Nitric oxide-mediated spinal disinhibition contributes to the sensitization of primate spinothalamic tract neurons

Experimentally induced spinal nociceptive sensitization increases with migraine frequency: a single-blind controlled study

The comparison of low-frequency migraine with high-frequency migraine after nitroglycerin administration shows progression in the degree of derangement of spinal nociception processing.

The nitric-oxide donor nitroglycerin (NTG) administration induces a facilitation of nociceptive pathways in episodic migraine. This study aims to test the hypothesis that induced spinal sensitization could be more pronounced in patients affected by high-frequency migraine (HF-MIG) with respect to low-frequency migraine (LF-MIG). We enrolled 28 patients with LF-MIG (1-5 migraine days/month), 19 patients with HF-MIG (6-14 migraine days/month), and 21 healthy controls (HCs). Spinal sensitization was evaluated with the neurophysiological recording of the temporal summation threshold (TST) of the nociceptive withdrawal reflex at the lower limb. Temporal summation threshold was recorded at baseline and 30, 60, and 120 minutes after NTG administration (0.9 mg sublingual). Spinal sensitization was detected in LF-MIG at 60 (P = 0.010) and 120 minutes (P = 0.001) and in HF-MIG at 30 (P = 0.008), 60 (P = 0.001), and 120 minutes (P = 0.001) after NTG administration. Temporal summation threshold did not change in HC (P = 0.899). Moreover, TST reduction was more pronounced in HF-MIG with respect to LF-MIG (P = 0.002). The percentage of patients who developed a migraine-like headache after NTG was comparable in the 2 migraine groups (LF-MIG: 53.6%, HF-MIG: 52.6%, P = 0.284), whereas no subjects in the HC group developed a delayed-specific headache. Notably, the latency of headache onset was significantly shorter in the HF-MIG group when compared with the LF-MIG group (P = 0.015). Our data demonstrate a direct relationship between migraine frequency and both neurophysiological and clinical parameters, to suggest an increasing derangement of the nociceptive system control as the disease progresses, probably as a result of the interaction of genetic and environmental factors.

Tapentadol and nitric oxide synthase systems

Tapentadol, a new analgesic drug with a dual mechanism of action (μ-opioid receptor agonism and norepinephrine reuptake inhibition), is indicated for the treatment of moderate to severe acute and chronic pain. In this paper, the possible additional involvement of the nitric oxide synthase (NOS) system in the antinociceptive activity of tapentadol was investigated using an unspecific inhibitor of NOS, L-NOArg, a relatively specific inhibitor of neuronal NOS, 7-NI, a relatively selective inhibitor of inducible NOS, L-NIL, and a potent inhibitor of endothelial NOS, L-NIO. Tapentadol (1-10 mg/kg, intraperitoneal) increased the threshold for mechanical (Randall-Selitto test) and thermal (tail-flick test) nociceptive stimuli in a dose-dependent manner. All four NOS inhibitors, administered intraperitoneally in the dose range 0.1-10 mg/kg, potentiated the analgesic action of tapentadol at a low dose of 2 mg/kg in both models of pain. We conclude that NOS systems participate in tapentadol analgesia.

Modulation of glycinergic synaptic transmission in the trigeminal and hypoglossal motor nuclei by the nitric oxide-cyclicGMP signaling pathway

In a previous work we found that nitric oxide (NO) and cyclicGMP (cGMP) inhibit glutamatergic synaptic transmission in trigeminal motoneurons (MnV). Here we study the actions of the NO/cGMP signaling pathway on glycinergic synaptic transmission in trigeminal and hypoglossal motoneurons (MnXII) in brain stem slices of neonatal rats. Glycinergic inhibitory postsynaptic currents (IPSCs) were recorded in MnV by stimulation of the supratrigeminal nucleus (SuV) and in MnXII by stimulation of the nucleus of Roller. The NO donor DETA/NONOate (DETA/NO) reduced the amplitude of the IPSC to 58.1±4.2% of control values in MnV. In the presence of YC-1, a modulator of guanylate cyclase that acts as a NO sensitizer, lower and otherwise ineffective concentrations of DETA/NO induced a reduction of the IPSC to 47.2±15.6%. NO effects were mimicked by 8 bromo cyclicGMP (8BrcGMP). They were accompanied by an increase in the paired pulse facilitation (PPF) and in the failure rate of evoked IPSCs. 8BrcGMP did not modify the glycinergic currents elicited by exogenous glycine. In MnXII the IPSCs were also reduced by NO donors and 8BrcGMP to 52.9±6.3% and 45.9±4% of control values, respectively. In these neurons, but not in MnV, we also observed excitatory postsynaptic actions of NO donors. We propose that the differences between the two motor pools may be due to a differential development of the nitrergic system in the two nuclei. Our data show that NO, through its second messenger cGMP, reduces inhibitory glycinergic synaptic transmission in both MnV and MnXII. For MnV, evidence in favor of presynaptic inhibition of glycine release is presented. Given our previous data together with the current results, we propose that the NO/cGMP signaling pathway participates pre- and postsynaptically in the combined regulation of MnV and MnXII activities in motor acts in which they participate.

