Beruflich Dokumente
Kultur Dokumente
March 2003: Describe the pathways involved in pain perception and its treatment.
March 2004: Describe the pathways responsible for the modulation of painful stimuli in
the central nervous system.
March 2005: Describe the neural mechanisms and pathways involved in nociception.
How is nociception modulated?
Introduction
Pain is often useful in alerting us to tissue damage and triggering appropriate
motor responses to minimize further bodily harm. NAME THE DISEASE WHERE
PAIN DOESN’T OCCUR AND DEMONSTRATE HOW USEFUL PAIN IS
However, pain that is unrelated to tissue injury, such as the persistence of pain after
healing of injury, is harmful and debilitating. In fact, chronic pain is a major medical
health problem that causes enormous emotional suffering and financial costs to patients
and their carers. Fortunately, advances in our understanding of how pain is modulated
physiologically have led to effective pain control techniques. There is a huge variability
in the way nociception leads to pain responses as the sensation of pain is modulated by
behavioural experiences. Nociception refers to the physiological process by which
noxious stimuli are detected by specialized transducers (nociceptors) and transmitted to
the central nervous system. Pain is defined as the subjective response of the individual to
the nociceptive input to the brain and may be unrelated to the actual physical parameters
of intensity and duration of the stimulus. Not all noxious stimuli cause pain to be felt and
conversely pain can occur in the absence of nociception, e.g. phantom pain. In 1965,
Wall & Melzack proposed the ‘gate control theory’ to explain how inhibitory
interneurons in lamina II of the dorsal horn (substantia gelatinosa) induce analgesia by
inhibiting spinothalamic tract transimission neurons in response to non-nociceptive
afferent inputs and descending inhibitory pathways. Analgesia can then be induced
clinically by fitting stimulating electrodes into the periventricular gray region or by
administering opiates to activate descending pain modulating pathways.
The two main types of nociceptive afferent fibres are small diameter, thinly
myelinated Aδ fibres and unmyelinated C fibres. Aδ fibres detect noxious thermal and
mechanical stimuli causing sharp, well-localised pain whereas C fibres are polymodal
(activated by high intensity mechanical, chemical, hot or cold stimuli) and cause dull
burning pain.
These nociceptive afferent fibres, with their cell bodies in the dorsal root ganglia,
enter the dorsolateral tract of Lissauer and give off branches that terminate in laminae I,
II and V of the dorsal horn.
Projection neurons in the dorsal horn relay nociceptive inputs to higher centers in
the brain via five major ascending pathways. The main ascending pathway is the
spinothalamic tract which arises from neurons in laminae I and V-VII. It decussates to
ascend in the contralateral anterolateral white matter region and terminates in the ventral
and posterior nuclei of the thalamus. The axons of nociceptive neurons in laminae VII
and VIII ascend via the spinoreticular tract and may be ipsilateral or contralateral.
Nociceptive neurons in laminae I and V form the spinomesencephalic tract which project
to the mesencephalic reticular formation. Neurons in laminae III and IV that are activated
by noxious stimuli project through the spinocervical tract to the lateral cervical nucleus.
Neurons from this nucleus then decussate and project through the medial lemniscus to
midbrain nuclei and to the ventroposterior lateral and posterior medial nuclei of the
thalamus. The last ascending pathway is the dorsal column of the spinal cord which
conveys information from nociceptive neurons in laminae III and IV to the cuneate and
gracile nuclei in the medulla. The thalamic nuclei that receive nociceptive information
project to different regions of the somatosensory cortex which suggest there are several
pathways that process nociceptive information in the cortex.