Isoflurane and an alpha 2-adrenoceptor agonist suppress nociceptive neurotransmission in neonatal rat spinal cord.

Analgesia is an important component of general anesthesia. alpha 2-adrenoceptor agonists such as clonidine and dexmedetomidine are effective analgesics at the spinal level, and furthermore, they reduce the volatile anesthetic requirement. In order to probe a possible spinal-level contribution to general anesthetic-induced analgesia, the effects of dexmedetomidine were tested in an isolated spinal cord preparation. The effects of dexmedetomidine were compared with those of isoflurane, and dexmedetomidine-isoflurane interactions were explored. The test response was a nociceptive-related slow ventral root potential (slow VRP) recorded from the isolated neonatal rat spinal cord in response to electrical stimulation of a dorsal root. At 0.2-1.28 vol%, isoflurane reversibly depressed the slow VRP. At a lower concentration (0.14 vol%), isoflurane increased the slow VRP in three of five preparations. At 1.0-1.28 vol%, isoflurane also depressed the monosynaptic reflex. Recovery on washout usually was to a level greater than control. The N-methyl-D-aspartate (NMDA) receptor antagonist (DL)-2-amino 5-phosphonovalerate (10 microM) prevented the rebound to levels above control on isoflurane washout. The earlier components of the slow VRP were more sensitive to isoflurane than were the later. Dexmedetomidine (0.5-10 nM) depressed the slow VRP and had no effect on the monosynaptic reflex. The slow VRP depends on both substance P and glutamate NMDA-receptor-mediated neurotransmission; isoflurance and dexmedetomidine depressed responses to both substance P and NMDA. Although the two agents depress responses to the same neurotransmitters, there is no evidence that they act at the same cellular site(s). There was no significant interaction between dexmedetomidine and isoflurane. The results suggest that isoflurane exerts marked inhibitory effects on spinal neurotransmission, depressing both substance P and glutamate-mediated pathways. There is a possible biphasic effect on the NMDA receptor. To the extent that nociception depends on these neurotransmitters, isoflurane may be expected to exert profound analgesic effects at the spinal level. By blocking responses to strongly arousing stimuli, these effects may contribute to general anesthesia. Suppression of nociceptive neurotransmission at the spinal level may contribute to dexmedetomidine's anesthetic-sparing properties as well as to analgesia by this agent.     

Perineural alpha(2A)-adrenoceptor activation inhibits spinal cord neuroplasticity and tactile allodynia after nerve injury

BACKGROUND: Nerve injury in animals increases alpha(2)-adrenoceptor expression in dorsal root ganglion cells and results in novel excitatory responses to their activation, perhaps leading to the phenomenon of sympathetically maintained pain. In contrast to this notion, peripheral alpha(2)-adrenoceptor stimulation fails to induce pain in patients with chronic pain. We hypothesized that alpha(2) adrenoceptors at the site of nerve injury play an inhibitory, not excitatory role. METHODS: Partial sciatic nerve ligation was performed on rats, resulting in a reduction in withdrawal threshold to tactile stimulation. Animals received perineural injection at the injury site of clonidine, saline, or clonidine plus an alpha(2)-adrenergic antagonist, and withdrawal threshold was monitored. Immunohistochemistry was performed on the sciatic nerve ipsi- and contralateral to injury and on the spinal cord. RESULTS: Clonidine reduced this hypersensitivity in a dose-dependent manner, and this was blocked by an alpha(2A)-preferring antagonist. Perineural clonidine injection had a slow onset (days) and prolonged duration (weeks). Systemic or intrathecal clonidine, or transient neural blockade with ropivacaine, had short lasting or no effect on hypersensitivity. alpha(2A)-adrenoceptor immunostaining was increased near the site of peripheral nerve injury, both in neurons and in immune cells (macrophages and T lymphocytes). Phosphorylated cAMP response element binding protein (pCREB) in lumbar spinal cord was increased ipsilateral to nerve injury, and this was reduced 1 week after perineural clonidine injection. CONCLUSIONS: These data suggest that peripheral alpha(2) adrenoceptors are concentrated at the site of peripheral nerve injury, and their activation receptors produce long-lasting reductions in abnormal spinal cord gene activation and mechanical hypersensitivity.     