Alcoholic neuropathy: possible mechanisms and future treatment possibilities

Chronic alcohol consumption produces painful peripheral neuropathy for which there is no reliable successful therapy, mainly due to lack of understanding of its pathobiology. Alcoholic neuropathy involves coasting caused by damage to nerves that results from long term excessive drinking of alcohol and is characterized by spontaneous burning pain, hyperalgesia and allodynia. The mechanism behind alcoholic neuropathy is not well understood, but several explanations have been proposed. These include activation of spinal cord microglia after chronic alcohol consumption, oxidative stress leading to free radical damage to nerves, activation of mGlu5 receptors in the spinal cord and activation of the sympathoadrenal and hypothalamo-pituitary-adrenal (HPA) axis. Nutritional deficiency (especially thiamine deficiency) and/or the direct toxic effect of alcohol or both have also been implicated in alcohol-induced neuropathic pain. Treatment is directed towards halting further damage to the peripheral nerves and restoring their normal functioning. This can be achieved by alcohol abstinence and a nutritionally balanced diet supplemented by all B vitamins. However, in the setting of ongoing alcohol use, vitamin supplementation alone has not been convincingly shown to be sufficient for improvement in most patients. The present review is focused around the multiple pathways involved in the development of peripheral neuropathy associated with chronic alcohol intake and the different therapeutic agents which may find a place in the therapeutic armamentarium for both prevention and management of alcoholic neuropathy.

Head pain referral during examination of the neck in migraine and tension-type headache

OBJECTIVE

To investigate if and to what extent typical head pain can be reproduced in tension-type headache (TTH), migraine without aura sufferers, and controls when sustained pressure was applied to the lateral posterior arch of C1 and the articular pillar of C2, stressing the atlantooccipital and C2-3 segments respectively.

BACKGROUND

Occipital and neck symptoms often accompany primary headache, suggesting involvement of cervical afferents in central pain processing mechanisms in these disorders. Referral of head pain from upper cervical structures is made possible by convergence of cervical and trigeminal nociceptive afferent information in the trigemino-cervical nucleus. Upper cervical segmental and C2-3 zygapophysial joint dysfunction is recognized as a potential source of noxious afferent information and is present in primary headache sufferers. Furthermore, referral of head pain has been demonstrated from symptomatic upper cervical segments and the C2-3 zygapophysial joints, suggesting that head pain referral may be a characteristic of cervical afferent involvement in headache.

METHODS

Thirty-four headache sufferers and 14 controls were examined interictally. Headache patients were diagnosed according the criteria of the International Headache Society and comprised 20 migraine without aura (females n = 18; males n = 2; average age 35.3 years) and 14 TTH sufferers (females n = 11; males n = 3; average age 30.7 years). Two techniques were used specifically to stress the atlantooccipital segments (Technique 1 - C1) and C2-3 zygapophysial joints (Technique 2 - C2). Two techniques were also applied to the arm--the common extensor origin and the mid belly of the biceps brachii. Participants reported reproduction of head pain with "yes" or "no" and rated the intensity of head pain and local pressure of application on a scale of 0 -10, where 0 = no pain and 10 = intolerable pain.

RESULTS

None of the subjects reported head pain during application of techniques on the arm. Head pain referral during the cervical examination was reported by 8 of 14 (57%) control participants, all TTH patients and all but 1 migraineur (P < .002). In each case, participants reported that the referred head pain was similar to the pain they usually experienced during TTH or migraine. The frequency of head pain referral was identical for Techniques 1 and 2. The intensity of referral did not differ between Technique 1 and Technique 2 or between groups. Tenderness ratings to thumb pressure were comparable between the Techniques 1 and 2 when pressure was applied to C1 and C2 respectively and across groups. Similarly, there were no significant differences for tenderness ratings to thumb pressure between Technique 1 and Technique 2 on the arm or between groups. While tenderness ratings to thumb pressure for Technique 2 were similar for both referral (n = 41) and non-referral (n = 7) groups, tenderness ratings for Technique 1 in the referral group were significantly greater when compared with the non-referral group (P = .01).

CONCLUSIONS

Our data support the continuum concept of headache, one in which noxious cervical afferent information may well be significantly underestimated. The high incidence of reproduction of headache supports the evaluation of musculoskeletal features in patients presenting with migrainous and TTH symptoms. This, in turn, may have important implications for understanding the pathophysiology of headache and developing alternative treatment options.

Oral nitric-oxide donor glyceryl-trinitrate induces sensitization in spinal cord pain processing in migraineurs: a double-blind, placebo-controlled, cross-over study

Nitric-oxide donor glyceryl-trinitrate (GTN) modulates cerebral and spinal regions that are involved in migraine and pain processing. We hypothesized that in migraineurs, the susceptibility to develop a migraine attack after GTN administration should parallel with an high sensitivity to GTN-induced change in the pain processing at spinal level. We used the temporal summation threshold (TST) of the lower limb nociceptive withdrawal reflex (NWR) and the related pain sensation to study in parallel the time-course of the effect of the GTN administration on the pain processing at spinal level in migraine and healthy subjects. Twenty-eight (21 F; 7M; mean age 34.2 ± 8.2) migraine and 15 (11 F; 4M; mean age 35.9 ± 8.9) healthy subjects were recruited in a double-blind, placebo-controlled, cross-over trial. Neurophysiological examinations were carried out before (baseline) and 30', 60', 120', 180' and 240' after GTN (0.9 mg sublingual) or placebo administration during two different sessions. In migraineurs, GTN administration was associated to a significant facilitation in temporal summation of pain (reduced TST and increased painful sensation) 60', 120' and 180' after drug intake when compared to baseline, to placebo condition and to controls after GTN intake. Furthermore, in migraineurs who developed migraine after GTN, a significant facilitation in temporal summation of pain was detected 60', 120' and 180' after drug intake when compared to patients without clinical response. In migraineurs the susceptibility to develop migraine attack after GTN administration seems to be a specific trait of a subgroup of patients linked to a supersensitivity of the pain system to GTN.

