Visceral nociception: peripheral and central aspects of visceral nociceptive systems

A Comprehensive study of the Abdominal Ganglia Part 3: An overview of the most commonly observed ganglion patterns, with particular emphasis on inferior mesenteric and gonadal ganglia

INTRODUCTION

Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology and interconnections of the abdominal ganglia.

METHODS

The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections and microscopic structure was studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology.

RESULTS

A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed.

CONCLUSIONS

The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved. This article is protected by copyright. All rights reserved.

Cerebral Metabolic Analysis of Patients With Colorectal Cancer and Chronic Enteritis: Inquiry Into Gut-Brain Crosstalk

Gut-brain crosstalk has been demonstrated previously. However, brain metabolic patterns of colorectal cancer and chronic enteritis remain unclear. A better understanding of gut-brain crosstalk from a radiological perspective is necessary. We conducted a retrospective study in which we acquired ¹⁸F-fluorodeoxyglucose positron emission tomography in 45 colorectal cancer cases, 45 age- and sex-matched chronic enteritis patients, and 45 age- and sex-matched healthy controls. We calculated a scaled sub-profile pattern based on principal component analysis and metabolic connectivity to explore the brain metabolic model and analyzed correlations between various brain regions and cancer to identify potential neuroimaging markers for non-pharmaceutical therapies. We found a characteristic cerebral metabolic pattern in colorectal cancer patients, which mainly involved visceral sensation and both affective and cognitive psychological processes. The metabolic patterns of patients with colorectal cancer and chronic enteritis were similar but not identical. The metabolic connectivity of the postcentral gyrus and paracentral lobule was found to be significantly different between the controls and patients with colorectal cancer (p < 0.05, false discovery rate correction). The maximal standard uptake value of the cancer focus in colorectal cancer patients was negatively correlated with the dorsolateral superior frontal gyrus (p < 0.05). Patients with colorectal cancer may show abnormal glucose cerebral metabolism characterized by “point-line-surface.” This preliminary study revealed the cerebral metabolic characteristics and neurobiological mechanisms of colorectal cancer and chronic enteritis (ChiCTR2000041020; registered December 16, 2020).

Visceral pain, mechanisms, and implications in musculoskeletal clinical practice

The global impact of visceral pain is extremely high, representing a significant portion of all forms of chronic pain. In musculoskeletal practice, at least one-third of people with persistent noncancerous pain report recurrent abdominal, pelvic, or chest pain symptoms. Visceral pain can be felt in several different areas of the body and can migrate throughout a region, even though the site of origin does not appear to change. Traditionally, clinicians have examined musculoskeletal pain through a reductionist lens that ignores the influence of the visceral system on musculoskeletal pain. The hypothesis presented is that visceral pain has an important influence on developing and maintaining different types of musculoskeletal pain through processes within the peripheral or central nervous systems, as a result of a visceral nociceptive stimulus generated by pathoanatomical or functional alterations. The hypothesis predicts that a consideration of the function of the visceral system in musculoskeletal pain conditions will improve clinical outcomes, moving beyond a linear model and adopting a more holistic approach, especially in the more complex groups of patients.

Optimized nerve block techniques while performing percutaneous hepatic ablation:

Percutaneous image guided thermal ablation has become a cornerstone of therapy for patients with oligometastatic disease and primary liver malignancies. Evolving from percutaneous ethanol injection (PEI), thermal ablation utilizing radiofrequency ablation (RFA) and microwave ablation (MWA) have become the standard approach in the treatment of isolated lesions that fit within the size criteria for curative intent therapy (typically 3-4cm). With the evolution of more intense thermal ablation, such as MWA, the dramatic increase in both the size of ablation zone and intensity of heat generation have extended the limits of this technique. As a result of these innovations, intra-procedural and post-procedural pain have also significantly increased, requiring either higher levels of intravenous sedation or, in some institutions, general anesthesia. In addition to the increase in therapeutic intensity, the use of intravenous sedation during aggressive ablation procedures carries the risk of over-sedation when the noxious insult (i.e. the ablation) is removed, adding further difficulty to post-procedural recovery and management. Furthermore, high subdiaphragmatic lesions become challenging in this setting due to issues relating to sedation and compliance with breath hold/breathing instructions. Although general anesthesia may mitigate these complications, the added resources associated with providing general anesthesia during ablation is not cost effective and may result in substantial delays in treatment. The reduction of Aerosol Generating Medical Procedures (AGMP), such as intubation due to the COVID-19 Pandemic, must also be taken into consideration. Due to the potential increased risk of infection transmission, alternatives to general anesthesia should be considered when safe and possible. Upper abdominal regional nerve block techniques have been used to manage pain related to trauma, surgery, and cancer; however, blocks of this nature are not well described in the interventional radiology literature. The McGill University group has developed experience in using such blocks as splanchnic, celiac and hepatic hilar nerve blocks to provide peri-procedural pain control [1]. Since incorporating these techniques (along with hydrodissection with tumescent anesthesia), we have also observed in our high volume ablation center a dramatic decrease in the amount of sedatives administered during the procedure, a decrease in patient discomfort during localization and ablation, as well as decreased pain post-procedure. Faster time to discharge and overall reduction in room procedural time serve as added benefits. The purpose of this publication is to outline and illustrate the practical application and use of nerve block/regional anesthesia techniques with respect to percutaneous hepatic thermal ablation.

The receptive field for visceral pain referred orofacially by the vagus nerves

BACKGROUND

The nociceptive receptive field of the vagus nerves in animals includes virtually the entire thoracic, abdominal and laryngopharyngeal regions. However, the role of the vagus nerves in the transmission of visceral pain in humans, with the exception of pain from coronary artery diseases, is believed to be insignificant.

AIM

The purpose of this report is to map out the clinical visceral pain receptive field of the vagus nerves relative to its nociceptive counterpart in animals.

