Contribution of Brain Processes to Tissue Loss After Spinal Cord Injury: Does a Pain-Induced Rise in Blood Pressure Fuel Hemorrhage?

Pain (nociceptive) input soon after spinal cord injury (SCI) expands the area of tissue loss (secondary injury) and impairs long-term recovery. Evidence suggests that nociceptive stimulation has this effect because it promotes acute hemorrhage. Disrupting communication with the brain blocks this effect. The current study examined whether rostral systems exacerbate tissue loss because pain input drives an increase in systolic blood pressure (BP) and flow that fuels blood infiltration. Rats received a moderate contusion injury to the lower thoracic (T12) spinal cord. Communication with rostral processes was disrupted by cutting the spinal cord 18 h later at T2. Noxious electrical stimulation (shock) applied to the tail (Experiment 1), or application of the irritant capsaicin to one hind paw (Experiment 2), increased hemorrhage at the site of injury. Shock, but not capsaicin, increased systolic BP and tail blood flow in sham-operated rats. Cutting communication with the brain blocked the shock-induced increase in systolic BP and tail blood flow. Experiment 3 examined the effect of artificially driving a rise in BP with norepinephrine (NE) in animals that received shock. Spinal transection attenuated hemorrhage in vehicle-treated rats. Treatment with NE drove a robust increase in BP and tail blood flow but did not increase the extent of hemorrhage. The results suggest pain input after SCI can engage rostral processes that fuel hemorrhage and drive sustained cardiovascular output. An increase in BP was not, however, necessary or sufficient to drive hemorrhage, implicating other brain-dependent processes.

Neuropathic Injury–Induced Plasticity of GABAergic System in Peripheral Sensory Ganglia

GABA is a major inhibitory neurotransmitter in the mammalian central nervous system (CNS). Inhibitory GABAA channel circuits in the dorsal spinal cord are the gatekeepers of the nociceptive input from the periphery to the CNS. Weakening of these spinal inhibitory mechanisms is a hallmark of chronic pain. Yet, recent studies have suggested the existence of an earlier GABAergic “gate” within the peripheral sensory ganglia. In this study, we performed systematic investigation of plastic changes of the GABA-related proteins in the dorsal root ganglion (DRG) in the process of neuropathic pain development. We found that chronic constriction injury (CCI) induced general downregulation of most GABAA channel subunits and the GABA-producing enzyme, glutamate decarboxylase, consistent with the weakening of the GABAergic inhibition at the periphery. Strikingly, the α5 GABAA subunit was consistently upregulated. Knock-down of the α5 subunit in vivo moderately alleviated neuropathic hyperalgesia. Our findings suggest that while the development of neuropathic pain is generally accompanied by weakening of the peripheral GABAergic system, the α5 GABAA subunit may have a unique pro-algesic role and, hence, might represent a new therapeutic target.

Effect sizes and test-retest reliability of the fMRI-based Neurologic Pain Signature

Identifying biomarkers that predict mental states with large effect sizes and high test-retest reliability is a growing priority for fMRI research. We examined a well-established multivariate brain measure that tracks pain induced by nociceptive input, the Neurologic Pain Signature (NPS). In N = 295 participants across eight studies, NPS responses showed a very large effect size in predicting within-person single-trial pain reports (d = 1.45) and medium effect size in predicting individual differences in pain reports (d = 0.49, average r = 0.20). The NPS showed excellent short-term (within-day) test-retest reliability (ICC = 0.84, with average 69.5 trials/person). Reliability scaled with the number of trials within-person, with ≥60 trials required for excellent test-retest reliability. Reliability was comparable in two additional studies across 5-day (N = 29, ICC = 0.74, 30 trials/person) and 1-month (N = 40, ICC = 0.46, 5 trials/person) test-retest intervals. The combination of strong within-person correlations and only modest between-person correlations between the NPS and pain reports indicates that the two measures have different sources of between-person variance. The NPS is not a surrogate for individual differences in pain reports, but can serve as a reliable measure of pain-related physiology and mechanistic target for interventions.

Spinal cord fractalkine (CX3CL1) signaling is critical for neuronal sensitization in experimental nonspecific, myofascial low back pain

Blocking fractalkine signaling by neutralizing antibodies completely prevented spinal sensitization induced by repetitive mild nociceptive input [2 nerve growth factor (NGF) injections into the multifidus muscle] Conversely, fractalkine given intrathecally caused the same pattern of spinal sensitization as the nociceptive NGF injections. Fractalkine signaling is critically involved in sensitization of dorsal horn neurons induced by repeated nociceptive low back muscle stimulation and may hence be a potential target for the prevention of nonspecific, myofascial low back pain.

