that increased spinal NE release from locally produced SNC or 6-NO(2)-NE is not the mechanism underlying the reliance of alpha(2)-adrenergic agonists on NO following peripheral nerve injury. Increased NE content and trend towards greater NE uptake in nerve injured spinal cord are consistent with increased noradrenergic innervation density of the spinal cord following peripheral nerve injury.

Intrathecal alpha2 adrenoceptor agonist clonidine inhibits mechanical transmission in mouse spinal cord via activation of muscarinic M1 receptors

We examined the role of the spinal muscarinic receptor subtype in the anti-nociceptive effect of intrathecal (i.t.) alpha2 adrenoceptor agonist clonidine in mice. I.t. injection of the muscarinic receptor antagonist atropine completely inhibited i.t. clonidine-induced increase in the mechanical threshold, but did not affect the increase in tail-flick latency induced by i.t. clonidine. The clonidine-induced increase in mechanical threshold was inhibited by i.t. injection of the M1 receptor antagonist pirenzepine in a dose-dependent manner, and by the M3 receptor antagonist 4-DAMP, but not by the M2 receptor antagonist methoctramine. The potency of pirenzepine was greater than that of 4-DAMP. These results suggest that the clonidine-induced increase in mechanical threshold is mediated via the activation of M1 receptors in the spinal cord.

Descending control of pain

Upon receipt in the dorsal horn (DH) of the spinal cord, nociceptive (pain-signalling) information from the viscera, skin and other organs is subject to extensive processing by a diversity of mechanisms, certain of which enhance, and certain of which inhibit, its transfer to higher centres. In this regard, a network of descending pathways projecting from cerebral structures to the DH plays a complex and crucial role. Specific centrifugal pathways either suppress (descending inhibition) or potentiate (descending facilitation) passage of nociceptive messages to the brain. Engagement of descending inhibition by the opioid analgesic, morphine, fulfils an important role in its pain-relieving properties, while induction of analgesia by the adrenergic agonist, clonidine, reflects actions at alpha(2)-adrenoceptors (alpha(2)-ARs) in the DH normally recruited by descending pathways. However, opioids and adrenergic agents exploit but a tiny fraction of the vast panoply of mechanisms now known to be involved in the induction and/or expression of descending controls. For example, no drug interfering with descending facilitation is currently available for clinical use. The present review focuses on: (1) the organisation of descending pathways and their pathophysiological significance; (2) the role of individual transmitters and specific receptor types in the modulation and expression of mechanisms of descending inhibition and facilitation and (3) the advantages and limitations of established and innovative analgesic strategies which act by manipulation of descending controls. Knowledge of descending pathways has increased exponentially in recent years, so this is an opportune moment to survey their operation and therapeutic relevance to the improved management of pain.

Formation of 6-nitro-norepinephrine from nitric oxide and norepinephrine in the spinal cord and its role in spinal analgesia

Spinally released norepinephrine is thought to produce analgesia in part by stimulating alpha(2)-adrenergic receptors, which in turn leads to nitric oxide synthesis. Also, nitric oxide is known to react with norepinephrine in vivo in the brain to form 6-nitro-norepinephrine, which inhibits neuronal norepinephrine reuptake. In the present study, we tested the hypothesis that formation of 6-nitro-norepinephrine occurs in the spinal cord and that intrathecal administration of 6-nitro-norepinephrine produces analgesia by stimulating norepinephrine release. 6-Nitro-norepinephrine was present in rat spinal cord tissue and microdialysates of the dorsal horn and intrathecal space. Intrathecal norepinephrine injection increased 6-nitro-norepinephrine. 6-Nitro-norepinephrine also stimulated norepinephrine release in dorsal spinal cord in vitro. Intrathecal injection of 6-nitro-norepinephrine produced antinociception and interacted additively with norepinephrine for antinociception. Spinal noradrenergic nerve destruction increased antinociception from intrathecally injected norepinephrine, but decreased antinociception from 6-nitro-norepinephrine. These results suggest a functional interaction between spinal nitric oxide and norepinephrine in analgesia, mediated in part by formation of 6-nitro-norepinephrine. Stimulation of auto-inhibitory alpha(2)-adrenergic receptors at noradrenergic synapses decreases norepinephrine release. Paradoxically, alpha(2)-adrenergic agonist injection increases and alpha(2)-adrenergic antagonist injection decreases norepinephrine release in the spinal cord. 6-Nitro-norepinephrine may be an important regulator of spinal norepinephrine release and could explain the positive feedback on norepinephrine release after activation of spinal alpha(2)-adrenergic receptors.