MATERIALS AND METHODS

The PubMed database and PMC were searched for case reports of patients with orofacial pain believed by the author(s) of the article to be referred from underlying non-cardiac thoracic, laryngopharyngeal or abdominal diseases. Reports of diseases for which non-neural explanations for the orofacial spread of pain were suggested were excluded.

RESULTS

A total of 52 case reports of jaw pain and/or otalgia referred from laryngopharyngeal and noncardiac thoracic sources were discovered. In addition, a multicenter prospective study found that 25.8% of more than 3,000 patients with thoracic aortic dissection experienced pain in the head and neck region. In stark contrast, no case reports of orofacially referred pain from abdominal diseases were found.

DISCUSSION

The results indicate that the laryngopharyngeal and thoracic portions of the vagal receptive field are capable of referring pain orofacially while the abdominal portion is not. The roles of the somatotopic organization of the trigeminal sub nucleus caudalis and neuromodulation in this referral of pain were discussed.

CONCLUSION

Referred orofacial pain can lead to delayed diagnosis and poorer outcome in visceral diseases.

Factor Analysis Defines Distinct Upper and Lower Gastrointestinal Symptom Groups Compatible With Rome IV Criteria in a Population-based Study

BACKGROUND & AIMS

The Rome IV criteria define functional gastrointestinal (GI) disorders by specific combinations of symptoms. It is possible to empirically evaluate these symptom combinations by factor analysis (a statistical procedure that groups variables that correlate). However, this analysis has not been performed for the Rome IV criteria, and factor analyses based on the previous versions of the Rome criteria did not use population-based data. We therefore investigated symptom grouping by the Rome IV questionnaire using factor analysis of a population-based sample.

METHODS

The Rome IV questionnaire was completed online in English by 5931 respondents from the United Kingdom, United States, and Canada (49% female, age range, 18-92 years). We performed an exploratory factor analysis on the Rome IV questions. Next, we performed a confirmatory factor analysis to compare the exploratory factor result to that of the Rome IV criteria.

RESULTS

The exploratory factor analysis identified 8 factors that accounted for 45% of the variance in response: constipation, diarrhea, irritable bowel syndrome, abdominal pain, heartburn, nausea or vomiting, globus, and other upper GI symptoms. Most factors corresponded to distinct functional GI disorders defined by the Rome IV criteria-exceptions included abdominal pain and upper GI symptoms. In confirmatory factor analysis, the exploratory model fitted slightly better than that based on the Rome IV criteria (root mean square error of approximation, 0.063 vs 0.077).

CONCLUSIONS

We used factor analysis to identify distinct upper and lower GI symptom groups that are compatible with the Rome IV criteria. Our findings support the use of the Rome IV criteria in research and clinical practice as a basis for development of diagnostics and management of patients.

Cutaneous neurogenic inflammation in the sensitized acupoints induced by gastric mucosal injury in rats

BACKGROUND

In acupuncture practice, the most important step is to confirm the location of a sensitized acupoint which reflects a diagnosis and can be stimulated with a specialized needle to treat the disease. Abnormal symptoms such as hyperalgesia or allodynia at the sensitized acupoints in patients with visceral disorders are considered to be in relation with referred pain and neurogenic inflammation. Yet, limited study has investigated the cutaneous neurochemical changes of the sensitized acuponits.

METHODS

The resent study developed an animal model of gastric mucosal injury (GMI) by HCl administered into the stomach of the rats. Evans Blue (EB) dye was applied by injection of tail vein after mucosal damage to observe the neurogenic plasma extravasation dots in the skin of the rats. The EB dots extravagated in the skin were compared with locations of acupoints. Immnohistochemistry analysis was used to detect the expression of calcitonin gene-related peptide (CGRP)- or substance P (SP)-labeled nerve fibers, histamine (HA)-, serotonin (5-HT)-, and tryptase-labeled cells in EB dots. Images were recorded and analyzed by Confocal imaging system and Olympus Image Processing Software.

RESULTS

The results showed that GMI resulted in neurogenic plasma extravasation in the skin of the acupoints over the back and abdomen, which mostly occurred in the T9-11 dermatomere. The EB extravasation dots appeared after GMI and disappeared gradually during the natural self-recovery of the gastric mucosa. More SP and CGRP positive nerve fibers were distributed in EB dots than that in regions beside EB dots and in the control, mostly distributed in the nerve fibers around both the vessels and root of hair follicle. Mast cells also aggregated and degranulated to release algogenic substances of 5-HT and HA around the vessels in areas of the EB dots.

CONCLUSIONS

Our results indicates that the mechanism of EB extravasation in the skin of the acupoints induced by GMI are closely related to neurogenic inflammation, and that the high expression of local allergic substances and nociceptive neuropeptides in the local skin including SP, CGRP, HA, 5-HT, and mast cell tryptase may be the underlying mechanism of the acupoint sensitization.

Acupuncture at homotopic acupoints exerts dual effects on bladder motility in anesthetized rats

BACKGROUND

In Chinese medicine, dual effects on target organs are considered a primary characteristic of acupoint. Acupoints may be classified as heterotopic or homotopic in terms of spinal segmental innervation: homotopic acupoints contain afferent innervation in the same segment from which efferent fibers innervate target visceral organs, and heterotopic acupoints utilize different spinal segments to innervate target visceral organs than the segment receiving the afferent signal. It is well-known that dual effects of acupuncture on the bladder can be generated based on different states of the bladder, however, the dual effects of single acupoint stimulation and acupoint site-specificity (homotopic acupoints and heterotopic acupoints) on the bladder have yet to be investigated.

METHODS

Twenty Sprague-Dawley rats were anesthetized and the intravesical pressure was measured via a manometric balloon inserted into the bladder. The acupuncture needle was separately inserted to a depth of 4 mm at the acupoints RN1 (Huiyin), RN3 (Zhongji), BL28 (Pangguangshu), BL32 (Ciliao), RN2 (Qugu) or BL23 (Shenshu), and manually rotated right then left with a frequency of 2 Hz for 1 min. Following acupuncture stimulation, bladder pressure was recorded and compared against the pre-stimulation measurements.