Superoxide signaling in pain is independent of nitric oxide signaling

Two reactive oxygen species (ROS), nitric oxide (NO(.)) and superoxide ((.)O2), contribute to persistent pain. Using three different animal models where ROS mediate pain, this study examined whether NO(.) and (.)O2 converge to peroxynitrite (ONOO(-)) or whether each has an independent signaling pathway to produce hyperalgesia. The hyperalgesia after spinal nerve ligation was attenuated by removing (.)O2 by TEMPOL or inhibiting NO(.) production by L-NAME, but not by removing peroxynitrite with FeTMPyP. Nitric oxide-induced hyperalgesia was not affected by removing (.)O2 but was reduced by a guanyl cyclase inhibitor. Superoxide-induced hyperalgesia was not affected by inhibiting NO(.) production but was suppressed by a protein kinase C inhibitor. The data suggest that NO(.) and (.)O2 operate independently to generate pain.

Tocotrienol ameliorates behavioral and biochemical alterations in the rat model of alcoholic neuropathy

Chronic alcohol consumption produces a painful peripheral neuropathy for which there is no reliable successful therapy, which is mainly due to lack of understanding of its pathobiology. Alcoholic neuropathy is characterized by spontaneous burning pain, hyperalgesia (an exaggerated pain in response to painful stimuli) and allodynia (a pain evoked by normally innocuous stimuli). Chronic alcohol intake is known to decrease the nociceptive threshold with increased oxidative-nitrosative stress and release of proinflammatory cytokines coupled with activation of protein kinase C. The aim of the present study is to investigate the effect of both isoforms of vitamin E, alpha-tocopherol (100mg/kg; oral gavage) and tocotrienol (50, 100 and 200mg/kg; oral gavage) against alcohol-induced neuropathic pain in rats. Male Wistar rats, were administered 35% v/v ethanol (10 g/kg; oral gavage) for 10 weeks, and were treated with alpha-tocopherol and tocotrienol for the same duration. Ethanol-treated animals showed a significant decrease in nociceptive threshold as evident from decreased tail flick latency (thermal hyperalgesia) and decreased paw-withdrawal threshold in Randall-Sellito test (mechanical hyperalgesia) and von-Frey hair test (mechanical allodynia) along with the reduction in nerve glutathione and superoxide dismutase levels. TNF-alpha and IL-1beta levels were also significantly increased in both serum and sciatic nerve of ethanol-treated rats. Treatment with alpha-tocopherol and tocotrienol for 10 weeks significantly improved all the above-stated functional and biochemical deficits in a dose-dependent manner with more potent effects observed with tocotrienol. The study demonstrates the effectiveness of tocotrienol in attenuation of alcoholic neuropathy.

Transient receptor potential vanilloid type 1 receptor regulates glutamatergic synaptic inputs to the spinothalamic tract neurons of the spinal cord deep dorsal horn

The spinothalamic tract (STT) neurons in the spinal dorsal horn play an important role in transmission and processing of nociceptive sensory information. Although transient receptor potential vanilloid type 1 (TRPV1) receptors are present in the spinal cord dorsal horn, their physiological function is not fully elucidated. In this study, we examined the role of TRPV1 in modulating neuronal activity of the STT neurons through excitatory and inhibitory synaptic inputs. Whole-cell patch-clamp recordings were performed on STT neurons labeled by a retrograde fluorescent tracer injected into the ventral posterior lateral (VPL) nucleus of the thalamus. Capsaicin (1 microM) increased the frequency of miniature excitatory postsynaptic currents (mEPSC) without changing the amplitude or decay time constant of mEPSC. In contrast, capsaicin had no distinct effect on GABAergic miniature inhibitory postsynaptic currents (mIPSC). Capsazepine (10 microM), a TRPV1 receptor antagonist, abolished the effect of capsaicin on mEPSCs. Capsazepine itself did not affect the baseline amplitude and frequency of mEPSC. The effect of capsaicin on mEPSC was also abolished by removal of external Ca(2+), but not by treatment with Cd(2+). Furthermore, capsaicin increased the firing activity of the STT neurons and this increase in neuronal activity by capsaicin was abolished in the presence of non-N-methyl-d-aspartic acid (NMDA) and NMDA receptor antagonists, 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione (NBQX) and (R)-amino-5-phosphonovaleric acid (APV). These data suggest that activation of TRPV1 potentiates the glutamate release from excitatory terminals of primary afferent fibers and subsequently increases the neural activity of STT neurons of the rat spinal cord deep dorsal horn.

Changes in synaptic effectiveness of myelinated joint afferents during capsaicin-induced inflammation of the footpad in the anesthetized cat

The present series of experiments was designed to examine, in the anesthetized cat, the extent to which the synaptic efficacy of knee joint afferents is modified during the state of central sensitization produced by the injection of capsaicin into the hindlimb plantar cushion. We found that the intradermic injection of capsaicin increased the N2 and N3 components of the focal potentials produced by stimulation of intermediate and high threshold myelinated fibers in the posterior articular nerve (PAN), respectively. This facilitation lasted several hours, had about the same time course as the paw inflammation and was more evident for the N2 and N3 potentials recorded within the intermediate zone in the L6 than in the L7 spinal segments. The capsaicin-induced facilitation of the N2 focal potentials, which are assumed to be generated by activation of fibers signaling joint position, suggests that nociception may affect the processing of proprioceptive and somato-sensory information and, probably also, movement. In addition, the increased effectiveness of these afferents could activate, besides neurons in the intermediate region, neurons located in the more superficial layers of the dorsal horn. As a consequence, normal joint movements could produce pain representing a secondary hyperalgesia. The capsaicin-induced increased efficacy of the PAN afferents producing the N3 focal potentials, together with the reduced post-activation depression that follows high frequency autogenetic stimulation of these afferents, could further contribute to the pain sensation from non-inflamed joints during skin inflammation in humans. The persistence, after capsaicin, of the inhibitory effects produced by stimulation of cutaneous nerves innervating non-inflamed skin regions may account for the reported reduction of the articular pain sensations produced by trans-cutaneous stimulation.

