GABA and central neuropathic pain following spinal cord injury

Spinal cord injury induces maladaptive synaptic transmission in the somatosensory system that results in chronic central neuropathic pain. Recent literature suggests that glial-neuronal interactions are important modulators in synaptic transmission following spinal cord injury. Neuronal hyperexcitability is one of the predominant phenomenon caused by maladaptive synaptic transmission via altered glial-neuronal interactions after spinal cord injury. In the somatosensory system, spinal inhibitory neurons counter balance the enhanced synaptic transmission from peripheral input. For a decade, the literature suggests that hypofunction of GABAergic inhibitory tone is an important factor in the enhanced synaptic transmission that often results in neuronal hyperexcitability in dorsal horn neurons following spinal cord injury. Neurons and glial cells synergistically control intracellular chloride ion gradients via modulation of chloride transporters, extracellular glutamate and GABA concentrations via uptake mechanisms. Thus, the intracellular “GABA-glutamate-glutamine cycle” is maintained for normal physiological homeostasis. However, hyperexcitable neurons and glial activation after spinal cord injury disrupts the balance of chloride ions, glutamate and GABA distribution in the spinal dorsal horn and results in chronic neuropathic pain. In this review, we address spinal cord injury induced mechanisms in hypofunction of GABAergic tone that results in chronic central neuropathic pain.This article is part of a Special Issue entitled ‘Synaptic Plasticity & Interneurons’.     

Pharmacological management of neuropathic pain

In health, the nervous system exists in a balance between inhibitory and excitatory influences. This balance may be upset if neural tissue is damaged or irritated and may give rise to neuropathic pain. Such neuropathic pain does not respond consistently to opioid analgesics or NSAIDs and it may therefore be necessary to utilise other therapeutic agents with known activity on either the excitatory or inhibitory components of the pain pathway. These other agents are traditionally considered with reference to their original uses; we still refer to tricyclic antidepressants (TCAs) and anticonvulsant drugs when a consideration of their modes of action may allow more rational use. For example, carbamazepine is related to the TCAs by virtue of its chemical structure and proposed mode of action and yet is still classified as an anticonvulsant drug. With respect to the opioids, increasing evidence points to an analgesic effect in neuropathic pain, although concerns regarding tolerance and dependence still prevent more widespread use. The anticonvulsants comprise a group of compounds possessing anticonvulsant and analgesic properties, but each possesses differing modes of action and so several members of the class should be tried before a conclusion is reached that they, as a whole, are ineffective. TCAs may also have a role in the treatment of neuropathic pain. As with all drugs, if their use is not associated with pain relief in a defined period of time, their use should be terminated. Topical TCAs may also have a role where the area of neuropathic pain is small. Other options, such as SSRIs, membrane stabilisers, capsaicin, baclofen and clonidine may have potential in treating neuropathic pain. The available evidence regarding the efficacy of currently available agents for the treatment of neuropathic pain is sparse. With the knowledge of achieving analgesia, according to the modes of actions of various agents it is hoped that the treatment of this difficult condition may be more logical and successful.     

Antinociceptive effect of ambroxol in rats with neuropathic spinal cord injury pain

Symptoms of neuropathic spinal cord injury (SCI) pain include evoked cutaneous hypersensitivity and spontaneous pain, which can be present below the level of the injury. Adverse side-effects obtained with currently available analgesics complicate effective pain management in SCI patients. Voltage-gated Na⁺ channels expressed in primary afferent nociceptors have been identified to mediate persistent hyperexcitability in dorsal root ganglia (DRG) neurons, which in part underlies the symptoms of nerve injury-induced pain. Ambroxol has previously demonstrated antinociceptive effects in rat chronic pain models and has also shown to potently block Na⁺ channel current in DRG neurons. Ambroxol was tested in rats that underwent a mid-thoracic spinal cord compression injury. Injured rats demonstrated robust hind paw (below-level) heat and mechanical hypersensitivity. Orally administered ambroxol significantly attenuated below-level hypersensitivity at doses that did not affect performance on the rotarod test. Intrathecal injection of ambroxol did not ameliorate below-level hypersensitivity. The current data suggest that ambroxol could be effective for clinical neuropathic SCI pain. Furthermore, the data suggest that peripherally expressed Na⁺ channels could lend themselves as targets for the development of pharmacotherapies for SCI pain.     

