Spinal mechanisms of acute and persistent pain

Although there is considerable information about the mechanisms through which injury stimuli produce acute pain, recent studies indicate that there are significant long-term consequences of persistent injury. Pain is exacerbated, in part, because of a reorganization of spinal cord circuitry in the setting of persistent injury. This review describes our studies of the contribution of the primary afferent neurotransmitter, substance P (SP), to these changes. By following internalization of the SP receptor in spinal cord dorsal horn neurons, we have identified the stimuli that evoke SP release and the neurons that respond to these stimuli. Importantly, based on the intensities of stimuli required to evoke internalization, we conclude that SP is only released under conditions in which severe pain would be produced, that the release can be evoked by intense stimulation of somatic and visceral tissue, and that multiple stimulus modalities are effective. We also found that the numbers of neurons that are influenced increases dramatically in the setting of inflammation. Using a knockout strategy, we have also raised mice with a deletion of the preprotachykinin-A (PPT-A) gene, which encodes for SP and neurokinin A (NKA), and have identified a specific behavioral phenotype in which the animals do not detect a window of "pain" intensities; this window cuts across stimulus modalities. These results provide an important behavioral correlate of the receptor internalization studies. On the other hand, the allodynia (lowered pain threshold) that occurs in the setting of injury was not altered in these animals. Among the factors that could underlie injury-induced allodynia are the second messenger systems that are activated in dorsal horn neurons. Our studies have recently implicated the gamma isoform of protein kinase C (PKC gamma) in the development of nerve injury-induced neuropathic pain. Specifically, we found that although acute pain responses of mice with a deletion of PKC gamma are not altered, partial injury to the sciatic nerve (which induces a severe thermal and mechanical allodynia in the wild type mouse) is without effect in the knockout. Furthermore, the anatomical/neurochemical reorganization that typically follows sciatic nerve section does not occur in the PKC gamma mutant mice. Because the spinal cord distribution of interneurons that express PKC gamma is concentrated almost exclusively in the inner part of lamina II, we believe that changes in the properties of these neurons are key to the development of nerve injury-induced neuropathic pain conditions. Taken together, these studies emphasize that persistent pain should be considered a disease state of the nervous system, not merely a symptom of some other disease conditions. In the setting of persistent injury, the nervous system undergoes dramatic changes that exacerbate and prolong the pain condition. Our studies underscore the importance of preventing the long-term changes that result from persistent injury.