Bee venom injection produces a peripheral anti-inflammatory effect by activation of a nitric oxide-dependent spinocoeruleus pathway

Our recent data, obtained using a zymosan-induced inflammatory air pouch model in mice, have demonstrated that subcutaneous bee venom (BV) injection into the hind limb selectively activates the contralateral brain stem locus coeruleus (LC) and then via a descending noradrenergic pathway and subsequent adrenal medullary catecholamine release induces a potent anti-inflammatory effect. While the efferent limb of this BV-induced neuroimmune anti-inflammatory pathway is well documented, the afferent limb of this pathway is poorly understood. In particular the spinal mechanisms involved with BV activation of the LC are currently unknown. Spinal nitric oxide (NO) and its synthase (NOS) have been shown to play an important role in the transmission and amplification of neuronal information from the spinal cord to the brain stem. In the present study we evaluated whether spinal NO plays a role in BV-induced LC activation, since we have previously shown that LC activation underlies this 'BV-induced anti-inflammatory effect' (BVAI) using the mouse air pouch model. Intrathecal (i.t.) pretreatment with l-nitro arginine methyl ester (l-NAME, non-selective NOS inhibitor), hemoglobin (NO scavenger) or 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ, soluble guanylate cyclase inhibitor) abolished BVAI on zymosan-induced leukocyte migration into the air pouch. Moreover, i.t. injection of l-N-iminoethyl-lysine (l-NIL, inducible NOS inhibitor), but not 7-nitroindazole (7-NI, neuronal NOS inhibitor), also inhibited BVAI. BV injection significantly increased both the number of Fos immunoreactive neurons and tyrosine hydroxylase-Fos double labeling neurons in the contralateral LC in zymosan-induced inflamed mice. Importantly this increase in Fos expression in the LC was also completely inhibited by i.t. injection of l-NIL, but not by i.t. injection of 7-NI. Collectively these results indicate that spinal NO generated from inducible NOS is involved in the BV-induced LC activation that underlies BVAI.

NO pain: potential roles of nitric oxide in neuropathic pain

The disabling human syndrome of "neuropathic pain" is an intractable complication of peripheral nerve injury or degeneration. A complex interaction between injured peripheral axons, sensory neurons and central nervous system signaling is thought to account for it. In this brief review, we present evidence that the free radical signaling molecule, nitric oxide (NO) may act at several levels of the nervous system during the development of experimental neuropathic pain. For example, NO may directly influence injured axons in the periphery, may indirectly influence pain by its role in the process of Wallerian degeneration, and may signal in the dorsal horn of the spinal cord. While it is premature to argue for therapeutic approaches that alter NO actions, it may be an important player in the cascade of events that generate neuropathic pain.

Localization of soluble guanylyl cyclase in the superficial dorsal horn

Nitric oxide (NO) has been implicated in pain processing at the spinal level, but the mechanisms mediating its effects remain unclear. In the present work, we studied the organization of the major downstream effector of NO, soluble guanylyl cyclase (sGC), in the superficial dorsal horn of rat. Almost all neurokinin 1 (NK1) receptor-positive neurons in lamina I (a major source of ascending projections) were strongly immunopositive for sGC. Many local circuit neurons in laminae I-II also stained for sGC, but less intensely. Numerous fibers, presumably of unmyelinated primary afferent (C fiber) origin, stained for calcitonin gene-related peptide or isolectin B4, but none of these was immunopositive for sGC. These data, along with immunoelectron microscopy results, imply that unmyelinated primary afferent fibers terminating in the superficial dorsal horn lack sGC. Double labeling showed that neuronal nitric oxide synthase (nNOS) seldom colocalized with sGC, but nNOS-positive structures were frequently closely apposed to sGC-positive structures, suggesting that in the superficial dorsal horn NO acts mainly in a paracrine manner. Our data suggest that the NK1 receptor-positive projection neurons in lamina I are a major target of NO released in superficial dorsal horn. NO may also influence local circuit neurons, but it does not act on unmyelinated primary afferent terminals via sGC.

Nitric oxide-dependent long-term potentiation revealed by real-time imaging of nitric oxide production and neuronal excitation in the dorsal horn of rat spinal cord slices

Nitric oxide (NO) is thought to be involved in the central mechanism of hyperalgesia and allodynia at the spinal level. Recently, we reported that NO played an important role in the induction of long-term potentiation (LTP) of synaptic strength in spinal dorsal horn, which is believed to underlie hyperalgesia and allodynia. In this study, to elucidate the relationship of NO to LTP in spinal dorsal horn, we measured the spatiotemporal distribution of NO signal with the NO-sensitive dye, DAR-4M, and neuronal excitation with the voltage-sensitive dye, RH482, in rat spinal cord slices, elicited by dorsal root stimulation. In superficial dorsal horn, neuronal excitation evoked by C fiber-activating dorsal root stimulation was potentiated for more than 2 h after low-frequency conditioning stimulation (LFS, 240 pulses at 2 Hz for 2 min). In the same slices that exhibited LTP, NO was produced and distributed in the superficial dorsal horn during the delivery of LFS, and the amplitude of LTP and amount of NO production showed close correlation from slice to slice. LTP and production of NO were inhibited in the presence of the NO synthase inhibitors and an inhibitor of heme oxygenase, the synthetic enzyme for carbon monoxide (CO). These results suggest that production and distribution of NO is necessary for the induction of LTP in spinal dorsal horn, and that CO contributes to the LTP induction and NO production by LFS.