Effects of alpha(2)-adrenoceptor agonists on perinatal excitotoxic brain injury: comparison of clonidine and dexmedetomidine.

BACKGROUND: A growing number of children have severe neurologic impairment related to very premature birth. Experimental data suggest that overstimulation of cerebral N-methyl-d-aspartate (NMDA) receptors caused by excessive glutamate release may be involved in the genesis of perinatal hypoxic-ischemic brain injury. alpha(2)-Adrenoceptor agonists are protective in models of brain ischemia in adults. The authors sought to determine whether they prevent perinatal excitotoxic neuronal damage. METHODS: Five-day-old mice were allocated at random to clonidine (4-400 microg/kg), dexmedetomidine (1-30 microg/kg), or saline injected intraperitoneally before an intracerebral stereotactic injection of the NMDA receptor agonist ibotenate; cortical and white matter lesions were quantified 5 days later by histopathologic examination. Cortical neuron cultures exposed to 300 microm NMDA were used to evaluate the effects of clonidine or dexmedetomidine on neuronal death assessed by counting the number of pycnotic nuclei after fluorescent chromatin staining. RESULTS: In vivo, both clonidine and dexmedetomidine induced significant concentration-dependent reductions in the size of ibotenate-induced lesions in the cortex and white matter. In vitro, the number of neurons damaged by NMDA exposure was significantly decreased by both dexmedetomidine (-28 +/- 12% at 10 microm; P < 0.01) and clonidine (-37 +/- 19% at 100 microm; P < 0.01) as compared with controls. In both models, the selective alpha2-adrenoceptor antagonist yohimbine abolished the neuroprotective effect of clonidine and dexmedetomidine. CONCLUSIONS: Clonidine and dexmedetomidine are potent neuroprotectors that act by stimulating the alpha(2) adrenoceptors. These results obtained in a murine model of perinatal excitotoxic injury may be relevant to some forms of neonatal brain damage in humans.     

The effects of alpha2-adrenoceptor agonists on circulation and respiration

In December 1999, the United States Food and Drug Administration approved dexmedetomidine, the active isomer of medetomidine, a veterinary anaesthetic, for use in the ICU. Dexmedetomidine is far more potent and selective as an α₂-agonist than clonidine, and it is the first of its class in the USA to be available for intravenous administration to critically ill patients. The clinical approval of dexmedetomidine stimulated this review of the applications of α₂-adrenergic agonists in the critically ill to modulate adrenergic output, to provide sedation and to limit narcotic analgesic use in this challenging group of patients. This chapter focuses on the salient features of the effects of α₂-adrenergic agonists on cardiovascular and respiratory function, commenting on the special aspects of the dynamic state of critical illness. The bulk of this review is devoted to a discussion of pertinent human trials of dexmedetomidine. The remainder of the chapter briefly addresses the effects of epidural clonidine administration and the comparative circulatory effects of two other α₂-adrenergic agents, mivazerol and tizanidine.     

Perioperative use of alpha2-adrenoceptor agonists and the cardiac patient

The centrally acting alpha2-adrenoceptor agonists clonidine and dexmedetomidine have been used with success to provide haemodynamic stability for patients undergoing surgery. Particularly in the case of patients with overt or underlying cardiac disease the actions of alpha2-adrenoceptor agonists, which include maintenance of stable systemic blood pressure and low heart rate and a reduction in overall oxygen consumption, can be expected to reduce the risk of procedure-related cardiac events. This expectation has been corroborated in clinical trials with clonidine, dexmedetomidine and mivazerol and meta-analyses; additional large controlled trials would be instructive in establishing a robust estimate of the scale of the benefit. In addition, alpha2-adrenoceptor agonists used as premedication have been shown to substantially reduce anaesthetic requirements among surgical patients, and the use of these agents has been associated with a reduced risk of postoperative delirium, which may be expected to improve considerably the postoperative course for at-risk patients. Dexmedetomidine is the only alpha2-adrenoceptor agonist currently approved for use in the intensive care unit. A distinctive feature of dexmedetomidine in that setting is that in addition to haemodynamic stability it confers a distinctive and advantageous quality of sedation: patients are tranquil but responsive to requests from attending staff. This review examines the pharmacological principles underlying the use of alpha2-adrenoceptor agonists as adjuncts to surgery and clinical experience in that indication.     