Cannabinoid receptor-mediated antinociception with acetaminophen drug combinations in rats with neuropathic spinal cord injury pain

Pre-clinical evidence demonstrates that neuropathic spinal cord injury (SCI) pain is maintained by a number of neurobiological mechanisms, suggesting that treatments directed at several pain-related targets may be more advantageous compared to a treatment focused on a single target. The current study evaluated the efficacy of the non-opiate analgesic acetaminophen, which has several putative analgesic mechanisms, combined with analgesic drugs used to treat neuropathic pain in a rat model of below-level neuropathic SCI pain. Following an acute compression of the mid-thoracic spinal cord, rats exhibited robust hind paw hypersensitivity to innocuous mechanical stimulation. Fifty percent antinociceptive doses of gabapentin, morphine, tramadol or memantine were combined with an ineffective dose of acetaminophen; acetaminophen alone was not antinociceptive. The combination of acetaminophen with either tramadol or memantine resulted in an additive antinociceptive effect. Acetaminophen combined with either morphine or gabapentin, however, resulted in supra-additive (synergistic) efficacy. One of the analgesic mechanisms of acetaminophen is inhibiting the uptake of endocannabinoids from the extracellular space. Pre-treatment with AM251, a cannabinoid-1 receptor (CB1) antagonist, significantly diminished the antinociceptive effect of the acetaminophen + gabapentin combination. Pre-treatment with AM630, a cannabinoid-2 receptor (CB2) antagonist, did not have an effect on this combination. By contrast, both AM251 and AM630 reduced the efficacy of the acetaminophen + morphine combination. None of the active drugs alone were affected by either CB receptor antagonist. The results imply that modulation of the endocannabinoid system in addition to other mechanisms mediate the synergistic antinociceptive effects of acetaminophen combinations. Despite the presence of a cannabinoid mechanism, synergism was not present in all acetaminophen combinations. The combination of currently available drugs may be an appropriate option in ameliorating neuropathic SCI pain if single drug therapy is ineffective.     

Pharmacological characterization of the chronic constriction injury model of neuropathic pain

The chronic constriction injury model is a rat model of neuropathic pain based on a unilateral loose ligation of the sciatic nerve. The aim of the present study was to test its sensitivity to various clinically validated and experimental drugs. Mechanical allodynia and thermal hyperalgesia developed within one week post-surgery and were reliably present for at least 7 weeks. Mechanical allodynia was strongly attenuated by morphine (minimal effective dose in brackets: 8 mg/kg, p.o.) and the cannabinoids Delta9-tetrahydrocannabinol (3 mg/kg, p.o.) and (-)-cis-3-[2-hydroxy-4(1,1-dimethylheptyl)phenyl]-trans-4-(3-hydroxypropyl) cyclohexanol (CP 55,940; 0.05 mg/kg, i.p.), and weakly/moderately attenuated by the anticonvulsants gabapentin (50 mg/kg, i.p.) and carbamazepine (32 mg/kg, i.p.), the muscle relaxant baclofen (3 mg/kg, i.p.), and the adenosine kinase inhibitor 4-amino-5-(3-bromophenyl)-7-(6-morpholino-pyridin-3-yl)pyrido[2,3-d]pyrimidine (ABT-702; 30 mg/kg, i.p.). Thermal hyperalgesia was strongly attenuated by morphine (16 mg/kg, p.o.), Delta9-tetrahydrocannabinol (6 mg/kg, p.o.), CP 55,940 (0.025 mg/kg, i.p.), carbamazepine (32 mg/kg, i.p.) and the antidepressant amitriptyline (32 mg/kg, p.o.), and weakly/moderately attenuated by gabapentin (50 mg/kg, i.p.), the anti-inflammatory cyclooxygenase-2 inhibitor rofecoxib (30 mg/kg, i.p.) and the adenosine A1 receptor positive allosteric modulator 2-amino-4,5,6,7-tetrahydrobenzo(b)thiophen-3-yl 4-chlorophenylmethanone (T62; 30 mg/kg, i.p.). Both symptoms were hardly or not affected by the nonselective N-methyl-d-aspartate receptor antagonists ketamine and dizocilpine, and the N-methyl-d-aspartate receptor NR2B-selective antagonists ifenprodil and R-(R*,S*)-alpha-(4-hydroxyphenyl)-beta-methyl-4-(phenyl-methyl)-1-piperidine propranol (Ro 25-6981). The finding that mechanical allodynia and/or thermal hyperalgesia are attenuated by various established compounds further supports the validity of the chronic constriction injury model for the study of neuropathic pain and its use for the identification of novel treatments.     