Immune and inflammatory mechanisms in neuropathic pain

Tissue damage, inflammation or injury of the nervous system may result in chronic neuropathic pain characterised by increased sensitivity to painful stimuli (hyperalgesia), the perception of innocuous stimuli as painful (allodynia) and spontaneous pain. Neuropathic pain has been described in about 1% of the US population, is often severely debilitating and largely resistant to treatment. Animal models of peripheral neuropathic pain are now available in which the mechanisms underlying hyperalgesia and allodynia due to nerve injury or nerve inflammation can be analysed. Recently, it has become clear that inflammatory and immune mechanisms both in the periphery and the central nervous system play an important role in neuropathic pain. Infiltration of inflammatory cells, as well as activation of resident immune cells in response to nervous system damage, leads to subsequent production and secretion of various inflammatory mediators. These mediators promote neuroimmune activation and can sensitise primary afferent neurones and contribute to pain hypersensitivity. Inflammatory cells such as mast cells, neutrophils, macrophages and T lymphocytes have all been implicated, as have immune-like glial cells such as microglia and astrocytes. In addition, the immune response plays an important role in demyelinating neuropathies such as multiple sclerosis (MS), in which pain is a common symptom, and an animal model of MS-related pain has recently been demonstrated. Here, we will briefly review some of the milestones in research that have led to an increased awareness of the contribution of immune and inflammatory systems to neuropathic pain and then review in more detail the role of immune cells and inflammatory mediators.

Activation of protein kinase B/Akt signaling pathway contributes to mechanical hypersensitivity induced by capsaicin

We investigated the involvement of the protein kinase B/Akt (PKB/Akt) signaling pathway in the mechanical hypersensitivity induced in rats by capsaicin. Intradermal injection of capsaicin results in activation of PKB/Akt in the lumbar spinal cord, most prominently in the dorsal horn, starting by 5 min after capsaicin injection and lasting at least 1h. The activated PKB/Akt in the spinal cord is in neurons, since phospho-PKB/Akt (p-PKB/Akt) colocalizes with the neuronal marker, neuronal-specific nuclear protein (NeuN). The mechanical hypersensitivity is shown by the enhanced paw withdrawal frequency to applications of von Frey filaments with different bending forces (30, 100, 200 mN) on the rat paw. Pre-treatment with several different PKB/Akt inhibitors, including SH-6, Akt inhibitor IV, and Akt inhibitor V, blocked the mechanical hypersensitivity induced by intradermal injection of capsaicin, a measure of spinal cord central sensitization. Two structurally unrelated phosphoinositide 3-Kinase (PI3K, upstream of PKB/Akt) inhibitors, Wortmannin and LY294002, also prevented the mechanical hypersensitivity induced by intradermal injection of capsaicin. Furthermore, post-treatment with the PI3K inhibitor, Wortmannin, or PKB/Akt inhibitors, such as NL-71-101, SH-6, Akt inhibitor IV, and inhibitor V significantly reduced the established mechanical hypersensitivity induced by capsaicin. The PKB/Akt signaling pathway in the spinal cord is therefore involved in pain hypersensitivity.

The spinal nitric oxide involved in the inhibitory effect of midazolam on morphine-induced analgesia tolerance

Previous studies had shown that pretreatment with midazolam inhibited morphine-induced tolerance and dependence. The present study was to investigate the role of spinal nitric oxide (NO) in the inhibitory effect of midazolam on the development of morphine-induced analgesia tolerance. Subcutaneous injection of 100 mg/kg morphine to mice caused an acute morphine-induced analgesia tolerance model. To develop chronic morphine tolerance in mice, morphine was injected for three consecutive days (10, 20, 50 mg/kg sc on Day 1, 2, 3, respectively). In order to develop chronic tolerance model in rats, 10 mg/kg of morphine was given twice daily at 12 h intervals for 10 days. Midazolam was intraperitoneally injected 30 min prior to administration of morphine. Tail-flick test, hot-plate and formalin test were conducted to assess the nociceptive response. Immunocytochemistry, histochemistry and western blot were performed to determine the effect of midazolam on formalin-induced expression of Fos protein, nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) and nitric oxide synthase (NOS) in chronic morphine-tolerant rats, respectively. The results showed that pretreatment with midazolam significantly inhibited the development of acute and chronic morphine tolerance in mice, which could be partially reversed by intrathecal injection of NO precursor L-arginine (L-Arg). In chronic morphine-tolerant rats, pretreatment with midazolam significantly decreased the formalin-induced expression of Fos and Fos/NADPH-d double-labeled neurons in the contralateral spinal cord and NADPH-d positive neurons in the bilateral spinal cord. Both inducible NOS (iNOS) and neuronal NOS (nNOS) protein levels in the spinal cord were significantly increased after injection of formalin, which could be inhibited by pretreatment with midazolam. The above results suggested that the decrease of the activity and expression of NOS contributed to the inhibitory effect of midazolam on the development of morphine tolerance.

