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Minimally invasive injection therapy is an effective approach for the treatment of sciatica with less complications. This therapy is a sufficient option in cases without absolute indications for operation.The paper describes in detail the different injection techniques like spinal nerve analgesia, epidural dorsal/perineural injections, vertebral joint infiltrations, and radiculographies.
Numerous neurotransmitters are involved in nociceptive transmission or regulation. Several reports have shown the analgesic effects of somatostatin and its analogues. Somatostatin, when given intrathecally, markedly reduced pain in cancer patients. Somatostatin analogues that possess a longer half-life time are more convenient for therapeutic use. Vapreotide, a somatostatin analogue, was shown to induce a long-lasting antinociceptive effect in rats. We studied the site and the mechanism of action of vapreotide in rats using the paw pressure test. Intrathecal administration of vapreotide induced no antinociception. Systemically administered vapreotide-induced antinociception was inhibited by several intrathecal (i.t.) administered antagonists (yohimbine, naloxone and to a lesser degree tropisetron). These results show a lack of spinal effect and suggest a supraspinal site of action with an involvement of noradrenergic and to a lesser degree serotonergic bulbospinal pathways. In addition, spinal opioid receptors also seen to be involved.
Orexins are neuropeptides located exclusively in neurons of the lateral hypothalamic area, which send projections to most monoaminergic nuclei, such as noradrenergic locus coeruleus, dopaminergic ventral tegmental areas, and histaminergic tuberomammillary nuclei. The present work was carried out to examine the role of orexins in nociception in mice. C57BL/6 mice were administered with orexin A and B intracerebroventricularly (i.c.v.), intrathecally (i.t.) and subcutaneously (s.c.) to reveal the sites of action of these peptides and to examine the pain thresholds using four kinds of nociceptive tasks. Orexins showed antinociceptive effects in all four types of assays for thermal (hot-plate, tail-flick, paw-withdrawal), mechanical (tail-pressure), chemical (formalin, capsaicin and abdominal stretch) nociceptions and nociceptin-induced behavioral responses, when administered i.c.v. or i.t., whereas the s.c. administration was ineffective. The antinociceptive effects of orexin A were more remarkable than those of orexin B. The i.c.v. administration of orexin A was as effective as, or more potent than the i.t. administration. The effects of orexin A were completely blocked by adenosine type 1 receptor antagonists, 1,3-dipropyl-8-cyclopentylxanthine (DPCPX) and theophylline, but not by naloxone, suggesting a possible involvement of the adenosine-containing neurons and/or the adenosine pathway in these orexin actions. The i.c.v. administration of nociceptin had no significant effects on orexin expression in the brain and spinal cord. The present findings suggest that orexins have an antinociceptive role in at least four different types of pains, probably acting on both the brain and spinal cord.
AIM: To analyze the mode of interaction of combined administration of intrathecal morphine with subcutaneous morphine or buprenorphine. METHODS: Different groups of rats were scheduled to undergo administration of intrathecal (ith) morphine, subcutaneous (s.c.) morphine, s.c. buprenorphine, and the combinations of ith morphine with s.c. morphine or buprenorphine in a series of dose ratios. Nociceptive responses of hind paws of each animal were measured by means of "plantar stimulation" test. The test latency was converted to the percent of maximal possible effect (% MPE). RESULT: Morphine ith, morphine s.c., buprenorphine s.c., as well as combinations in all dose ratios increased the % MPE in a dose-dependent manner. Isobolograms showed that the ED50 points determined for the combinations were plotted significantly left to the theoretical additive line. CONCLUSION: The combination of morphine ith with either morphine s.c. or buprenorphine s.c. resulted in a synergistic effect. This interaction might be due to the activation of the synergistic antinociceptive mechanisms between supraspinal and spinal levels.