RESULTS

During the bladder's active state, manual acupuncture (MA) at RN1, RN3, BL28, BL32 or RN2 inhibited bladder motility (P < 0.01). In the static bladder, MA at RN1, RN3, BL28, BL32, RN2 or BL23 increased bladder motility (P < 0.01).

CONCLUSIONS

MA at homotopic acupoints may produce dual effects on bladder motility: inhibiting bladder motility when in an active state and enhancing bladder motility when in a static state.

Oxytocin down-regulates mesenteric afferent sensitivity via the enteric OTR/nNOS/NO/KATP pathway in rat

BACKGROUND

Oxytocin plays an analgesic role in modulation of nociception and pain. Most work to date has focused on the central mechanisms of oxytocin analgesia, but little is known about whether peripheral mechanisms are also involved.

METHODS

The mesenteric afferent discharge was recorded in vitro. The expressions of oxytocin receptor (OTR) and neuronal nitric oxide synthase (nNOS) in longitudinal muscle myenteric plexus (LMMP) was identified by immunofluorescence.

KEY RESULTS

Oxytocin per se had no effect on the jejunal mesenteric afferent discharge, however, it markedly attenuated the bradykinin- or distention-evoked increase of mesenteric afferent discharge, which was mimiced by the nitric oxide (NO) donor sodium nitroprusside (SNP). Pretreatment of either NOS inhibitor L-NAME or NPLA largely reduced the inhibitory effect of oxytocin on bradykinin-evoked mesenteric afferent discharge. Such effect, to a large extent, was also alleviated by N-and P-type voltage-dependent calcium channel antagonists or KATP blocker glibenclamide. In addition, immunofluorescence studies show strong colocalization of OTR with nNOS in LMMP of the rat jejunum.

CONCLUSIONS & INFERENCES

Oxytocin down-regulates the mesenteric afferent sensitivity through nNOS-NO-KATP pathway. Our findings may reveal a new peripheral mechanism for oxytocin analgesia.

Anatomo-Functional Correlation between Head Zones and Acupuncture Channels and Points: A Comparative Analysis from the Perspective of Neural Therapy

Background. Neural therapy and traditional Chinese medicine (TCM) are part of complementary and alternative medicine in western world. Both of them share characteristics in diagnosis and therapeutics in search of changes in tenderness, pain, and skin stiffness related to visceral disease, as well as therapeutic procedures with specific stimuli on the skin that generate local, segmental, or remote reactions. Head zones explain segmental viscerocutaneous relations in neural therapy; however, interference fields and remote reactions after infiltration of local anesthetic go beyond this segmental distribution. Methods. This descriptive research required review and analysis of texts of Henry Head and traditional Chinese medicine. Results. Anatomical and functional relationships were found between Head zones in body, and head and neck with 14 acupuncture channels and their points. Anatomical areas of strong correlations were found: Head zones of heart and lung with heart and pericardium channels; Head zones of genitals with bladder and kidney channels. Strong functional relations between all Head zones, channels, and acupoints were found when following the pattern of segmental dermatomes; 235 acupuncture points were found in concordance.

Monoaminergic modulation of spinal viscero-sympathetic function in the neonatal mouse thoracic spinal cord

Descending serotonergic, noradrenergic, and dopaminergic systems project diffusely to sensory, motor and autonomic spinal cord regions. Using neonatal mice, this study examined monoaminergic modulation of visceral sensory input and sympathetic preganglionic output. Whole-cell recordings from sympathetic preganglionic neurons (SPNs) in spinal cord slice demonstrated that serotonin, noradrenaline, and dopamine modulated SPN excitability. Serotonin depolarized all, while noradrenaline and dopamine depolarized most SPNs. Serotonin and noradrenaline also increased SPN current-evoked firing frequency, while both increases and decreases were seen with dopamine. In an in vitro thoracolumbar spinal cord/sympathetic chain preparation, stimulation of splanchnic nerve visceral afferents evoked reflexes and subthreshold population synaptic potentials in thoracic ventral roots that were dose-dependently depressed by the monoamines. Visceral afferent stimulation also evoked bicuculline-sensitive dorsal root potentials thought to reflect presynaptic inhibition via primary afferent depolarization. These dorsal root potentials were likewise dose-dependently depressed by the monoamines. Concomitant monoaminergic depression of population afferent synaptic transmission recorded as dorsal horn field potentials was also seen. Collectively, serotonin, norepinephrine and dopamine were shown to exert broad and comparable modulatory regulation of viscero-sympathetic function. The general facilitation of SPN efferent excitability with simultaneous depression of visceral afferent-evoked motor output suggests that descending monoaminergic systems reconfigure spinal cord autonomic function away from visceral sensory influence. Coincident monoaminergic reductions in dorsal horn responses support a multifaceted modulatory shift in the encoding of spinal visceral afferent activity. Similar monoamine-induced changes have been observed for somatic sensorimotor function, suggesting an integrative modulatory response on spinal autonomic and somatic function.

Visceral pain: the ins and outs, the ups and downs

PURPOSE OF REVIEW

Visceral pain represents a major clinical problem, yet far less is known about its mechanisms compared with somatic pains, for example, from cutaneous and muscular structures.

RECENT FINDINGS

In this review, we describe the neuroanatomical bases of visceral pain signalling in the peripheral and central nervous system, comparing to somatic pains and also the channels and receptors involved in these events. We include an overview of potential new targets in the context of mechanisms of visceral pain and hypersensitivity.

SUMMARY

This review should inform on the recognition of what occurs in patients with visceral pain, why comorbidities are common and how analgesic treatments work.

B-Afferents: A fundamental division of the nervous system mediating homeostasis?