Effects of alpha2-adrenoceptor agonists on tetrodotoxin-resistant Na+ channels in rat dorsal root ganglion neurons

BACKGROUND AND OBJECTIVE: When intrathecally or epidurally administered, alpha2-adrenoceptor agonists produce potent antinociception by affecting the activity of primary afferent fibres and spinal cord neurons. Recent reports have indicated that in dorsal root ganglion neurons, tetrodotoxin-resistant Na+ channels play important roles in the conduction of nociceptive sensation. We therefore investigated the effects of alpha2-adrenoceptor agonists on tetrodotoxin-resistant Na+ currents. METHODS: Using the whole-cell patch-clamp technique, we recorded tetrodotoxin-resistant Na+ currents from rat dorsal root ganglion neurons. RESULTS: Both clonidine and dexmedetomidine reduced the peak amplitude of the tetrodotoxin-resistant Na+ current concentration- and use-dependently. The concentration required for a half-maximal effect was significantly lower for dexmedetomidine (58.0 +/- 10.2 micromol) than for clonidine (257.2 +/- 30.9 micromol) at holding potential -70 mV. The current inhibitions induced by these agonists were not prevented by 1 micromol yohimbine, an alpha2-adrenoceptor antagonist. Both clonidine and dexmedetomidine shifted the inactivation curve for the tetrodotoxin-resistant Na+ current in the hyperpolarizing direction. The combinations clonidine with lidocaine and dexmedetomidine with lidocaine produced an additive blockade-type interaction on the tetrodotoxin-resistant Na+ current. CONCLUSIONS: The results suggest that a direct inhibition of tetrodotoxin-resistant Na+ channels may contribute to the antinociceptive effects of clonidine and dexmedetomidine when used as additives to regional anaesthesia.     

Treatment of spinal cord compression by epidural malignancy in childhood

Epidural spinal cord compression by a malignant tumor is a rare occurrence in children. Both the tumors involved and the extent of involvement of the vertebral column are different in children and adults. Often, the epidural tumor in a child is identified before significant spinal canal compromise has occurred, and these children frequently can be managed by radiation therapy and/or chemotherapy. There is a group of children, however, who have severe spinal canal encroachment by a tumor, as evidenced by a near complete or complete block on myelography. In this study, we report a group of patients with severe spinal cord compression, as documented by imaging studies. We compared the results of a decompressive laminectomy and subtotal tumor resection followed by adjuvant therapy with the results obtained with radiation therapy and/or chemotherapy alone. Thirty-three patients met the criteria for inclusion in the study. Twenty-six were treated with a laminectomy and adjuvant therapy, and 7 were treated without surgical intervention. With surgical therapy, 25 of 26 epidurals were either improved or stable, whereas 4 of 7 nonsurgical patients deteriorated. Especially notable was a decrease in pain in the operative patients immediately after their procedure. There was no surgical mortality or morbidity. The results of this study indicate that children with severe spinal cord compression as evidenced by a near complete or complete block on myelography or filling of 50% or more of the spinal canal on magnetic resonance imaging are best treated by a combination of surgical decompression and tumor removal followed by adjuvant therapy.     

A simple and reproducible model of spinal cord injury induced by epidural balloon inflation in the rat.

This paper describes a modification of a balloon-compression technique to produce spinal cord injury in adult rats. A 2-French Fogarty catheter is inserted into the dorsal epidural space through a small hole made in T10 vertebral arch, advanced cranially to T8-9 spinal level, and inflated for 5 min. Spinal cord damage is graded by increasing the volume of saline used to inflate the balloon. Quantitative neurological and histopathological outcomes are presented with three different volumes (10, 15, and 20 microl of saline) to characterize the gradation of injury. Volume of 15 microl produced complete paraplegia followed by gradual recovery, finally reaching approximately the middle of the scale used to quantitate the locomotor performance. With these animals, after 4 weeks, the center of the lesion shows complete loss of grey matter and partial sparing of the white matter. We conclude that 15 microl volume produced submaximal injury that will be useful for studying the pathophysiology and effects of protective therapies with this compression-injury model.     