Non-surgical management of spinal cord injury

Spinal cord injury remains a devastating neurological condition with limited therapeutic opportunities. Since decompressive surgery and high-dose methylprednisolone have limited utility for most patients, spinal cord injury clearly represents a major medical challenge. Experimental evidence has suggested that secondary cellular injury processes may be a realistic target for therapeutic intervention with the goal of inhibiting the progression of detrimental changes that normally follows traumatic injury to the cord. Preventing or reducing this delayed cellular injury may alone improve neurological recovery or facilitate future regenerative approaches to the injured cord. This review summarises recent advances in the development of pharmacological agents targeting the acute phase of spinal cord injury as well as potential strategies to facilitate regeneration of the spinal cord.     

Pharmacological treatment of diabetic neuropathic pain

Neuropathic pain continues to be a difficult and challenging clinical issue to deal with effectively. Painful diabetic polyneuropathy is a complex pain condition that occurs with reasonable frequency in the population and it may be extremely difficult for clinicians to provide patients with effective analgesia. Chronic neuropathic pain may occur in approximately one of every four diabetic patients. The pain may be described as burning or a deep-seated ache with sporadic paroxysms of lancinating painful exacerbations. The pain is often constant, moderate to severe in intensity, usually primarily involves the feet and generally tends to worsen at night. Treatment may be multimodal but largely involves pharmacological approaches. Pharmacological therapeutic options include antidepressants (tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors), α2δ ligands and topical (5%) lidocaine patch. Other agents may be different antiepileptic drugs (carbamazepine, lamotrigine, topiramate), topical capsaicin, tramadol and other opioids. Progress continues with respect to understanding various mechanisms that may contribute to painful diabetic neuropathy. Agents that may hold some promise include neurotrophic factors, growth factors, immunomodulators, gene therapy and poly (adenosine diphosphate-ribose) polymerase inhibitors. It is hoped that in the future clinicians will be able to assess patient pathophysiology, which may help them to match optimal therapeutic agents to target individual patient aberrant mechanisms.     

Pharmacological strategies in relieving neuropathic pain

The pharmacological treatment of neuropathic pain relies, to a large extent, on drugs belonging to a small number of defined classes. Opioids, tricyclic antidepressants, antiepileptic drugs and membrane stabilisers form the current basis of treatment. Varying levels of evidence support the use of individual members of these classes and overall show no indication that one class of drug, or individual drug has universal effectiveness. More refined knowledge of the modes of action of these agents used to treat neuropathic pain should lead to a more logical approach to the management of this difficult series of conditions. A number of drugs currently licensed for a different indication have recently had an analgesic effect in neuropathic pain attributed to them. In addition, a number of novel compounds are undergoing investigation and provide hope of dicovering more efficacious treatment options in the future.     

Pharmacological strategies in relieving neuropathic pain

The pharmacological treatment of neuropathic pain relies, to a large extent, on drugs belonging to a small number of defined classes. Opioids, tricyclic antidepressants, antiepileptic drugs and membrane stabilisers form the current basis of treatment. Varying levels of evidence support the use of individual members of these classes and overall show no indication that one class of drug, or individual drug has universal effectiveness. More refined knowledge of the modes of action of these agents used to treat neuropathic pain should lead to a more logical approach to the management of this difficult series of conditions. A number of drugs currently licensed for a different indication have recently had an analgesic effect in neuropathic pain attributed to them. In addition, a number of novel compounds are undergoing investigation and provide hope of dicovering more efficacious treatment options in the future.     