The peripheral nervous system (PNS) has classically been separated into a somatic division composed of both afferent and efferent pathways and an autonomic division containing only efferents. J. N. Langley, who codified this asymmetrical plan at the beginning of the twentieth century, considered different afferents, including visceral ones, as candidates for inclusion in his concept of the “autonomic nervous system” (ANS), but he finally excluded all candidates for lack of any distinguishing histological markers. Langley's classification has been enormously influential in shaping modern ideas about both the structure and the function of the PNS. We survey recent information about the PNS and argue that many of the sensory neurons designated as “visceral” and “somatic” are in fact part of a histologically distinct group of afferents concerned primarily autonomic function. These afferents have traditionally been known as “small dark” neurons or B-neurons. In this target article we outline an association between autonomic and B-neurons based on ontogeny, cell phenotype, and functional relations, grouping them together as part of a common reflex system involved in homeostasis. This more parsimonious classification of the PNS, made possible by the identification of a group of afferents associated primarily with the ANS, avoids a number of confusions produced by the classical orientation. It may also have practical implications for an understanding of nociception, homeostatic reflexes, and the evolution of the nervous system.

Spinal NMDA NR1 subunit expression following transient TNBS colitis

BACKGROUND

N-methyl-D-aspartic acid (NMDA) receptors play an important role in the development of hypersensitivity to visceral and somatic stimuli following inflammation or tissue injury. Our objective was to investigate the role of NMDA NR1 receptors in the spinal cord (T10-L1; L4-S1) of a subset of rats that remain hypersensitive following the histological resolution of TNBS-induced colitis compared to saline treated rats and rats that had recovered both behaviorally and histologically. We hypothesized that NMDA NR1 subunit expression mediates hypersensitivity following transient TNBS colitis.

METHODS

Male Sprague-Dawley rats (150 g-250 g) received 20 mg/rat intracolonic trinitrobenzene sulfonic acid (TNBS) in 50% ethanol or saline. Animals underwent nociceptive visceral/somatic pain testing 16 weeks after resolution of TNBS colitis. Animals were sacrificed and their spinal cords (T10-L1; L4-S1) were retrieved and 2-dimensional polyacrylamide gel electrophoresis and immunohistocytochemistry techniques were used to investigate spinal-NMDA receptor expression.

RESULTS

NR1(001) was the only NMDA NR1 receptor subunit that was expressed in recovered and control rats, whereas hypersensitive animals expressed NR1(011) and NR1(111) as well as NR1(001) subunits. Immunohistochemistry analysis demonstrated increased expression of NMDA NR1-N1, C1, and C2-plus expression in laminae I and II of the spinal cord (T10-L1; L4-S1) in hypersensitive rats but not in recovered/control rats.

CONCLUSIONS

Selective increases in the expression of the NMDA NR1 splice variants occur in hypersensitive rats following resolution of TNBS colitis. This suggests that the NMDA NR1 receptor plays an important role in the development of neuronal plasticity and central sensitization. The recombination of NR1 splice variants may serve as a key functional protein that maintains hypersensitivity following resolution of TNBS colitis.

Bolus isoproterenol infusions provide a reliable method for assessing interoceptive awareness

Interoception, defined as the perception of internal body states, plays a central role in classic and contemporary theories of emotion. In particular, deviations from baseline body states have been hypothesized to be integral to the experience of emotion and feeling. Consequently, reliable measurement of interoception is critical to the testing of emotion theories. Heartbeat perception tasks have been considered the standard method for assessing interoceptive awareness, primarily due to their non-invasive nature and technical feasibility. However, these tasks are limited by the fact that above chance group performance rates on heartbeat detection (or the frequency of 'good detectors') are rarely higher than 40%, meaning that such tasks (as they are typically utilized) do not obtain a measure of interoceptive awareness in the majority of individuals. Here we describe a novel protocol for inducing and assessing a range of deviations in body states via bolus infusions of isoproterenol, a non-selective beta adrenergic agonist. Using a randomized, double-blinded, and placebo-controlled experimental design, we found that bolus isoproterenol infusions elicited rapid and transient increases in heart rate and concomitant ratings of heartbeat and breathing sensations, in a dose-dependent manner. Our protocol revealed changes in interoceptive awareness in all 15 participants tested, thus overcoming a major limitation of heartbeat detection tasks. These findings indicate that bolus isoproterenol infusions provide a reliable method for assessing interoceptive awareness, which sets a foundation for further investigation of the role of interoceptive sensations in the experience of emotion.

NMDA Receptors and Colitis: Basic Science and Clinical Implications

During the last decade, research focusing primarily on alterations in the peripheral and central nervous system has improved our understanding of the pathophysiological mechanisms of chronic visceral pain. These studies have demonstrated significant physiological changes following injury to the viscera in the firing patterns of both primary afferent neurons that transmit nociceptive information from the viscera and in central neurons that process the nociceptive information. A number of receptors, neurotransmitters, cytokines, and second messenger systems in these neurons have been implicated in the enhancement of visceral nociception. N-methyl-d-aspartic acid (NMDA) receptors play an important role in chronic visceral pain and hypersensitivity that is present in the setting of colonic inflammation. NMDA receptors are found in the peripheral nervous system as well as the central terminal of primary afferent neurons and have been shown to play an important role in regulating the release of nociceptive neurotransmitters. Recent work has demonstrated the presence of NMDA receptors in the enteric nervous system. In this article, we will discuss more recent evidence of the role of NMDA receptors in visceral pain associated with colitis.

The VR1-Positive Primary Afferent-Mediated Expression of pERK in the Lumbosacral Neurons in Response to Mechanical and Chemical Stimulation of the Urinary Bladder in Rats

OBJECTIVE

This study characterized the neurons in the lumbosacral cord that express phospho ERK (pERK) after distension or irritation of the bladder, and their relation to the vanilloid receptor 1 (VR1) positive primary afferents.

METHODS

Mechanical distension and chemical irritation of the bladder were induced by intravesical injection of the saline and mustard oil, respectively. Spinal neurons expressing pERK and the primary afferent fibers were characterized using multiple immunofluorescence for neurokinin 1 (NK1), neuronal nitric oxide synthetase (nNOS) and VR1.

