2014B05 Describe the physiology of pain pathways and how drugs may modulate the perception of pain.

 

List:

·         Nociceptive receptor

·         Primary afferent

·         Secondary afferent and tracts

·         Tertiary afferent and above

·         Descending modulation

 

Nociceptive receptor:

Physiology

·   Free nerve ending on 1° afferent in periphery

·   Activated by mechanical, thermal, chemical insults

·   Sensitised by inflammation

·   Ionotropic and metabotropic

Pharmacology

·   Local anaesthetic (LA): inhibits VDNaC

·   NSAID: inhibits prostaglandin-induced receptor sensitisation and activation

 

Primary afferent (nociceptor):

Physiology

·   From periphery -> dorsal horn, with cell body in dorsal root ganglion

·   Ascent or descent 1-2 levels via Lissauer’s tract

·   Aδ fibre -> layer 1: sharp, fast, well localized. Release glutamate. Synapse at superficial layers.

·   C fibre -> layer 2: dull, slow, poorly localized. Release glutamate, substance P. Synapse at deeper layers.

·   Silent nociceptor: conveys pain only when sensitized

Pharmacology

·   Paracetamol: inhibits bradykinin-sensitive nociceptors

·   Regional LA (nerve, plexus): inhibits axonal VDNaC

·   Pre-synaptic inhibition:

o Neuraxial LA: VdNaC at dorsal root ganglion, spinal nerve root

o Opioid

o Noradrenaline and serotonin reuptake inihbitors

o Gabapentinoids: antagonists at synaptic VdCC α2δ subunit

o Cannabinoids: at own receptor

 

Secondary afferent and tracts:

Physiology: cell

·   Nociceptive-specific: superficial layers, variable threshold

·   Wide dynamic range: deeper layers, high threshold, only when sensitized

·   Note also interneurons: excitatory and inhibitory

·   Note inhibitory afferents: e.g. Aβ conveying light touch

Physiology: tracts

·   Decussation in anterior commissure

·   Ascent in spinothalamic tracts

o Neo-STT: to thalamus (VPL nucleus)

o Paleo-/archi-STT: to brainstem

Pharmacology

·   Post-synaptic inhibition:

o NMDA antagonist: ketamine, N2O, Xe, Mg2+, tramadol, methadone

 

Tertiary afferents and above

Physiology:

·   VPL thalamus -> primary somatosensory cortex (localisation)

·   Brainstem -> medial thalamus, hypothalamus, amygdala (affective, autonomic)

Pharmacology

·   NMDA antagonist (as above) -> thalamocortical dissociation

·   Paracetamol: COX-3 inhibition

·   General anaesthetics: inhibit brainstem ARAS -> no perception

 

Descending modulation:

Physiology

·   Pathway: PAG or RVM -> dorsal horn via Lissauer’s tract

·   Mediators: noradrenaline -> serotonin

·   Effect: inhibit 1° afferent (pre-synaptic) and 2° afferent (post-synaptic)

Pharmacology

·   Opioids: ↓activity of OFF cell -> ↓Inhibition of ON cell

·   Noradrenaline reuptake inhibition: ketamine, tramadol, tapentadol, NRI

·   Serotonin reuptake inhibition: tramadol, SSRI

·   Dorsal horn α2 agonism: clonidine, dexmedetomidine

 

 

 

Feedback welcome at ketaminenightmares@gmail.com