Pain mechanisms: labeled lines versus convergence in central processing

The issue of whether pain is represented by specific neural elements or by patterned activity within a convergent somatosensory subsystem has been debated for over a century. The gate control theory introduced in 1965 denied central specificity, and since then most authors have endorsed convergent wide-dynamic-range neurons. Recent functional and anatomical findings provide compelling support for a new perspective that views pain in humans as a homeostatic emotion that integrates both specific labeled lines and convergent somatic activity.

The pathogenesis of muscle pain

Nociceptive nerve endings in muscles and other tissues are equipped with a multitude of receptor molecules for endogenous pain-producing and sensitizing agents. Particularly interesting molecules are the purinergic receptors, which can be activated by adenosine triphosphate (ATP), and the vanilloid receptor, which is sensitive to protons (low pH). The purinergic receptors are activated by tissue damage because cell necrosis is associated with the release of ATP. A low pH is present in many pathologic conditions such as ischemia and inflammation. At the spinal and medullar level, painful muscle lesions induce marked neuroplastic changes that result in hyperexcitability and hyperactivity of nociceptive neurons. This central sensitization is the basis for the spontaneous pain and hyperalgesia of patients. The transition from acute to chronic muscle pain is complete when the initially functional changes are transformed into structural ones. Patients with morphologic alterations in their nociceptive system are difficult to treat because the changes need time to normalize.

The trigeminocervical complex and migraine: current concepts and synthesis

Neurones in the trigeminocervical complex are the major relay neurones for nociceptive afferent input from the meninges and cervical structures; therefore, they are the neural substrates of head pain. This review highlights the importance of two basic mechanisms in headache physiology: convergence of nociceptive afferents and sensitization of trigeminocervical neurones. These physiologic findings have clinical correlates such as hypersensitivity and spread and referral of pain frequently seen in patients with primary headache, such as migraine. Special reference is made to the influence of structures from the upper cervical spine in generating and contributing to migraine headaches. The pathophysiology and functional relevance of these basic mechanisms to headaches is discussed in the context of recent experimental findings with regard to pain processing.

Nitric oxide modulates striatal neuronal activity via soluble guanylyl cyclase: an in vivo microiontophoretic study in rats

It is now well established that nitric oxide (NO) acts as a neuromodulator in the central nervous system. To assess the role of NO in modulating striatal activity, single-unit recording was combined with iontophoresis to study presumed spiny projection neurons in urethane-anesthetized male rats. Striatal neurons recorded were essentially quiescent and were therefore activated to fire by the iontophoretic administration of glutamate, pulsed in cycles of 30 sec on and 40 sec off. In this study, iontophoresis of 3-morpholinosydnonimine hydrochloride (SIN 1), a nitric oxide donor, produced reproducible, current-dependent inhibition of glutamate-induced excitation in 12 of 15 striatal neurons, reaching its maximal inhibitory effect (76.2 +/- 5.6% below baseline) during the application of a 100 nA current. Conversely, microiontophoretic application of N-omega-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide synthase, produced clear and reproducible excitation of glutamate evoked firing in 7 of 10 cells (51.4 +/- 2.3%, at 100 nA). To evaluate the involvement of cyclic guanosine monophosphate (cGMP) in the electrophysiological effects produced by the NO donor, the effects of methylene blue, an inhibitor of guanylyl cyclase, on the responses of nine neurons to SIN 1 were tested. In six of nine neurons the effect of SIN 1 was significantly reduced during continuous iontophoretic administration (50 nA) of methylene blue. Taken together, these data show that NO modulates the striatal network and that inhibitory control of the output neurons is involved in this effect. These results also suggest that the effects of nitric oxide on striatal neurons are partially mediated via cGMP.

Long-term potentiation in spinothalamic neurons

Sensitization of nociceptive dorsal horn neurons, including spinothalamic tract (STT) cells, is thought to underlie the development of secondary hyperalgesia and allodynia following tissue injury. In central sensitization, responses to stimulation of sensory receptors are enhanced without any change in the excitability of the primary afferent neurons. We hypothesize that central sensitization of STT neurons is a variety of long-term potentiation (LTP). Evidence that LTP occurs in the spinal cord is reviewed. Neurotransmitters that trigger central sensitization include excitatory amino acids and peptides. Evidence for this is that co-activation of N-methyl-D-aspartate and NK1 receptors can produce long-lasting increases in the responses of STT cells, and antagonists of these receptors prevent central sensitization. Responses to excitatory amino acids increase and those to inhibitory amino acids decrease during central sensitization, presumably accounting for the changed excitability of STT cells. We believe these changes result from the activation of signal transduction pathways, including the protein kinase C, NO/protein kinase G and protein kinase A cascades. Recent evidence shows that calcium/calmodulin dependent kinase II (CaMKII) is also upregulated early in the process of central sensitization and that several types of ionotropic glutamate receptors become phosphorylated. It is proposed that the phosphorylation of neurotransmitter receptors leads to alterations in the sensitivity of these receptors and to central sensitization. Comparable events occur during LTP in brain structures.

Human brain plasticity: an emerging view of the multiple substrates and mechanisms that cause cortical changes and related sensory dysfunctions after injuries of sensory inputs from the body

Injuries of peripheral inputs from the body cause sensory dysfunctions that are thought to be attributable to functional changes in cerebral cortical maps of the body. Prevalent theories propose that these cortical changes are explained by mechanisms that preeminently operate within cortex. This paper reviews findings from humans and other primates that point to a very different explanation, i.e. that injury triggers an immediately initiated, and subsequently continuing, progression of mechanisms that alter substrates at multiple subcortical as well as cortical locations. As part of this progression, peripheral injuries cause surprisingly rapid neurochemical/molecular, functional, and structural changes in peripheral, spinal, and brainstem substrates. Moreover, recent comparisons of extents of subcortical and cortical map changes indicate that initial subcortical changes can be more extensive than cortical changes, and that over time cortical and subcortical extents of change reach new balances. Mechanisms for these changes are ubiquitous in subcortical and cortical substrates and include neurochemical/molecular changes that cause functional alterations of normal excitation and inhibition, atrophy and degeneration of normal substrates, and sprouting of new connections. The result is that injuries that begin in the body become rapidly further embodied in reorganizational make-overs of the entire core of the somatosensory brain, from peripheral sensory neurons to cortex. We suggest that sensory dysfunctions after nerve, root, dorsal column (spinal), and amputation injuries can be viewed as diseases of reorganization in this core.