RESULTS

Neurons in lamina I, medial dorsal horn (MDH), dorsal gray commissure (DGC) and sacral parasympathetic nucleus (SPN) were immunoreactive for pERK after either mechanical or chemical stimulation. The majority of pERK positive cells were positive for NK1 in lamina I and SPN, but not in the DGC. Most of pERK positive cells are not stained for nNOS except in a small population of the cells in the SPN and DGC. Contacts between perikarya and dendrites of pERK-positive cells and terminals of primary afferents expressing VR1 were identified in lamina I, lateral collateral path (LCP) and SPN.

CONCLUSION

In this study, the lumbosacral neurons activated by mechanical and chemical stimulation of the urinary bladder were identified with expression of the pERK, and also provided the evidence that VR1-positive primary afferents may mediate the activation of these neurons.

Sensory neurons and fibers from multiple spinal cord levels innervate the rabbit lumbar disc

OBJECTIVE

To establish the neurotransmission pathway from the lumbar L5/6 intervertebral disc (IVD) to the spinal cord in the rabbit.

DESIGN

Fluorogold particles injected into the posterior portion of the rabbit L5/6 IVD were traced by examining gold-positive neurons and fibers in the dorsal root ganglion (DRG) and spinal cord at various root levels.

RESULTS

Fluorogold-labeled neurons were observed bilaterally in primary afferent DRG neurons from the L3 through L5 segments; a small number of gold-labeled neurons were found at the L1 level. Fluorogold-labeled neurons were predominantly present in the ipsilateral DRG (the side of the injection) at the L5 level, but they were more equally distributed (on both sides) at the L4 and L3 levels. In the posterior horn of the spinal cord, Fluorogold particles were found in nerve fibers as rostral as the T12 level.

CONCLUSIONS

Our study has shown that Fluorogold particles injected into the rabbit L5/6 IVD are taken up by primary sensory neurons in the DRGs and primary sensory fibers in the posterior horn of the spinal cord at multiple levels. This diffuse innervation pattern of the lumbar disc may help explain why discogenic back pain in humans is often poorly localized.

Phosphorylation of NMDA NR1 subunits in the myenteric plexus during TNBS induced colitis

N-Methyl-d-aspartic acid (NMDA) receptors are known to function in the mediation of pain and have a significant role in the development of hyperalgesia following inflammation. Serine phosphorylation regulation of NMDA receptor function occurs in a variety of conditions. No studies have demonstrated a change in phosphorylation of enteric NMDA receptors following colonic inflammation. We examined the levels of NMDA NR1 phosphorylation in trinitrobenzene sulfonic acid (TNBS) induced colitis in rats and compared it to protein translation and the development of visceral hypersensitivity. We have previously, demonstrated an increase in the C1 cassette of NR1 mRNA expression at 14, 21, and 28 days following TNBS administration. In this study, we examined the NR1 serine phosphorylation at 14 days following TNBS injection. Male Sprague-Dawley rats (200-250 g) were treated with TNBS (20mg per rat) diluted in 50% ethanol (n=3) and vehicle controls of 50% ethanol (n=3). TNBS and vehicle controls were administered with a 24 gauge catheter inserted into the lumen of the rat colon. The animals were sacrificed at 14 days after induction of the colitis and their distal colon was retrieved for two-dimensional (2D) western blot analysis. Serine phosphorylation of the NR1 subunit with C1 cassette appears at 14 days after TNBS injection. In contrast, there was no NR1-C1 expression in the vehicle controls and untreated normal controls. These results suggest a role for colonic-NMDA receptor phosphorylation in the development of neuronal plasticity following colonic inflammation. Phosphorylation of NR1 may partially explain visceral hypersensitivity present during colonic inflammation.

Selective up-regulation of NMDA-NR1 receptor expression in myenteric plexus after TNBS induced colitis in rats

Background

N-methyl-D-aspartic acid (NMDA) spinal cord receptors play an important role in the development of hyperalgesia following inflammation. It is unclear, however, if changes in NMDA subunit receptor gene expression in the colonic myenteric plexus are associated with colonic inflammation. We investigated regulation of NMDA-NR1 receptor gene expression in TNBS induced colitis in rats. Male Sprague-Dawley rats (150 g–250 g) were treated with 20 mg trinitrobenzene sulfonic acid (TNBS) diluted in 50% ethanol. The agents were delivered with a 24 gauge catheter inserted into the lumen of the colon. The animals were sacrificed at 2, 7, 14, 21, and 28 days after induction of the colitis, their descending colon was retrieved for reverse transcription-polymerase chain reaction; a subset of animals' distal colon was used for two-dimensional (2-D) western analysis and immunocytochemistry.

Results

NR1-exon 5 (N1) and NR1-exon 21 (C1) appeared 14, 21 and 28 days after TNBS treatment. NR1 pan mRNA was up-regulated at 14, 21, and 28 days. The NR1-exon 22 (C2) mRNA did not show significant changes. Using 2-D western analysis, untreated control rats were found to express only NR1₀₀₁ whereas TNBS treated rats expressed NR1₀₀₁, NR1_011, and NR1₁₁₁. Immunocytochemistry demonstrated NR1-N1 and NR1-C1 to be present in the myenteric plexus of TNBS treated rats.

Conclusion

These results suggest a role for colonic myenteric plexus NMDA receptors in the development of neuronal plasticity and visceral hypersensitivity in the colon. Up-regulation of NMDA receptor subunits may reflect part of the basis for chronic visceral hypersensitivity in conditions such as post-infectious irritable bowel syndrome.