Morphine tolerance increases [3H]MK-801 binding affinity and constitutive neuronal nitric oxide synthase expression in rat spinal cord

N-Methyl-D-aspartate (NMDA) receptor antagonists and nitricoxide synthase (NOS) inhibitors inhibit morphine tolerance.In the present study, a lumbar subarachnoid polyethylene (PE₁₀)catheter was implanted for drug administration to study alterationsin NMDA receptor activity and NOS protein expression in a morphine-tolerantrat spinal model. Antinociceptive tolerance was induced by intrathecal(i.t.) morphine infusion (10 µg h^–1) for 5 days.Co-administered (+)-5-methyl-10,11-dihydro-⁵H-dibenzo[a,d]cyclohepten-5,10-iminemaleate (MK-801) (10 µg h^–1 i.t.) with morphinewas used to inhibit the development of morphine tolerance. Lumbarspinal cord segments were removed and prepared for [³H]MK-801binding assays and NOS western blotting. The binding affinityof [³H]MK-801 was higher in spinal cords of morphine-tolerantrats (mean (SEM) K_D=0.41 (0.09) nM) than in control rats (1.50(0.13) nM). There was no difference in B_max. Western blot analysisshowed that constitutive expression of neuronal NOS (nNOS) proteinin the morphine-tolerant group was twice that in the controlgroup. This up-regulation was partially prevented by MK-801.The results suggest that morphine tolerance affects NMDA receptorbinding activity and increases nNOS expression in the rat spinalcord. Br J Anaesth 2000; 85: 587–91 ^* Corresponding author     

脊髓α2-肾上腺素能受体在异丙酚抗大鼠内脏性伤害刺激中的作用

目的 探讨脊髓α2-肾上腺素能受体在异丙酚抗大鼠内脏性伤害刺激中的作用.方法 雄性成年大鼠,进行蛛网膜下腔置管,3～5 d后鞘内置管成功的28只大鼠于结直肠放置气囊,随机分为4组(n=7),Ⅰ组和Ⅱ组鞘内注射生理盐水(NS)10μl后10 min,分别腹腔注射NS 0.5ml或异丙酚10 mgkg;Ⅲ组和Ⅳ组鞘内注射育亨宾15μg后10 min,分别腹腔注射NS 0.5 ml或异丙酚10 mg/kg.分别于鞘内给药前及注射异丙酚后5、10、15、20、25、30、40和60 min时进行气囊充气,测定内脏痛阈,计算最大镇痛效应百分率(MPE).结果 与Ⅰ组比较,Ⅱ组和Ⅳ组MPE升高(P<0.05或0.01);与Ⅱ组比较,Ⅳ组MPE降低(P<0.01).结论 脊髓α2-肾上腺素能受体激活参与了异丙酚抗大鼠内脏性伤害刺激反应.     

Nitrous oxide decreases substance P receptor binding in the rat spinal cord

Synaptic transmission of substance P (SP) in the spinal cord during nitrous oxide (N2O) exposure was examined in rats. In the analgesia study, 75% N2O significantly increased tail-flick latency by 57% during the first 2-h N2O exposure and by 19% after a second 2-h N2O exposure, suggesting development of acute tolerance. In the SP content study, SP in the dorsal part of the spinal cord significantly increased by 120% at the end of first N2O exposure, but returned to the control level by the end of second N2O exposure. In the receptor binding study, N2O significantly decreased the [I]Bolton-Hunter-SP ([I]BH-SP) binding (SP-P) in laminae I-II of the dorsal horn by 19, 18, and 18% at the end of first N2O exposure, at the end of the second N2O exposure, and at 4 h after the second N2O exposure, respectively, as compared to the control. This decrease in the [I]BH-SP binding became statistically insignificant by 12 h after the second N2O exposure. In contrast, [I]Bolton-Hunter-eledoisin binding (SP-E) remained unchanged. In the equilibrium binding study, the number of SP-P receptor (Bmax) in laminae I-II of the dorsal horn significantly decreased by 24, 38, and 30% at the end of the first and at the end of the second N2O exposure, and at 4 h after the second N2O exposure, respectively, without significant changes in the affinity (Ka). The present study demonstrated that tolerance to N2O analgesia occurred during the two repeated N2O exposures. SP receptor binding decreased and remained decreased 4 h after discontinuation of N2O. This evidence is the first demonstration of the functional changes caused by N2O in SP synaptic transmission of the spinal cord.     

