Fig. 37.1
Pain pathways from peripheral to cerebral cortex and treatment targets
External stimuli are received via specialized neurologic structures called sensation receptors. Receptors are intensively located in the skin but are also located in the muscles, periosteum, capsule of internal organs, and vessel walls [7, 8]. Activation of the receptors induces release of algogenic substances like bradykinin, potassium, prostaglandins, hydrogen ions, serotonin, and substance P. These algogenic substances stimulate the sensation receptors aggressively and make them much more sensitive [9–11]. The receptors are sensitive to different forms of physical energy (mechanical, thermal, and chemical). Stimulated sensation receptors transform the external stimulus to “electrochemical energy,” which is brought to the spinal cord dorsal horn via A–delta fibers (fast, surrounded by thin myelin film) and C–afferent fibers (slow, unmyelinated) (transduction [membrane potential], transformation [action potential]) [2, 12]. This message (action potential) activates the spinal cord dorsal horn neurons that reach the central part of the brain, thalamus, and frontal cortex and produces suprasegmental reflexes and cortical responses via afferent fibers (transmission) [2]. Tissue damage activates neurological pathways, and various mechanisms form which control the quantity of transported afferent activation when the stimuli are transported to central areas. Consequently, the stimuli transport is inhibited or facilitated at the spinal cord or supraspinal levels (modulation) [2]. There is simultaneous efficiency of afferent fibers and efferent inhibitor fibers for this purpose [2]. Spinal cord dorsal horn cells are the first level that processes the painful stimulus [2, 4]. The stimulus comes from the peripheral sensation nerve fibers terminating at this level. There are three types of neurons in the spinal cord dorsal horn: projection neurons, excitatory neurons, and inhibitory neurons [4]. Projection neurons transmit the stimulus to the upper centers via the anterolateral afferent system [13]. Excitatory neurons transmit the painful stimulus to the projection neurons and stimulate them [13]. Inhibitory neurons are activated with the signals that come via C-delta and A-delta fibers and transmit the painful stimulus to the projection neurons. When they are activated via large fibers, they inhibit the projection neurons [4]. On the other hand, pain is the patient’s experience, not only a physical stimulus. When the stimulus reaches the cerebral cortex, the patient’s previous experiences and perception of stimulus are the important factors for specification of pain (Perception) [2]. Perception of pain is the last stage of neuronal painful stimulus transport. Painful stimulus reaching thalamus and brain system activate various cortical areas, and then responses appear. These are the reticular system, somatosensory cortex, and limbic system [7, 8]. Reticular system plays a major role in the formation of autonomic and motor responses (sudden movement of the back of hand after touching a hot object). Also, it has a role in affective motivational response too (looking at the hand and estimating the injury after moving back of the hand from the surface of a hot object) [7, 8]. Somatosensory cortex establishes pain severity, localization, and type, and associates it with previous experiences and memory [7, 8]. Limbic system produces emotional and behavioral responses in response to pain (attention, emotional state, and motivation) [7, 8].
Formation of Spinal and Supraspinal Reflexes
Stimuli reach the anterior and anterolateral horns of spinal cords, induce sympathetic preganglionic somatomotor neurons, and then produce autonomic spinal reflex response. Spinal and suprasegmental reflexes produce important physiological alterations that affect cardiopulmonary, gastrointestinal, urinary, endocrine, and immunological systems [2].
Perception of Pain Recalls Different Emotional Responses That Are Defined by Anxiety and Fear
Perception and interpretation of pain level increase catecholamine, cortisone, clotting time, fibrinolysis, and platelet aggregation in circulation [2].
Neuronal centers in the cerebral cortex and subcortical areas respond to painful stimuli coming from the periphery and activate inhibitory or exciting efferent pathways, thus modifying painful signals [7, 8]. Centrally located gray matter in the central part of the brain (periaqueductal gray matter, PAG) receives cortical and subcortical responses and starts afferent inhibitory nerve stimulation in the central nervous system (CNS). CNS sends responses to the periphery and can induce the release of neurotransmitters which reduce painful stimulus transport. Inhibitory stimuli reach the dorsal horn of spinal cord, that is, the first place for processing peripheral painful stimuli, and activate the inhibitory neurons therein; as a result, inhibitory transmitters, such as endogenous endorphins, noradrenalin, and serotonin are released [7, 8]. Conversely, supraspinal centers can produce responses that increase afferent painful stimuli transport.