The anatomic and physiologic basis of local, referred and radiating lumbosacral pain syndromes related to disease of the spine

Conscious perception and unconscious effects originating from the vertebral column and its neural structures, although complex, have definite pathways represented in a network of peripheral and central nervous system (CNS) ramifications. These neural relationships consequently result in superimposed focal and diffuse, local and remote conscious perceptions and unconscious effects. Any one or combination of somatic and autonomic signs and symptoms may potentially be observed in a particular patient. This variety and inconsistency may mislead or confuse both the patient and the physician. A clear understanding of the basic anatomic and physiologic concepts underlying this complexity should accompany clinical considerations of the potential significance of spondylogenic and neurogenic syndromes in any disease process affecting the spine.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Psychophysical analysis of visceral and cutaneous pain in human subjects

Clinical evidence suggests that cutaneous and visceral pain differ in sensory, affective, and motivational realms, yet there has been little comparative characterization of these types of pain. This study uses psychophysical measures to compare directly visceral and cutaneous pain and sensitivity. Healthy subjects (10 males, seven females, age 19-29) evaluated perceptions evoked by balloon distention of the distal esophagus and contact heat on the upper chest. Subjects gave continuous ratings of pain intensity using an on-line visual analog scale (VAS), reported maximum pain intensity and unpleasantness on printed VASs, chose phrases from the McGill Pain Questionnaire and Spielberger State-Trait Anxiety Inventory, and drew the area of perceived sensation. For esophageal distention, the threshold for pain intensity was higher than that observed for unpleasantness, whereas for contact heat, pain and unpleasantness thresholds did not differ for either phasic (10s) or tonic (36s) stimulus application. The relative unpleasantness, calculated as the difference between the unpleasantness and the intensity ratings, was higher during esophageal distention than during either phasic or tonic cutaneous heat; this difference in relative unpleasantness was seen at all intensities of esophageal stimulation. Subjects chose significantly more affective words and reported more anxiety during visceral pain than during phasic cutaneous heat pain. A similar tendency was observed when visceral pain was compared to tonic cutaneous heat pain. Subjects also chose a wider range of words to describe visceral than cutaneous pain. On-line VAS ratings revealed greater pain sensation after stimulus termination during visceral than during phasic cutaneous pain; likewise, a similar tendency was observed between visceral and tonic cutaneous pain. Finally, visceral pain led to a more spatially diffuse sensation and was referred to the entire chest and sometimes to the back. Our results show that visceral pain is more unpleasant, diffuse, and variable than cutaneous pain of similar intensity, independent of the duration of the presented stimuli. The data suggest the likelihood of both similarities and differences in the neural substrates underlying visceral and cutaneous pain.

Role of calcium channels in the spinal transmission of nociceptive information from the mesentery

Opioids, alpha(2)-adrenoceptor agonists and blockers of voltage-gated calcium channels (VGCCs) have been attributed antinociceptive activity in various experimental set-ups. The present study tested the ability of morphine, clonidine and drugs acting at various VGCCs to inhibit the transmission of noxious stimuli from the mesentery at the level of the spinal cord. In rats under barbiturate anaesthesia traction of 20 g was applied to a bundle of mesenteric blood vessels. This caused immediate transient changes of mean arterial pressure that were taken as indication of nociception. Similar reflexes were elicited by applying 0.6% acetic acid to the same bundle of vessels. The reflexes were dose-dependently reduced by intrathecal administration of morphine or clonidine, but were left unaltered by intrathecal administration of verapamil, Bay-K 8644 or omega-conotoxin MVIIA. Neither verapamil nor Bay-K 8644 influenced clonidine-induced analgesia. Conotoxin markedly enhanced the effectiveness of all doses of clonidine against both types of mesenteric stimuli. Verapamil, Bay-K 8644, as well as conotoxin reduced the ability of morphine to inhibit mechanically evoked reflexes, while there was no statistically significant effect in chemonociception. These data suggest that, at the spinal level, both morphine and clonidine are effective drugs to decrease the cardiovascular changes caused by acute mesenteric pain. In the dorsal spinal cord neither L-type nor N-type VGCCs are responsible on their own for the transmission of noxious stimuli from the mesentery. Inhibition of N-type channels markedly augments the action of clonidine, whereas blocking either VGCC seems to inhibit antinociceptive mechanisms induced by morphine. It is suggested that in patients the combined administration of clonidine with omega-conotoxin MVIIA might lead to effective pain control with reduced side effects.

Functional neuroimaging of visceral sensation

The use of functional brain imaging techniques has led to considerable advances in our understanding of brain processing of human visceral sensation. The use of complementary techniques such as functional MRI, positron emission tomography, magnetoencephalography, and EEG has led to the identification of a network of brain areas that process visceral sensation. These studies suggest that unlike somatic sensation, which has an intense homuncular representation in the primary somatosensory cortex (SI), visceral sensation is primarily represented in the secondary somatosensory cortex, whereas representation in SI is vague. This difference could account for the poor localization of visceral sensation in comparison with somatic sensation. However, in a manner similar to that of somatic sensation, visceral sensation is represented in the paralimbic and limbic structures such as the insular, anterior cingulate, and prefrontal cortices. These areas are likely to mediate the affective and cognitive components of visceral sensation. Recent studies suggest that negative emotional factors such as fear, and cognitive factors such as attention can modulate the brain processing of visceral sensation in the insular and anterior cingulate cortices. In addition, alterations in the pattern of cortical processing of visceral sensation have been described in patients with functional gastrointestinal pain. It is likely that future research into the factors that modulate the brain processing of visceral sensation in health and disease are likely to improve further our understanding of the pathophysiology of functional visceral pain disorders.

Cortical processing of human somatic and visceral sensation

Somatic sensation can be localized precisely, whereas localization of visceral sensation is vague, possibly reflecting differences in the pattern of somatic and visceral input to the cerebral cortex. We used functional magnetic resonance imaging to study the cortical processing of sensation arising from the proximal (somatic) and distal (visceral) esophagus in six healthy male subjects. Esophageal stimulation was performed by phasic distension of a 2 cm balloon at 0.5 Hz. For each esophageal region, five separate 30 sec periods of nonpainful distension were alternated with five periods of similar duration without distension. Gradient echoplanar images depicting bold contrast were acquired using a 1.5 T GE scanner. Distension of the proximal esophagus was localized precisely to the upper chest and was represented in the trunk region of the left primary somatosensory cortex. In contrast, distension of the distal esophagus was perceived diffusely over the lower chest and was represented bilaterally at the junction of the primary and secondary somatosensory cortices. Different activation patterns were also observed in the anterior cingulate gyrus with the proximal esophagus being represented in the right midanterior cingulate cortex (BA 24) and the distal esophagus in the perigenual area (BA32). Differences in the activation of the dorsolateral prefrontal cortex and cerebellum were also observed for the two esophageal regions. These findings suggest that cortical specialization in the sensory-discriminative, affective, and cognitive areas of the cortex accounts for the perceptual differences observed between the two sensory modalities.

