Skip to main content
SpringerLink
Log in

The Anatomy of Pain and Its Implications for Regional Anesthesiology Practice

  • Chapter
  • First Online:
Essentials of Regional Anesthesia

  • 2069 Accesses

Abstract

In years past, the prevailing approach to providing pain control was focused on identifying underlying etiologies or pathologic syndromes, e.g., low back pain, trigeminal neuralgia, and cancer pain, that produce the pain. While treating the presumed source of the pain, attempts to improve the accompanying discomfort relied largely on the use of non-opioid medications and the limited use of opioid and adjuvant analgesics. Over the past 25 years, however, there has been a dramatic increase in our understanding of the nervous system and how stimuli associated with actual or potential tissue injury are transduced, transmitted, modulated, perceived, and interpreted to form the basis for initiating appropriate evasive or protective behavior, thereby avoiding or limiting injury. Our current bank of knowledge has led to the recognition that (1) pain in the chronic state is in itself a disease deserving consideration, assessment, and management; (2) pain is not a single entity but a complex, multifaceted experience that warrants detailed and comprehensive evaluation to elucidate symptoms that may reflect specific associated mechanisms amenable to targeted treatment (Woolf and Decosterd, Pain 6(Suppl), S141–7, 1999; Woolf and Max, Anesthesiology 95, 241–9, 2001); and (3) treatment modalities and management approaches not heretofore considered can be effective and can improve the quality of life for those suffering with pain. This chapter will provide a brief overview of the anatomy of pain that forms the basis for current practice.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 249.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Woolf CJ, Decosterd I. Implications of recent advances in the understanding of pain pathophysiology for the assessment of pain in patients. Pain. 1999;6(Suppl):S141–7.

    Article  PubMed  Google Scholar 

  2. Woolf CJ, Max MB. Mechanism-based pain diagnosis. Issues for analgesic drug development. Anesthesiology. 2001;95:241–9.

    Article  CAS  PubMed  Google Scholar 

  3. Bevan S. Nociceptive peripheral neurons: cellular properties. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 85–104.

    Google Scholar 

  4. Raja SN, Meyer RA, Ringkamp M, Campbell JN. Peripheral neural mechanisms of nociception. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 11–57.

    Google Scholar 

  5. Byers MR, Bonica JJ. Peripheral pain mechanisms and nociceptor plasticity. In: Loeser JD, Butler SH, Chapman CR, Turk DC, editors. Bonica’s management of pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 26–72.

    Google Scholar 

  6. Rang HP, Bevan S, Dray A. Nociceptive peripheral neurons: cellular properties. In: Wall PD, Melzack R, editors. Textbook of pain. 3rd ed. Edinburgh: Churchill Livingstone; 1994. p. 57–78.

    Google Scholar 

  7. Devor M, Seltzer Z. The pathophysiology of damaged peripheral nerves. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 129–64.

    Google Scholar 

  8. Terman GW, Bonica JJ. Spinal mechanisms and their modulation. In: Loeser JD, Butler SH, Chapman CR, Turk DC, editors. Bonica’s management of pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 73–152.

    Google Scholar 

  9. Basbaum AI, Bautista DM, Scherrer G, Julius D. Cellular and molecular mechanisms of pain. Cell. 2009;139:267–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Snyder LM, Ross SE. Itch and its inhibition by counter stimuli. Handb Exp Pharmacol. 2015;226:191–206.

    Article  CAS  PubMed  Google Scholar 

  11. Meyer RA, Campbell JN, Raja SN. Peripheral neural mechanisms of nociception. In: Wall PD, Melzack R, editors. Textbook of pain. 3rd ed. Edinburgh: Churchill Livingstone; 1994. p. 13–44.

    Google Scholar 

  12. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971–9.