Chronic Pain
Pain persisting for more than 3–6 months is called chronic pain [2]. Inappropriate and insufficient treatment of acute pain makes the CNS sensitive, and thus can produce chronic pain [9, 14]. There is no condition relating to tissue damage in chronic pain. Patients define pain and agony like acute pain. There is no autonomic hyperactivity. Normal activity pathways change, or there is spontaneous activity [2].
Chronic pain is a complicated problem that affects quality of life. Fast and long-term changes take place in different regions of CNS regarding transport and modulation of the painful stimuli [15]. Due to this abnormal mechanism in the peripheral and central nervous system, pain becomes independent of the original injury. The pathologic physiology is not absolutely clear.
There is coordination between input and output of painful stimulus at the spinal cord level (spinal modulation of painful stimulus). The ratio of rise in hyperalgesia and allodynia sometimes reduces and analgesia is formed [4]. If noxious stimuli reach the synapses located in the spinal cord dorsal horn with intense intervals in the long term, progressively increasing painful stimuli occur (windup). Patients feel severe pain even from painless stimulus like touch (Allodynia) [4, 15].
Neuropathic Pain
The primary initiatory cause of pain is nervous system dysfunction or primary lesion. There is no constant painful stimulus [4]. Trauma (complex regional pain syndrome, postsurgical chronic pain), infection (postherpetic neuralgia), ischemia (diabetic neuropathy), and cancer are some etiologic factors. Some neuropathic pain occurs with peripheral nerve system damage. Repetitive transport of a painful stimulus by nerve fibers and hypersensitive nerve fibers is responsible for pain formation [15].
General Treatment Approach
It is possible to evaluate pain treatment in surgical practice with two modalities: preoperative analgesia and postoperative analgesia (Table 37.1). The purpose of pain treatment in orthopedic practice is reducing pain, simplifying rehabilitation, and returning to normal functions promptly.
Table 37.1
Postsurgical pain treatment
Preoperative analgesia | Postoperative analgesia |
---|---|
Regional blocks | Patient controlled analgesia |
Parenteral drug administration | Drugs (basic; opioids and NSAIDs) |
Oral drug administration | Local/regional anesthetics |
Nonpharmacological applications |
Success in reaching these targets, potentially, can be achieved by reducing both pain and inflammation peripherally and centrally [1]. The main principle is utilizing treatment alternatives that affect the pain process at different levels, thus preventing the transformation of acute pain to its chronic form (Fig. 37.1) [1].
Pharmacologic Treatment
Narcotics
Nonsteroidal anti-inflammatory drugs
Local anesthetics
Centrally effective nonopioids
Acetaminophen
Codeine
Others
Antidepressants
Antiepileptics
Membrane-stabilized drugs
Adrenergic drugs (alpha-adrenergic blocker)
Combined analgesia
Preventive analgesia
Narcotics
Opioids involve both endogenous and exogenous composites like morphine (Table 37.2) [3]. They are used for the treatment of average-severe pain, which has an acute character in orthopedic practice [1, 3]. Opioids produce their effects via opioid receptors in the CNS [16]. They are the most important drugs in the treatment of acute pain. They have central and peripheral (spinal cord level) actions. Parenteral, oral, transdermal, mucosal, and epidural utilization is possible [1]. Effective dose level is uncertain among individuals; full effects and toxicity levels are associated with the dose level [1]. There are CNS (sedation, confusion) and visceral (ileus, urinary retention, constipation, vomiting, nausea, respiration depression) side effects [16, 17]. Combination with the other drugs is helpful to reduce side effects.
Table 37.2
Narcotics (opioids)
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