阿米替林对神经病理性疼痛大鼠脊髓GLAST的影响

目的观察阿米替林对SNI大鼠脊髓谷氨酸-天冬氨酸转运体(GLAST)表达影响。方法60只♂SD大鼠,分为空白对照组(A)、SNI模型组(B)、阿米替林(AMI)注射对照组(C)、SNI模型+AMI治疗组(D),经腹腔分别给予0.2ml生理盐水(A、B)、10mg.kg-1AMI(C和D),每日两次。术后1、3、5d取各组大鼠L3~L6脊髓,分别检测GLAST的蛋白和mRNA表达改变,同时观察机械缩足反射阈值(mechanical withdrawal threshold,MWT)改变。结果与对照组相比,B组大鼠MWT随时间明显下降,GLAST蛋白和mRNA表达先增加再降低,C组大鼠MWT无改变,但是GLAST蛋白和mRNA表达随时间逐渐增加,D组大鼠MWT给药后3d停止下降,GLAST蛋白和mRNA表达明显增高,但不随时间变化。结论阿米替林可以增加GLAST蛋白表达,可能是治疗神经病理性疼痛的机制之一。     

Pharmacological sensitivity and gene expression analysis of the tibial nerve injury model of neuropathic pain

The tibial nerve injury model is a novel, surgically uncomplicated, rat model of neuropathic pain based on a unilateral transection (neurotomy) of the tibial branch of the sciatic nerve. The aim of the present study was to describe some behavioral and molecular features of the model, and to test its sensitivity to a number of drugs which are currently used for the treatment of neuropathic pain. The model was characterized by a pronounced mechanical allodynia which was present in all subjects and a less robust thermal hyperalgesia. Mechanical allodynia developed within 2 weeks post-surgery and was reliably present for at least 9 weeks. Neurotomized rats showed no autotomy and their body weight developed normally. Gene expression in ipsilateral L5 dorsal root ganglia, analyzed by quantitative polymerase chain reaction (PCR), showed a pronounced up-regulation of galanin and vasointestinal peptide (VIP). This up-regulation developed rapidly (within 1 to 2 days following neurotomy) and remained present for at least 12 days. On the other hand, expression of calcitonin gene-related peptide (CGRP) and substance P mRNA was down-regulated 12 days following neurotomy. Mechanical allodynia was completely reversed by morphine [minimal effective dose (MED): 8 mg/kg, i.p.] and partially reversed by carbamazepine (MED: 64 mg/kg, i.p.), baclofen (MED: 3 mg/kg, i.p.) and amitriptyline (trend for efficacy at 32 mg/kg, i.p.), but not by gabapentin (50-100 mg/kg, i.p.). The finding that the tibial nerve injury model shows a robust and persistent mechanical allodynia which is sensitive to a number of established analgesics, as well as a gene expression profile which is compatible with that obtained in other models of neuropathic pain, further supports its validity as a reliable and surgically uncomplicated model for the study of neuropathic pain.     

脊髓p38MAPK在大鼠背根节慢性压迫神经病理性疼痛中的作用

目的观察背根节慢性压迫(chronic compression of dorsal root ganglion,CCD)痛大鼠脊髓p-p38MAPK表达的变化,探讨p38MAPK与慢性神经病理性痛的相关性。方法♂SD大鼠36只,随机分为正常组(Naive组,n=4)、假手术组(Sham组,n=16)和背根节慢性压迫组(CCD组,n=16),Sham组和CCD组又分别分为5,7,14d和21d4个亚组(n=4),分别用免疫印迹法(Westernblot)检测各组大鼠脊髓磷酸化p38丝裂原活化蛋白激酶(p-p38MAPK)表达的变化。结果3组大鼠脊髓均见p-p38MAPK蛋白表达。Naive组和Sham组间比较差异无统计学意义。CCD组大鼠脊髓p-p38MAPK蛋白表达较Naive组和Sham组明显增多;与Sham组相比,CCD后5,7,14,21d各组大鼠脊髓背角神经元胞质p-p38MAPK蛋白分别增加了138·1%(P<0·01)、184·3%(P<0·01)、247·4%(P<0·01)和90·4%(P<0·05)。胞核p-p38MAPK蛋白分别增加了167·3%(P<0·01)、177·8%(P<0·01)、262·7%(P<0·01)和72·7%(P<0·05)。结论在CCD大鼠模型中,脊髓p38MAPK的活化与背根节慢性压迫致神经病理性痛的形成和发展存在密切联系。     