Meperidine exerts agonist activity at the alpha(2B)-adrenoceptor subtype

BACKGROUND: The opioid agonist meperidine has actions, such as antishivering, that are more pronounced than those of other opioid agonists and that are not blocked with nonselective opioid antagonists. Agonists at the alpha(2) adrenoceptors, such as clonidine, are very effective antishivering drugs. Preliminary evidence also indicates that meperidine interacts with alpha(2) adrenoceptors. The authors therefore studied the ability of meperidine to bind and activate each of the alpha(2)-adrenoceptor subtypes in a transfected cell system. METHODS: The ability of meperidine to bind to and inhibit forskolin-stimulated cyclic adenosine monophosphate formation as mediated by the three alpha(2)-adrenoceptor subtypes transiently transfected into COS-7 cells has been tested. The ability of the opioid antagonist naloxone and the alpha(2)-adrenoceptor antagonists yohimbine and RX821002 to block the analgesic action of meperidine in the hot-plate test was also assessed. The ability of meperidine to fit into the alpha(2B) adrenoceptor was assessed using molecular modeling techniques. RESULTS: Meperidine bound to all alpha2-adrenoceptor subtypes, with alpha(2B) having the highest affinity (alpha(2B), 8.6 +/- 0.3 microm; alpha(2C), 13.6 +/- 1.5 microm, P < 0.05; alpha(2A), 38.6 +/- 0.7 microm). Morphine was ineffective at binding to any of the receptor subtypes. Meperidine inhibited the production of forskolin-stimulated cyclic adenosine monophosphate mediated by all receptor subtypes but was most effective at the alpha(2B) adrenoceptor (alpha(2B), 0.6 microm; alpha(2A), 1.3 mm; alpha(2C), 0.3 mm), reaching the same level of inhibition (approximately 70%) as achieved with the alpha2-adrenoceptor agonist dexmedetomidine. The analgesic action of meperidine was blocked by naloxone but not by the alpha 2-adrenoceptor antagonists yohimbine and RX821002. The modeling studies demonstrated that meperidine can fit into the alpha(2B)-adrenoceptor subtype. CONCLUSION: Meperidine is a potent agonist at the alpha2 adrenoceptors at its clinically relevant concentrations, especially at the alpha(2B)-adrenoceptor subtype. Activation of the alpha(2B) receptor does not contribute significantly to the analgesic action of meperidine. This raises the possibility that some of its actions, such as antishivering, are transduced by this mechanism.     

Antinociceptive interactions between alpha 2-adrenergic and opiate agonists at the spinal level in rodents

This study was undertaken to evaluate the antinociceptive interactions of alpha 2 adrenergic and opiate receptors at the spinal level. Morphine and clonidine were administered intrathecally (i.t.) by lumbar puncture to rats either alone or in the presence of either i.t. yohimbine, an alpha 2 antagonist, or systemic naloxone, an opioid antagonist. The effect of tolerance to systematically administered morphine on responses to i.t. morphine and clonidine was examined in mice. Antinociception was determined by observing the response to a clamp applied to the tail (Haffner test) in mice and by the tail-flick test in rats; log dose-response curves for antinociception were generated for morphine, clonidine, and each drug combination. Morphine and clonidine both produced dose-dependent antinociception when given i.t. in both species. The i.t. administration of yohimbine attenuated the antinociceptive effect of both clonidine and morphine, but naloxone attenuated only the response to morphine. Further, a sub-analgetic dose of i.t. clonidine potentiated the effect of i.t. morphine. In morphine-tolerant mice, i.t. morphine was not efficacious whereas clonidine retained full efficacy, although potency was slightly diminished. Thus, it appears that alpha 2 adrenoceptor-mediated antinociception is independent of opiate receptor mechanisms. Clinical use of intrathecal combinations of alpha 2 adrenergic and opiate receptor agonists to increase analgesia and use of intrathecal alpha 2 agonists for pain relief in patients tolerant to opiates might deserve evaluation.