We investigation the effect of injection speed on sensory blockade in spinal anesthesia. Forty two female patients, scheduled for total abdominal hysterectomy, were allocated randomly to 3 groups of 14 each according to the injection speed of 0.5% hyperbaric tetracaine: Group F (fast; injection speed > or = 0.2 ml.s-1), Group M (moderate; 0.1 < injection speed < 0.2 ml.s-1) and Group S (slow; injection speed < or = 0.1 ml.s-1). Spinal puncture was performed via the median approach at the L3-4 interspace with the patient in a lateral position. The maximum level of sensory blockade was assessed by means of the pin-prick method in the midline 3, 5, 10, 20, 30, 60 minutes after injection. In Group F, the level of sensory blockade became higher quickly (within 5 min), but anesthetic effects were not so satisfactory. And, in this group, there were more patients with dyspnea than in other groups. We speculate that the turbulence made by fast injection in subarachnoid space caused unsatisfactory effects. In Group S, anesthetic level was becoming higher also 20 or 30 min after injection. The fixation of anesthetics requires about 30 min. In our opinion, anesthetics injected slowly were diluted less by CSF, and the actual baricity of them was higher, and this made the difference within 30 min. In Group M, anesthetic effects and patient's condition were stable. We suppose that this injection speed (0.1-0.2 ml.s-1) is suitable for spinal anesthesia.
Participation of opiate, serotonergic and noradrenergic components in the antinociceptive action of intrathecally administered morphine was evaluated by measuring the ability of subcutaneously administered doses of naloxone, methysergide and phentolamine to alter analgesia. Morphine produced a dose-dependent elevation of the tail-flick latency, due exclusively to local spinal actions. For example, 10 nmol of the drug, when administered intrathecally in rats with bilateral lesions of the dorsolateral funiculus, produced an increase in the tail-flick latency, that was similar to that observed in intact animals. Furthermore, morphine was ineffective when administered intracerebroventricularly into the fourth ventricle of intact rats. The spinal antinociceptive action of the opiate was antagonized by naloxone (ID50 = 0.035 mg/kg, s.c.) but was also significantly attenuated by methysergide (ID50 = 4.28 mg/kg, s.c.). Phentolamine was ineffective. Doses of methysergide that were most effective in reversing the spinal action of morphine also produced hyperalgesia when administered alone. On the other hand, when the dorsolateral funiculus was lesioned, the hyperalgesia was no longer observed, yet the antagonist remained effective against morphine. These data suggested that the doses of methysergide needed to antagonize the action of morphine were in the same range as those needed to block the synaptic actions of serotonin (5-HT) released from the tonically-acting, descending pain inhibitory nerves. The results demonstrate that local opiate, as well as serotonergic, mechanisms mediate the antinociceptive action of morphine in the spinal cord. The recruitment of a serotonergic component may be related to an action of opiates within the spinal cord, to cause the release of serotonin from the terminal fields of the spinipetal serotonergic nerves.
Intracerebral injection of neurotensin into specific brain loci in rats produces hyperalgesia due to the release of cholecystokinin (CCK) in the spinal cord. The present purpose was to show in another species that neurotensin can antagonize the antinociceptive action of morphine through the spinal CCK mechanism in mice. Neurotensin given intracerebroventricularly (i.c.v.) at doses higher than 100 ng produced antinociception in the tail flick test. However, at lower doses between 1 pg to 25 ng, neurotensin antagonized the antinociceptive action of morphine given intrathecally (i.t.), thus demonstrating the antianalgesic activity of neurotensin. The rightward shift in the morphine dose-response curve produced by i.c.v. neurotensin was eliminated by an i.t. pretreatment with CCK8 antibody (5 microl of antiserum solution diluted 1:1000). I.t. administration of lorglumide, a CCK(A)-receptor antagonist (10-1000 ng), and PD135,158, a CCK(B)-receptor antagonist (250-500 ng), also eliminated the antianalgesic action of neurotensin. Thus, the mechanism of the antianalgesic action of neurotensin given i.c.v. involved spinal CCK. This mode of action is similar to that for the antianalgesic action of supraspinal pentobarbital which also involves spinal CCK.