Effects of protein kinase a activation on the responses of primate spinothalamic tract neurons to mechanical stimuli

Behavioral and anatomical studies by our group have suggested that the protein kinase A (PKA) signal transduction cascade contributes to long-term changes in nociceptive processing at the spinal cord level. In this study, we have examined the effects of activation of the PKA cascade on the responses of spinothalamic tract (STT) neurons to peripheral mechanical stimuli in anesthetized and paralyzed monkeys. PKA in the spinal cord was activated by intra-spinal infusion of forskolin, an activator of adenylate cyclase, by microdialysis. There was a consistent increase in responses to mechanical pressure and pinch stimuli in all STT cells tested when forskolin was administered. Enhanced responses remained at relatively high levels when forskolin had been washed out for 30 min. However, in most STT cells tested (65%), the responses to brushing stimuli were not obviously changed when forskolin was given. Background activity was slightly increased when forskolin was administered. An inactive isomer of forskolin, D-forskolin, did not produce significant effects on cellular activity. The sensitization of STT cells to noxious mechanical stimuli produced by forskolin could be blocked by pretreatment of the spinal cord with the PKA inhibitor, N-[2-((p-bromocinnamyl)amino)ethyl]-5-isoquinolinesulfonamine (H89). The same dose of H89 did not affect the enhanced responses to mechanical stimuli produced by activation of protein kinase G by intra-spinal infusion of 8-bromo-cGMP, indicating that the effect of forskolin was selective. The present data suggest that activation of PKA can preferentially enhance the responses of STT cells to noxious mechanical stimuli without producing an increase in responses to innocuous brushing stimuli. We speculate that the PKA signal transduction cascade may contribute more to secondary mechanical hyperalgesia than to secondary mechanical allodynia.

The role of nitric oxide in the phosphorylation of cyclic adenosine monophosphate—responsive element-binding protein in the spinal cord after intradermal injection of capsaicin

We investigated the involvement of nitric oxide (NO) in the phosphorylation of cyclic adenosine monophosphate-responsive element-binding protein (CREB) in the spinal cord of rats during central sensitization after intradermal capsaicin injection. CREB and phosphorylated CREB (p-CREB) were measured by immunoblotting. The level of p-CREB increased by 20 minutes, peaked between 20 and 60 minutes after capsaicin injection, and started to decrease after 150 minutes. CREB itself did not show an obvious change after capsaicin injection. The p-CREB expression on the ipsilateral side of the spinal dorsal horn, but not on the contralateral side, increased significantly after capsaicin injection. The increase in p-CREB induced by capsaicin injection was partially blocked by pretreatment with N(G)-nitro-L-arginine methyl ester (L-NAME), an NO synthase inhibitor, administered through a microdialysis fiber placed across the spinal cord. D-NAME, an inactive form of L-NAME, had no effect. CREB phosphorylation, not the level of CREB, was induced within 20 minutes by microdialysis administration of SIN-1, an NO donor. These results indicate that CREB phosphorylation in the spinal cord results from both endogenous and exogenous NO release and that p-CREB may play a role in central sensitization or in longer-term changes in gene expression induced by strong peripheral noxious stimulation.

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.

Nitric oxide synthase in spinal cord central sensitization following intradermal injection of capsaicin

Nitric oxide (NO) is believed to be an important messenger molecule in signal transduction pathways that enhance nociceptive transmission in the central nervous system (CNS). The role of nitric oxide synthase (NOS) I and II, which synthesize NO, in central sensitization induced by an intradermal capsaicin injection was investigated. To elucidate whether changes in NOS I and NOS II activities caused by capsaicin injection contribute to behavioral changes, responses to von Frey filaments with two different innocuous bending forces applied on the rat foot were tested. The allodynic responses induced by capsaicin injection in the foot were partially reversed by the administration of either the selective NOS I inhibitor, 7-nitroindazole (7-NINA), or the selective NOS II inhibitor, 2-amino-5,6-dihydro-6-methyl-4H-1,3-thiazine (AMT). To confirm changes at the level of single nociceptive neurons, extracellular recordings were made from rat dorsal horn neurons. The electrophysiological results showed that increased responses to noxious and innocuous stimuli caused by capsaicin injection were blocked by either 7-NINA or AMT delivered through a microdialysis fiber inserted through the dorsal horn. Finally, the expression of both NOS I and NOS II in the spinal cord as demonstrated by Western blots was increased by 20 min following intradermal capsaicin injection in the rat foot. These results suggest that both NOS I and NOS II are upregulated following intradermal capsaicin injection and that both cause NO release that contributes to the secondary hyperalgesia and allodynia following this noxious chemical stimulus.