    Article  CAS  PubMed  Google Scholar 

  13. Milligan ED, Watkins LR. Pathological and protective roles of glia in chronic pain. Nat Rev. 2009;10:23–36.

    Article  CAS  Google Scholar 

  14. Adams RD, Victor M. Principles of neurology. 4th ed. New York: McGraw Hill; 1989.

    Google Scholar 

  15. Basbaum AI, Fields HL. Endogenous pain control systems: brain stem spinal pathways and endorphin circuitry. Annu Rev Neurosci. 1984;7:309–38.

    Article  CAS  PubMed  Google Scholar 

  16. Levine JD, Reichling DB. Peripheral mechanisms of inflammatory pain. In: Wall PD, Melzack R, editors. Textbook of pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 59–84.

    Google Scholar 

  17. Paul D, Gould HJ III. Sodium channel modulation in the perception and management of pain. Spec Top Pain Manag Sci Am Pain Manag. 2018. In press.

    Google Scholar 

  18. Amir R, Devor M. Spike-evoked suppression and burst patterning in dorsal root ganglion neurons. J Physiol (Lond). 1997;501:183–96.

    Article  CAS  Google Scholar 

  19. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet. 1999;353:1959–64.

    Article  CAS  PubMed  Google Scholar 

  20. Wall PD, Woolf CJ. The brief and the prolonged facilitatory effects of unmyelinated afferent input on the rat spinal cord are independently influenced by peripheral nerve section. Neuroscience. 1986;17:1199–205.

    Article  CAS  PubMed  Google Scholar 

  21. Voigt AW, Gould HJ III. Chronic daily headache—mechanisms and principles of management. Curr Pain Headache Rep. 2016;20:1–7.

    Article  Google Scholar 

  22. Reichling DB, Levine JD. Critical role of nociceptor plasticity in chronic pain. Trends Neurosci. 2009;32:611–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Woolf CJ, Shortland P, Coggeshall RE. Peripheral nerve injury triggers central sprouting of myelinated afferents. Nature. 1992;355:75–8.

    Article  CAS  PubMed  Google Scholar 

  24. Kaye AD, Novitch MB, Gould HJ III. Pain, a comprehensive review and update. Neurosci Biobehav Psychology: Elsevier; 2017. ISBN 9780128093245.

    Google Scholar 

Download references

Acknowledgments

The authors wish to thank Dr. Dennis Paul for his helpful comments and suggestions in the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Neurology and Neuroscience, Louisiana State University Health Sciences Center—New Orleans, New Orleans, LA, USA

    Harry J. Gould III MD, PhD

  2. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA

    Alan David Kaye MD, PhD

Authors
  1. Harry J. Gould III MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alan David Kaye MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Harry J. Gould III MD, PhD .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA

    Alan David Kaye

  2. Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Richard D. Urman

  3. Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA

    Nalini Vadivelu

Review Questions

Review Questions

  1. 1.

    Inhibitory interneurons within the dorsal horn release inhibitory neurotransmitters such as:

    1. (a)

      Glycine and gamma (γ)-aminobutyric acid (GABA)

    2. (b)

      Glutamate and aspartate

    3. (c)

      Calcitonin gene-related peptide (CGRP), galanin, and substance P (sP)

    4. (d)

      Neurokinin, vasoactive intestinal peptide (VIP), and neuropeptide Y (NP-Y)

  2. 2.

    There are two components of the lateral spinothalamic pathway:

    1. (a)

      Neospinothalamic tract and paleospinothalamic tract

    2. (b)

      Subthalamic tract and cerebellar vermis tract

    3. (c)

      Anterior and posterior longitudinal tract

    4. (d)

      Neocerebellar and tuberculum tract

  3. 3.

    When glutamate concentration remains high due to repetitive firing of primary afferent neurons, the depolarized postsynaptic membrane in the presence of increased levels of glycine, released from local inhibitory interneurons, stimulates the opening of:

    1. (a)

      Serotonin receptors

    2. (b)

      Bradykinin receptors

    3. (c)

      Muscarinic receptors

    4. (d)

      N-methyl-d-aspartate (NMDA) glutamate receptors

  4. 4.