Chronic recurrent abdominal pain

Chronic recurrent abdominal pain remains a common medical and surgical problem, frequently dismissed as functional. Instead, these patients should be approached systematically, based on the pattern of recurrent abdominal pain. It is vital to seek out the potential cause of this type of chronic pain because specific and often curative treatment is available.

Intraoperative EEG changes in relation to the surgical procedure during isoflurane-nitrous oxide anesthesia: hysterectomy versus mastectomy

STUDY OBJECTIVES

To investigate topographical changes in electroencephalographic (EEG) frequencies and spectral power density in relation to different surgical procedures (abdominal hysterectomy versus mastectomy) during steady-state isoflurane-nitrous oxide (N2O) anesthesia.

DESIGN

Prospective, nonrandomized, open study.

SETTING

University hospital.

PATIENTS

34 ASA status I and II patients scheduled for elective abdominal hysterectomy or mastectomy.

INTERVENTIONS

12 patients were studied without surgery (Group I, control). 22 patients were studied for the first 14 minutes following skin incision during hysterectomy (Group 2, n = 11) or mastectomy (Group 3, n = 11).

MEASUREMENTS AND MAIN RESULTS

Anesthesia was maintained with 0.6% isoflurane in 66% N2O in oxygen (O2). EEG was recorded via 17 channels followed by calculation of spectral power densities in selected frequency bands for each recording site. In addition, heart rate, mean arterial pressure (MAP), end-tidal carbon dioxide tensions, and isoflurane concentration were recorded. Total observation time was 20 minutes in all groups. At baseline, EEG variables were comparable in all groups. The EEG demonstrated slow wave activity superimposed with alpha waves. Start of surgery resulted in increases of slower waves and decreases in alpha activity. In both surgical groups, these EEG changes were most pronounced at frontal recording sites (p < 0.05) with differences in the frequency content. In Group 2 (hysterectomy), delta-activity became dominant, whereas in Group 3 (mastectomy), a shift to theta waves was observed. During surgery MAP was increased by 40% (Group 2; p < 0.05) and 21% (Group 3; p < 0.05), respectively.

CONCLUSIONS

These results show that specific surgical procedures may induce EEG slow wave activity to a different degree. The EEG response varied in relation to the surgical procedure and/or the intensity of noxious stimulation. Mastectomy resulted in the appearance of theta activity whereas, during laparotomy, the EEG frequency content was shifted to delta waves. The topographical analysis indicates spatial inhomogeneities in the EEG responses with a dominance at frontal areas. From this findings, it may be concluded that the electrode montage used for intraoperative EEG recordings has to be carefully selected.

Relaxation training reduces symptom reports and acid exposure in patients with gastroesophageal reflux disease

BACKGROUND/AIMS

Previous studies have shown that psychological factors play a role in symptom perception among patients with gastroesophageal reflux disease. This report describes the first controlled study showing the effects of relaxation training on symptom reports and esophageal acid exposure in patients with reflux disease.

METHODS

Twenty subjects with documented reflux disease were studied during psychologically neutral and stressful tasks, followed immediately by either a relaxation or attention-placebo control intervention.

RESULTS

Stressful tasks, relative to neutral tasks, produced significant increases in blood pressure, subjective ratings of anxiety, and reports of reflux symptoms. Despite increased symptom reports, stressful tasks did not significantly increase objective measures of esophageal acid exposure. Subjects who received a relaxation intervention after the stressful task had significantly lower heart rate values and subjective ratings of anxiety compared with subjects who received the attention-placebo control intervention. Subjects who received relaxation training also had significantly lower reflux symptom ratings and total esophageal acid exposure than subjects who received the attention-placebo control intervention.

CONCLUSIONS

Relaxation may be a useful adjunct to traditional antireflux therapy in patients who experience increased symptoms during stress.

Arterial baroreflex inhibition by uterine distension in rats

Arterial baroreflexes are inhibited during activation of some viscero-sensory receptors. The present study was designed to determine whether stimulation of mechanoreceptors of the uterus also inhibits the baroreflex bradycardia (BB). The aortic depressor nerve (ADN) was electrically stimulated to elicit BB in chloralose/urethane-anesthetized, succinylcholine-immobilized, and artificially ventilated rats. Hydraulic distension of the uterus with warm 0.9% NaCl solution was found to suppress BB with a threshold intra-uterine pressure of 25-100 mmHg. The inhibition was variably affected by successive transections of the hypogastric nerve (HgN) and the pelvic nerve (PN). In 6 rats out of the 16 tested, preceding transection of either HgN or PN (HgN, 4; PN, 2) abolished the inhibition, whereas in 8 rats the inhibition was not affected by preceding transection of either nerve but was abolished by subsequent transection of the other nerve (PN, 3; HgN, 5). In 2 rats, preceding HgN or PN section reduced the inhibition and subsequent PN or HgN section completed the withdrawal of the inhibition. Recording study confirmed that both the HgN and PN contain afferent fibers, signalling mechanoceptive information arising in the uterine wall. Electrical stimulation of the HgN as well as the PN remarkably suppressed the BB. In conclusion, uterine distension suppresses the BB and this inhibition is mediated by afferent fibers running in the HgN and PN with variable contributions among animals. The reflex suppression of BB due to uterine sensory activation may contribute to cardiovascular regulation during parturition.

