Cellular and molecular mechanisms of pain

Abstract

The nervous system detects and interprets a wide range of thermal and mechanical stimuli, as well as environmental and endogenous chemical irritants. When intense, these stimuli generate acute pain, and in the setting of persistent injury, both peripheral and central nervous system components of the pain transmission pathway exhibit tremendous plasticity, enhancing pain signals and producing hypersensitivity. When plasticity facilitates protective reflexes, it can be beneficial, but when the changes persist, a chronic pain condition may result. Genetic, electrophysiological, and pharmacological studies are elucidating the molecular mechanisms that underlie detection, coding, and modulation of noxious stimuli that generate pain.

Figure 1. Anatomy of the pain pathway

Primary afferent nociceptors convey noxious information to projection neurons within the dorsal horn of the spinal cord. A subset of these projection neurons transmits information to the somatosensory cortex via the thalamus, providing information about the location and intensity of the painful stimulus. Other projection neurons engage the cingulate and insular cortices via connections in the brainstem (parabrachial nucleus) and amygdala, contributing to the affective component of the pain experience. This ascending information also accesses neurons of the rostral ventral medulla and midbrain periaqueductal gray to engage descending feedback systems that regulate the output from the spinal cord.

Figure 2. Connections between primary afferent fibers and the spinal cord

There is a very precise laminar organization of the dorsal horn of the spinal cord; subsets of primary afferent fibers target spinal neurons within discrete laminae. The unmyelinated, peptidergic C (red) and myelinated Aδ nociceptors (purple), terminate most superficially, synapsing upon large projection neurons (red) located in lamina I. The unmyelinated, non-peptidergic nociceptors (blue) target small interneurons (blue) in the inner part of lamina II. By contrast, innocuous input carried by myelinated Aβ fibers terminates on PKCγ (yellow) expressing interneurons in the ventral half of the inner lamina II. A second set of projection neurons within lamina V (purple) receive convergent input from Aδ and Aβ fibers.

Figure 3. Nociceptor diversity

There are a variety of nociceptor subtypes that express unique repertoires of transduction molecules and detect one or more stimulus modalities. For example, heat-sensitive afferents express TRPV1 and possibly other, as yet unidentified heat sensors; the majority of cold-sensitive afferents express TRPM8, whereas a small subset express an unidentified cold sensor; mechanosensitive afferents express one or more as yet unidentified mechanotransduction channels. These fibers also express a host of sodium channels (such as NaV 1.8 and 1.9) and potassium channels (such as TRAAK and TREK-1) that modulate nociceptor excitability and/or contribute to action potential propagation. Some of these channels are widely expressed among nociceptors, but we illustrate those for which a modality-specific regulatory role has been reported. Three major C-fiber nociceptor subsets are shown here, but the extent of functional and molecular diversity is undoubtedly more complex. Furthermore, the contribution of each subtype to behavior is a matter of ongoing study.

Figure 4. Peripheral mediators of inflammation

Tissue damage leads to the release of inflammatory mediators by activated nociceptors or non-neural cells that reside within or infiltrate into the injured area, including mast cells, basophils, platelets, macrophages, neutrophils, endothelial cells, keratinocytes, and fibroblasts. This “inflammatory soup” of signaling molecules includes serotonin, histamine, glutamate, ATP, adenosine, substance P, calcitonin-gene related peptide (CGRP), bradykinin, eicosinoids prostaglandins, thromboxanes, leukotrienes, endocannabinoids, nerve growth factor (NGF), tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), extracellular proteases, and protons. These factors act directly on the nociceptor by binding to one or more cell surface receptors, including G protein coupled receptors (GPCR), TRP channels, Acid-sensitive ion channels (ASIC), two-pore potassium channels (K2P), and receptor tyrosine kinases (RTK), as depicted on the peripheral nociceptor terminal.

Figure 5. Spinal cord (central) sensitization

1. Glutamate/NMDA receptor-mediated sensitization. Following intense stimulation or persistent injury, activated C and Aδ nociceptors release a variety of neurotransmitters including dlutamate, substance P, calcitonin-gene related peptide (CGRP), and ATP, onto output neurons in lamina I of the superficial dorsal horn (red). As a consequence, normally silent NMDA glutamate receptors located in the postsynaptic neuron can now signal, increase intracellular calcium, and activate a host of calcium dependent signaling pathways and second messengers including mitogen-activated protein kinase (MAPK), protein kinase C (PKC), protein kinase A (PKA) and Src. This cascade of events will increase the excitability of the output neuron and facilitate the transmission of pain messages to the brain. 2. Disinhibition. Under normal circumstances, inhibitory interneurons (blue) continuously release GABA and/or glycine (Gly) to decrease the excitability of lamina I output neurons and modulate pain transmission (inhibitory tone). However, in the setting of injury, this inhibition can be lost, resulting in hyperalgesia. Additionally, disinhibition can enable non-nociceptive myelinated Aβ primary afferents to engage the pain transmission circuitry such that normally innocuous stimuli are now perceived as painful. This occurs, in part, through the disinhibition of excitatory PKCγ expressing interneurons in inner lamina II. 3. Microglial activation. Peripheral nerve injury promotes release of ATP and the chemokine fractalkine that will stimulate microglial cells. In particular, activation of purinergic, CX₃CR1, and Toll-like receptors on microglia (purple) results in the release of brain-derived neurotrophic factor (BDNF), which through activation of TrkB receptors expressed by lamina I output neurons, promotes increased excitability and enhanced pain in response to both noxious and innocuous stimulation (that is, hyperalgesia and allodynia). Activated microglia also release a host of cytokines, such as tumor necrosis factor α (TNFα), interleukin-1β and 6 (IL-1β, IL-6), and other factors that contribute to central sensitization.