Neuronal application of capsaicin modulates somatic pressor reflexes

Static contraction of skeletal muscle elicits a reflex increase in cardiovascular function. Likewise, noxious stimuli activate somatic nociceptors eliciting a reflex increase in cardiovascular function. On the basis of recent work involving spinothalamic cells in the dorsal horn, we hypothesized that the dorsal horn cells involved in the aforementioned reflexes would be sensitized by applying capsaicin (Cap) to a peripheral nerve. If correct, then Cap would enhance the cardiovascular increases that occur when these reflexes are evoked. Cats were anesthetized, and the popliteal fossa was exposed. Static contraction was induced by electrical stimulation of the tibial nerve at an intensity that did not directly activate small-diameter muscle afferent fibers, whereas nociceptors were stimulated by high-intensity stimulation (after muscle paralysis) of either the saphenous nerve (cutaneous nociceptors) or a muscular branch of the tibial nerve (muscle nociceptors). The reflex cardiovascular responses to these perturbations (contraction or nociceptor stimulation) were determined before and after direct application of Cap (3%) onto the common peroneal nerve, using a separate group of cats for each reflex. Compared with control, application of Cap attenuated the peak change in mean arterial pressure (MAP) evoked by static contraction (DeltaMAP in mmHg: 38 +/- 10 before and 24 +/- 8 after ipsilateral Cap; 47 +/- 10 before and 33 +/- 10 after contralateral Cap). On the other hand, Cap increased the peak change in MAP evoked by stimulation of the saphenous nerve from 57 +/- 8 to 77 +/- 9 mmHg, as well as the peak change in MAP elicited by activation of muscle nociceptors (36 +/- 9 vs. 56 +/- 14 mmHg). These results show that the reflex cardiovascular increases evoked by static muscle contraction and noxious input are differentially affected by Cap application to the common peroneal nerve. We hypothesize that a Cap-induced alteration in dorsal horn processing is the locus for this divergent effect on these reflexes.

The role of nitric oxide in nociception

Pharmacologic, electrophysiologic, and immunohistochemical studies have suggested a role of nitric oxide (NO) in nociception processing. Recent studies have indicated that NO may modulate spinal and sensory neuron excitability through multiple mechanisms that may underlie its distinctive roles in different pain states. Differential regulation of a family of NO-producing enzymes, NO synthases, contributes mainly to the complexity underlying the role of NO in nociception. This review summarizes the latest advances in our understanding of the contribution of NO to pain transduction. Possible cellular mechanisms regarding the connection between NO production and the abnormal sensation derived from different stimuli and pathologic conditions are discussed.

S-nitroso-l-cysteine releases norepinephrine in rat spinal synaptosomes

Although nitric oxide (NO) participates in development of hypersensitivity states in the spinal cord thought to underlie chronic pain, it also participates in analgesia produced by various drugs. In rats with a hypersensitivity state following peripheral nerve injury, spinal administration of an NO donor or l-cysteine alone produced no effect, whereas their combination, which yields s-nitroso-l-cysteine (SNC) powerfully reduced hypersensitivity. In the current study, we examined the ability of SNC to stimulate release of a known spinal analgesic neurotransmitter, norepinephrine (NE), as a possible mechanism of analgesic action of NO in the spinal cord. SNC (but not the NO donor alone or decomposed SNC) produced a concentration-dependent release of NE from rat spinal cord synaptosomes. The d-isomer of SNC was less potent than the l-isomer, and the effect of SNC was partially blocked by l-, but not d-leucine, implicating an interaction with the l-amino acid transporter. SNC-induced NE release was partially Na(+) dependent, but largely Ca(2+) independent. NE uptake inhibitors partially antagonized the effect of SNC, but guanylate cyclase inhibitors were without effect. These data are therefore consistent with NO stimulating NE release in the spinal cord via reaction with thiol containing compounds, such as cysteine, entry into NE terminals via active transport, and production of both exocytotic and carrier mediated release.

Fos expression is induced by increased nitric oxide release in rat spinal cord dorsal horn

The relationship between exogenous or endogenous nitric oxide and c-fos, an immediate-early gene which can further activate the production of other substances in the central nervous system, was investigated in this study. We found that Fos expression is increased after intradermal capsaicin injection, which also leads to endogenous nitric oxide release in the spinal cord. The increased Fos expression is distributed in neurons of the superficial layers and lamina V of the dorsal horn on the side ipsilateral to the injection. The increased Fos expression is blocked by N(G)-nitro-L-arginine methyl ester, a nitric oxide synthase inhibitor, but not by its inactive isomer N(G)-nitro-D-arginine methyl ester. Fos expression was also increased following the perfusion of 3-morpholino-sydnonimine, a nitric oxide donor, into the dorsal horn through a microdialysis fiber. The increased Fos was distributed within 400 microm from the edge of the microdialysis fiber. Although Fos expression was increased with 3-morpholino-sydnonimine perfusion compared to that seen with artificial cerebrospinal fluid perfusion, there was still some Fos immunostaining in the control sections. Following perfusion of artificial cerebrospinal fluid in the spinal cord of rats pretreated with N(G)-nitro-L-arginine methyl ester, it was found that Fos staining was reduced significantly compared to the control sections from animals without N(G)-nitro-L-arginine methyl ester pretreatment. These results suggest that nitric oxide helps mediate Fos expression induced by an intradermal capsaicin injection. We conclude that both endogenous and exogenous nitric oxide induce Fos expression. Involvement of nitric oxide in the development of central sensitization may affect nociceptive processing by increasing Fos expression. Since many other substances which are related to pain mechanisms can be induced by Fos, it is suggested that nitric oxide may regulate production of these substances through activation of Fos. Nitric oxide is not only involved in the development of central sensitization, but is also involved in the activation of control mechanisms affecting nociception.