Persistent postoperative hiccups: a review

The pathogenesis of persistent postoperative hiccups is not known. Hiccups can present as a symptom of a subphrenic abscess of gastric distention, and metabolic alterations may also cause hiccups. The hiccups may develop because of increased activity in neural reflex pathways not yet fully defined. Numerous treatment modalities have been tried but with questionable success. Valproate has proven effective in two trials investigating persistent non-surgical hiccups. The simple application of a nasogastric tube may successfully treat the hiccups, possibly because of an alteration of the activity in the reflex neural pathways involved. The available literature on the treatment of persistent hiccups is reviewed, and a treatment protocol for persistent postoperative hiccups is provided.

Morphine or U-50,488 suppresses Fos protein-like immunoreactivity in the spinal cord and nucleus tractus solitarii evoked by a noxious visceral stimulus in the rat

Immunohistochemical visualization of Fos protein, the nuclear phosphoprotein product of the early-immediate gene c-fos, permits identification of populations of neurons that are activated in response to a variety of stimuli. This study examined the distribution of Fos-like immunoreactive (FLI) neurons in the spinal cord and the nucleus tractus solitarii (NTS) of the caudal medulla evoked by a noxious visceral stimulus in the unanesthetized rat. It also compared the inhibition of pain behavior and Fos expression by a mu-selective opioid agonist, morphine, and a kappa-selective opioid agonist, U-50,488. Intraperitoneal injection of 3.5% acetic acid in the unanesthetized rat evoked the expression of FLI in a discrete population of spinal cord neurons, the distribution of which closely mirrored the spinal terminations of visceral primary afferents. Specifically, FLI neurons were concentrated in laminae I, IIo, V, VII, and X. Large numbers of Fos-immunoreactive neurons were also present in the NTS of the caudal medulla, most likely as a result of spinosolitary tract and vaginal afferent input. The number of labeled neurons in both the spinal cord and the NTS was significantly correlated with the number of abdominal stretches, a pain behavior measure. Both morphine (1-10 mg/kg s.c.) and U-50,488 (3-30 mg/kg s.c.) produced a dose-dependent inhibition of the pain behavior in these animals and a dose-dependent suppression of the number of FLI neurons in both the spinal cord and in the NTS; complete suppression of FLI neurons was, however, not necessary for the production of antinociception. Furthermore, although equianalgesic doses of morphine and U-50,488 reduced the number of labelled neurons in the spinal cord to a comparable extent, morphine reduced the number of immunoreactive neurons in the NTS to a greater extent than did U-50,488. These results suggest that morphine and U-50,488 have comparable effects on the transmission of visceral nociceptive messages by spinal neurons, but differentially affect the autonomic response to noxious visceral stimuli.

Sensorial and intestinointestinal reflex pathways in the human jejunum

Using an intestinal barostat that maintains a constant pressure within an air-filled bag (12 cm long), the authors have previously shown reflex changes in intestinal tone induced by distention. The aim of this study was to investigate the sensitivity and the responsiveness to such reflexes along the jejunum. Eight healthy volunteers were studied using two barostats operating simultaneously in the proximal and the distal jejunum (located 10 cm and 52 cm caudad to the ligament of Treitz, respectively). With one barostat, standardized distentions (1 minute duration at 10-minute intervals in 4-mm Hg increments) were produced; with the other barostat, intestinal tone was measured as volumetric variations at constant pressure. Perception was scored (0-6) by a questionnaire. The proximal jejunum relaxed in response to distention of the distal jejunum (mean +/- SE, 40% + 7% delta vol; 5.1 + 0.1 perception score at the threshold for discomfort; P less than 0.05 for both). In contrast, the distal jejunum did not respond to distention of the proximal jejunum, whereas the perception scores were similar (10% +/- 5% delta vol; 5.1 +/- 0.1 perception score). Thus, the responsiveness of the proximal jejunum to intestinointestinal reflexes fades distally, whereas intestinal sensitivity to distention remains uniform.

Role of visceral afferent mechanisms in functional bowel disorders

This report analyzes the clinical and physiological evidence supporting a role for altered visceral afferent mechanisms in the pathogenesis of two functional bowel syndromes: noncardiac chest pain and the irritable bowel syndrome. Considerable recent evidence indicates that increased contractility is present only in a minority of patients and that hypercontractile episodes are not temporally related to abdominal pain. In contrast, altered sensation and motor reflexes in response to physiological stimuli, such as mechanical distention or acid, is common when appropriately investigated. The vagal and spinal afferent innervation mediates visceral sensation and is involved in multiple reflex loops regulating gastrointestinal effector function, such as motility and secretion. Sensory input can be modulated peripherally at the afferent nerve terminal, at the level of prevertebral ganglia, the spinal cord, and the brainstem. An up-regulation of afferent mechanisms would result both in altered conscious perception of physiological stimuli and in altered motor reflexes. Current evidence is consistent with an alteration in the peripheral functioning of visceral afferents and/or in the central processing of afferent information in the etiology of altered somatovisceral sensation and motor function observed in patients with functional bowel disease.

Capsaicin desensitization in vivo is inhibited by ruthenium red

The effect of systemic administration of Ruthenium Red on the excitatory and desensitizing effect of capsaicin was investigated in rats. Ruthenium Red was injected s.c. 30 min before capsaicin was administered. The excitatory effect of capsaicin on corneal, perivascular and visceral afferents was not influenced by treatment with Ruthenium Red. However, determination of the neuropeptide content and evoked neuropeptide release in peripheral organs and dorsal spinal cord 48 h after treatment showed that Ruthenium Red attenuated the 'desensitizing' effect of capsaicin at peripheral, but not at central, endings of primary afferents. On the other hand, a capsaicin-elicited autonomic reflex mediated by visceral afferents was still obtained in 9 of 14 rats that had received Ruthenium Red and capsaicin. The results indicate that a single dose of Ruthenium Red, which does not reduce the acute excitatory effect of capsaicin, reduces the desensitizing effect of capsaicin on peripheral endings of primary afferents in vivo. This long-lasting protective effect of Ruthenium Red suggests that it is possible to pharmacologically differentiate between the acute and chronic effects of capsaicin.