UNLABELLED: We sought to analyze the mode of interaction of spinal morphine with systemic morphine or buprenorphine, administered in a wide range of antinociceptive doses. The study was performed on Sprague-Dawley rats by using a plantar stimulation test and isobolographic and fractional analyses of drug interaction. The isobolographic and fractional analyses demonstrated that intrathecal morphine interacted with subcutaneous morphine in a synergistic manner while producing a 50% or 75% antinociceptive effect. The sum of D(75) fractions was more than that for 50% antinociception, suggesting a less dramatic interaction. The combination with a maximal relative dose of systemic morphine (0.66:1) showed a maximal degree of supraadditivity. The interaction between spinal morphine and systemic buprenorphine was similar to that of morphine/morphine, although the supra-additivity was not as pronounced. For the doses that produced a 50% antinociceptive effect, a synergistic interaction was observed only for the combination with a morphine/buprenorphine ratio of 1.33:1. When the relative amount of intrathecal morphine was decreased or increased, the effect became additive. At the doses that produced 75% antinociception, both combinations of morphine and buprenorphine demonstrated supraadditive interaction. IMPLICATIONS: Spinal morphine interacts with systemic morphine or buprenorphine in asupraadditive manner. This mode of interaction most probably results from the simultaneous activation of spinal and supraspinal antinociceptive systems. Supraspinal structures played a more important role in the antinociceptive effect of experimental combinations than structures of the spinal cord.
OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center. PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline. Main outcome measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire. RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities. Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS, providing one third of our patient population with sustained relief and more than half with sustained improvement in function.
The antinociceptive effect of dipyrone, a nonsteroidal and inflammatory drug, was studied in a series of experiment employing tail-flick and hot-place models and the abdominal constrictor test. The drug was given via intracerebroventricular (i.c.v.), intrathecal (i.t.) or subcutaneous (s.c.) routes. Dipyrone exhibited no analgesic activity in the tail-flick and hotplate tests while it inhibited the number of stretches in a dose-dependent manner. The antinociceptive effect of dipyrone administered by the i.c.v. and i.t. routes was almost complete reversed by naloxone treatment. The same procedure attenuated but not completely inhibited the dipyrone action induced by s.c. administration. Histopathological examination revealed that i.t. dipyrone application produces no significant lesion in the spinal cord. The results suggest that dipyrone may exert a central antinociceptive action reversed by naloxone.
OBJECTIVE AND IMPORTANCE: Spinal epidural lipomatosis, which causes symptomatic compression of neural elements, is a well known but uncommon complication of Cushing's syndrome. Spinal epidural lipomatosis has been reported frequently in association with chronic systemic corticosteroid therapy, but thus far only one case has been attributed to local epidural corticosteroid injections. CLINICAL PRESENTATION: We report another case of symptomatic spinal epidural lipomatosis after epidural corticosteroid injections. This is the first such case documented by magnetic resonance imaging and confirmed with surgical exploration. INTERVENTION: The patient's symptoms of neurogenic claudication resolved after lumbar laminectomy in the region of previous corticosteroid injections and the removal of epidural fat, which was compressing the thecal sac. CONCLUSION: This case should alert clinicians that epidural lipomatosis, which causes symptomatic thecal sac compression, is a possible complication, not only of systemic glucocorticoid therapy, but also of local epidural corticosteroid injections.
The role of medullary and spinal 5-HT(1A) receptors in endogenous regulation of neuropathic hypersensitivity was studied. When administered in the rostroventromedial medulla or subcutaneously, WAY-100635, a 5-HT(1A) receptor antagonist, attenuated mechanical hypersensitivity in rats with a spinal nerve injury. Thermal or mechanical nociception outside of the injured area was not influenced by medial medullary or subcutaneous administration of WAY-100635. Intrathecal administration of WAY-100635 had no significant effect on pain-related behavior. Suppression of mechanical hypersensitivity induced by medial medullary administration of WAY-100635 was reversed by intrathecal administration of WAY-100635 or atipamezole, an alpha2-adrenoceptor antagonist, but not by naloxone, an opioid receptor antagonist. The results indicate that endogenous release of 5-HT, via action on medial medullary 5-HT(1A) receptors, tonically suppresses descending inhibition in neuropathic animals. Following medial medullary administration of a 5-HT(1A) receptor antagonist, descending pain regulatory pathways are disinhibited. This leads to selective attenuation of neuropathic hypersensitivity, due to action on spinal 5-HT(1A) receptors and alpha2-adrenoceptors.