Buprenorphine alleviates neuropathic pain-like behaviors in rats after spinal cord and peripheral nerve injury

We have studied and compared the antinociceptive and anti-hyperalgesic effect of the partial opioid receptor agonist buprenorphine in normal and neuropathic rats. In normal rats, systemic buprenorphine produced dose-dependent antinociception on the hot plate test. In rats with peripheral nerve or spinal cord injury, buprenorphine markedly alleviated neuropathic pain-related behaviors, including mechanical and cold allodynia/hyperalgesia at doses comparable to that producing antinociception. The results suggest that buprenorphine may be a useful analgesic for treating neuropathic pain and thus is an atypical opioid since morphine tends to be less potent after nerve injury.     

Pharmacologic management of diabetic peripheral neuropathic pain

Introduction: Diabetic peripheral neuropathic pain (DPNP) is a debilitating and distressing complication that occurs in patients with diabetes mellitus. This article provides an overview of diabetic peripheral neuropathy focusing on DPNP.

Areas covered: This article reviews the diagnosis, pathogenesis, prevention and treatment of diabetic neuropathy and neuropathic pain. A comprehensive and systematic Medline search of the published literature for treatment of diabetic peripheral neuropathy was done from 1965 to December 2012. Studies not in English language were excluded.

Expert opinion: Neuropathic pain is difficult to treat, and patients rarely experience complete pain relief. Despite several pharmacological agents being used in the treatment of DPNP, only duloxetine and pregabalin have evidence-based support for controlling DPNP.     

Promising pharmacological agents in the management of acute spinal cord injury

The search for a pharmacologic treatment of acute spinal cord injury (SCI) dates back to the 1960s. It was not until 1990 that the pharmacologic agent methylprednisolone demonstrated improved outcomes in humans. Methylprednisolone has shown superiority to placebo in humans in two large, multicenter trials, and is the standard of care thus far. Other potentially useful agents include tirilazad, ganglioside (GM-1), and naloxone. Additional studies are needed for these agents to determine the optimal dose and timing of administration.     

Role of reactive oxygen species and spinal cord apoptotic genes in the development of neuropathic pain.

A mouse model of neuropathic pain consisting of chronic constriction injury (CCI) of the sciatic nerve was used to examine the involvement of reactive oxygen species (ROS) in early spinal cord pro-apoptotic gene over-expression during the development of neuropathic pain. RT-PCR analysis showed increased expression of bax, apoptotic protease-activating factor-1 (apaf-1), and caspase-9 in the dorsal horn spinal cord 3 days after chronic constriction injury of sciatic nerve. Consistent with biomolecular data, a marked increase in TUNEL-positive and caspase-3 active form was observed by 3 days CCI. Administration of phenyl-N-tert-butylnitrone (PBN), a potent ROS scavenger, reduced the development of thermal hyperalgesia and mechanical allodynia at 1 and 3 days post-CCI, and decreased the mRNA levels of bax, apaf-1, and caspase-9. PBN also reduced apoptotic and active Caspase-3 positive profiles in the superficial laminae (I-III) of the spinal cord. This study provides evidence that PBN inhibits over-expression of pro-apoptotic genes and neural apoptosis in the spinal cord dorsal horn induced by early-CCI of the sciatic nerve. These findings suggest that ROS regulate expression of some apoptotic genes which might play a role in the onset of neuropathic pain.