Long-term sensitization of rat spinal neurons induced by adolescent psychophysical stress is further enhanced by a mild-nociceptive lumbar input

Background: Non-specific low back pain (LBP) is one of the most common chronic pain conditions and adverse childhood experiences (ACEs) are known mediators for chronicity of LBP. Sensitization of dorsal horn neurons (DHNs) is a significant element that contributes to chronic LBP. Repeated restraint stress in adult animals is known to cause manifest DHN sensitization when combined with a short-lasting nociceptive input. Objective: In this study, we investigated whether repeated restraint stress in early adolescence leads to a long-term sensitization of DHNs and if an additional mild-nociceptive input by intramuscular nerve growth factor (NGF) leads to further sensitization. Methods: Adolescent Wistar rats were stressed repeatedly in a narrow plastic restrainer, 1 hour per day for 12 consecutive days. Control animals were handled but not restrained. In adulthood, rats were treated with intramuscular injections of saline or NGF (short-lasting mild-nociceptive input) into the lumbar multifidus muscle (L5). Behavioral tests for pain sensitivity were performed before, after stress and inconjunction with intramuscular injections. Rats were transcardially perfused and immunohistochemistry was performed on lumbar (L2) spinal segments. Results: Adolescent restraint stress significantly lowered the low back pressure pain threshold (PPT) immediately after the stress (p<0.0001) and was maintained throughout adulthood (p<0.05). Additionally, paw withdrawal threshold (PWT) was significantly lowered by stress (p<0.0001) but normalized towards adulthood. An NGF injection in adulthood in previously stressed animals lowered the PPT (Cohen d=0.87) and increased microglia marker (Iba-1) immunoreactive area in the superficial DHN (p<0.01) with a trend in increased feret diameter of the immunoreactive cell (p=0.05). Conclusions: Our adolescence stress model induced behavioral signs of sensitization and enhanced sensitivity to further sensitization and dorsal horn microglia activation by subsequent mild nociceptive input (NGF injection). These findings help to understand certain aspects of how adolescent stress might predispose to exacerbation of pain with an additional insult.

A Multisensory fMRI Investigation of Nociceptive-Preferential Cortical Regions and Responses

The existence of nociceptive-specific brain regions has been a controversial issue for decades. Multisensory fMRI studies, which examine fMRI activities in response to various types of sensory stimulation, could help identify nociceptive-specific brain regions, but previous studies are limited by sample size and they did not differentiate nociceptive-specific regions and nociceptive-preferential regions, which have significantly larger responses to nociceptive input. In this study, we conducted a multisensory fMRI experiment on 80 healthy participants, with the aim to determine whether there are certain brain regions that specifically or preferentially respond to nociceptive stimulation. By comparing the evoked fMRI responses across four sensory modalities, we found a series of brain regions specifically or preferentially involved in nociceptive sensory input. Particularly, we found different parts of some cortical regions, such as insula and cingulate gyrus, play different functional roles in the processing of nociceptive stimulation. Hence, this multisensory study improves our understanding of the functional integrations and segregations of the nociceptive-related regions.

The temporal characteristics of expectations and prediction errors in pain

In the context of a generative model, such as predictive coding, pain perception can be construed as the integration of expectation and nociceptive input with their difference denoted as a prediction error. In a previous neuroimaging study (Geuter et al., 2017) we observed an important role of the insula in such a model, but could not establish its temporal aspects. Here we employed electroencephalography to investigate neural representations of predictions and prediction errors in heat pain processing. Our data show that alpha-to-beta activity was associated with pain expectation, followed by gamma band activity associated with absolute prediction errors. Source reconstruction revealed the insula as a common region for both effects. This temporal sequence of expectation related alpha-to-beta activity, followed by prediction error associated gamma activity in the insula, provides a possible mechanisms for the temporal integrating of pain predictions and prediction errors in the context of a generative model.

Analgesics, opioids, and NSAIDs

In this chapter, we discuss nociceptive treatment targets for pain in rheumatoid arthritis (RA), including non-steroidal anti-inflammatory drugs (NSAIDs). Sustained nociceptive input, as found in RA, can lead to changes in central pain processing. Nociceptive input is increased following local sensitization of peripheral nerves within the joint. Coupled with inflammation, it is known that major mediators of pain include neuropeptides (e.g. calcitonin gene-related peptide, CGRP) and neurotrophins such as nerve growth factor (NGF), each of which can also sensitize peripheral nerves. Immune cells within the central nervous system (CNS) directly contribute to developing central sensitization through the generation of cytokines such as IL-1. Interest has therefore grown in analgesics for RA pain that may target the CNS, including opiates and centrally acting analgesics. In this chapter, we discuss the scientific basis of pain in RA, followed by treatments currently widely used in clinical practice, including NSAIDs, opioids, and centrally acting analgesics.