The site of action involved in the suppression by exposure to footshock (FS)- and psychological (PSY)-stress of the development of antinociceptive tolerance to morphine has been investigated. Daily treatment with 10 mg/kg, s.c.; 3 micrograms, i.t.; and 5 micrograms, i.c.v. of morphine, regardless of the administration route, resulted in the development of tolerance. Daily exposure to FS- or PSY-stress suppressed the development of tolerance to s.c. and i.t. administered morphine but not that to i.c.v. administered morphine. Pretreatment with 2 mg/kg, i.p. of nor-binaltorphimine (nor-BNI) abolished the suppressive effect of PSY-stress on the development of tolerance to morphine given s.c. The suppression by PSY-stress was also antagonized by 2 micrograms, i.t. of nor-BNI and not by 2 micrograms, i.c.v. of nor-BNI. Thus, the development of tolerance in the spinal cord due to interaction of morphine at mu-opioid receptors can be suppressed by exposure to these stresses, probably through the descending signals from the supraspinal area, and activation of kappa-opioid receptors in the spinal cord could also participate in the suppression by PSY-stress.
Morphine antinociception after various administration routes was estimated by the tail-flick method in rats. The antinociceptive ED50 (AD50) values for i.c.v., i.t., i.c.v. + i.t. (4:1 dose ratio) and s.c. were 6.9 micrograms, 0.49 + 0.12 micrograms and 2.7 mg/kg, respectively. Isobolographic analysis of AD50 (except s.c.) suggested that concurrent administration of i.c.v. and i.t. morphine interacted multiplicatively to produce antinociception. Morphine content in the CNS after administration of AD50 morphine for each route was estimated. Isobolographic analysis of morphine content revealed that supraspinal and spinal morphine interacted multiplicatively to produce antinociception after i.c.v. + i.t. and s.c. administration. Comparison of the dose-response curves (i.c.v. alone, i.t. alone, various i.c.v. + fixed i.t., fixed i.c.v. + various i.t.) suggested that supraspinal and spinal morphine can potentiate the antinociception induced by the other site, and that they have almost equal importance in the antinociceptive synergism. These results provide direct evidence for the synergism between supraspinal and spinal morphine to play an important role in the antinociception of systemically administered morphine.
The site of action of the kappa opioid receptor agonist, U-50,488H in suppressing the development of tolerance to morphine antinociception was examined by local application, either intrathecal (i.t., spinal) or intracerebroventricular (i.c.v., supraspinal) in mice. Mice given morphine s.c., i.c.v. or i.t. daily developed tolerance regardless of the route. Co-administration of U-50,488H i.p. at a subanalgesic dose suppressed the development of tolerance to s.c. and i.t. administered morphine without affecting the antinociceptive effect of morphine. U-50,488H did not influence the development of tolerance to i.c.v. administered morphine. The antinociceptive effect of s.c. administered morphine was not affected by co-administration of U-50,488H given i.t. or i.c.v.; however, the development of tolerance to morphine was suppressed by i.t. but not i.c.v. administered U-50,488H. The suppressive effect of U-50,488H on the development of tolerance to morphine was abolished by pretreatment with nor-binaltorphimine (nor-BNI) given i.p. or i.t. Intracerebroventricularly administered nor-BNI failed to abolish the effect of U-50,488H. We suggest that U-50,488H suppresses the development of tolerance to morphine at the spinal level by interacting with kappa opioid receptors in this area.
A 64-year-old diabetic man underwent total maxillectomy with orbital exenteration because of recurrent carcinoma. In order to decrease pressure at the surgical site, 50 mL of cerebrospinal fluid were withdrawn. After the procedure was completed, 5% glutaraldehyde was inadvertently injected into the subarachnoid space instead of reinjection of the original cerebrospinal fluid. The patient suffered hypotension and coma culminating in death five days after the procedure. Postmortem examination revealed exquisite fixation of the outer cortical shell of the spinal cord and brain stem. The mishap occurred because an unlabeled vial was mistaken for the withdrawn cerebrospinal fluid. Graicunas' theory and formula on relationship complexities in organizations is exemplified by this occurrence. One may calculate the theoretical potential for 24,708 miscommunications during such a complex and lengthy surgical procedure. Proper operating room procedures must be developed and followed in order to prevent such tragedies.
A novel class of enteric neurons projecting directly from the rectal wall to the spinal cord, "rectospinal neurons", was investigated in rats by combined retrograde neuronal tracing, immunocytochemistry and electron microscopy. Rectospinal neurons were almost confined to myenteric ganglia of the distal rectum below the pelvic diaphragm and were labeled preferentially by injections into spinal cord segments L6/S1. Injections into more rostral spinal cord segments resulted in hardly any labeled enteric neurons. Dorsal and ventral rhizotomy experiments indicated an almost exclusive projection of rectospinal neurons through dorsal roots L6/S1 to the respective spinal cord segments. Among various peptides immunostained, vasoactive intestinal polypeptide and calcitonin gene-related peptide were selectively found in rectospinal neurons, which were also shown to contain calbindin, neurofilament protein- and peripherin-immunoreactivity. Vasoactive intestinal polypeptide- and calbindin-immunostaining were frequently co-localized in the same perikarya, while calcitonin gene-related peptide-immunoreactive rectospinal neurons probably represented a separate population. Neonatal capsaicin treatment did not significantly reduce the number of rectospinal neurons. Electron microscopy revealed synaptic contacts on the surface of rectospinal neurons. Taken together, these results establish rectospinal neurons as an anatomically and neurochemically distinct class of enteric neurons. Synaptic contacts on rectospinal neurons suggest that these neurons may function as a direct link from the enteric to the central nervous system, thus indicating that connections between these two networks are reciprocal.
The role of central (supraspinal and spinal) and peripheral alpha-adrenoceptors in the regulation of gastrointestinal propulsion in the mouse was studied using clonidine, an alpha 2-adrenoceptor agonist. Clonidine produced a dose-dependent inhibition of propulsion when given intracerebroventricularly, intrathecally, or subcutaneously, but was most potent when given intracerebroventricularly. The antitransit effects of centrally given clonidine were antagonized by intracerebroventricular (i.c.v.) yohimbine, but higher doses were required when this antagonist was given peripherally. Whereas i.c.v. and s.c. administration of clonidine were effective in inhibiting gut transit in spinally transected mice, intrathecal (i.th.) administration of this agonist was not. A supraspinal site of clonidine action is suggested based upon (a) the higher central to peripheral potency of clonidine; (b) the greater potency of i.c.v., compared with s.c., administration of yohimbine in blocking i.c.v. clonidine; (c) the lack of effect of i.th. administration of clonidine in spinally transected mice; and (d) the reduced potency of i.c.v., but not s.c., administration of clonidine in spinally transected mice. Additionally, a peripheral site of clonidine action is suggested by (a) the lower potency of i.c.v. yohimbine in blocking s.c., compared with i.c.v., clonidine; (b) the lower potency of i.c.v. yohimbine in blocking i.c.v. clonidine in transected mice (compared with normal mice); (c) the equal potency of s.c. clonidine in slowing propulsion in normal and spinally transected mice; and (d) the equal potency of i.c.v. yohimbine in blocking s.c. clonidine in normal and spinally transected mice. These data in mice would thus support the concept that normal (peripheral) therapeutic administration of clonidine would affect gut motor function by interactions within the brain and directly at the level of the gut.