    Inputs to the wide dynamic range neurons provide the essential segmental framework for the “gate control theory” proposed by:

    1. (a)

      Melzack and Wall (1965)

    2. (b)

      Racz and Raj (1971)

    3. (c)

      Bonica (1958)

    4. (d)

      Lema (1986)

  5. 5.

    The gate control theory:

    1. (a)

      Is completely false

    2. (b)

      States that impulses transmitted by low-threshold mechanoreceptors can reduce the nociceptive signal that is relayed to higher integrative levels for conscious perception

    3. (c)

      Explains the mechanism of the gamma reflex loop

    4. (d)

      Is the basis of our understanding of saltatory conduction

  6. 6.

    The regular and frequent signals which can be passed to the central nervous system and through a process of central sensitization are called:

    1. (a)

      “Windup”

    2. (b)

      Diffusion

    3. (c)

      Archicerebellum redundancy

    4. (d)

      Schmidt-Lanterman syndrome

  7. 7.

    The consequences of “windup” include:

    1. (a)

      Quicker reflexes

    2. (b)

      Increased micturition and defecation

    3. (c)

      The repetitive firing of peripheral C fibers which produces a gradual increase in the perception of a stimulus irrespective of an increase in stimulus intensity

    4. (d)

      The sequential discharge of β fibers which produces γ-mediated pain

  8. 8.

    Unique structures, which are depolarized by stimuli in response to tissue damage:

    1. (a)

      Touch receptors

    2. (b)

      Nociceptors

    3. (c)

      Temperature receptors

    4. (d)

      Chloride channels

  9. 9.

    As the axons approach the spinal cord, they diverge from the main nerve trunk and enter the dorsal root where they course by their cell bodies in the DRG and enter the spinal cord to terminate on neurons in:

    1. (a)

      Rexed laminae I and II

    2. (b)

      Rexed laminae III and V

    3. (c)

      Rexed lamina X

    4. (d)

      All of the above

  10. 10.

    The axons of the C fiber system:

    1. (a)

      Are unmyelinated

    2. (b)

      Are myelinated

    3. (c)

      Are never found in the peripheral nerves of the somatic sensory system

    4. (d)

      Have fast conduction velocity of over 20 m/s

  11. 11.

    Neurons in the ventral posterior nucleus (VPN) of the thalamus relay the nociceptive signal to:

    1. (a)

      The primary somatosensory cortex

    2. (b)

      The secondary somatosensory cortex

    3. (c)

      The inferotemporal and frontal cortices

    4. (d)

      All of the above

  12. 12.

    After an injury, a significant portion of stimulus enhancement can occur during the process of peripheral sensitization and is limited to injury by:

    1. (a)

      Thermal stimulus

    2. (b)

      Mechanical stimulus

    3. (c)

      Chemical stimulus

    4. (d)

      All of the above

  13. 13.

    Which is false regarding wide dynamic range neurons?

    1. (a)

      They are found primarily in lamina V.

    2. (b)

      They are responsible for much of the information that is transmitted to the brain stem and thalamus.

    3. (c)

      These neurons receive polymodal inputs.

    4. (d)

      One limitation is that they do not receive inputs from collaterals of non-nociceptive, low-threshold mechanical Aβ afferents and local internuncial neurons of the dorsal horn.

  14. 14.

    C fibers:

    1. (a)

      Respond to polymodal stimuli but preferentially respond to noxious heat.

    2. (b)

      Their central elements course medially in the dorsal root and terminate on neurons in Rexed lamina I, the outer portion of lamina II, and lamina V.

    3. (c)

      Upon entering the spinal cord, the axons of the primary nociceptors ascend and descend in the zone of Lissauer.

    4. (d)

      The majority of these fibers ascend approximately two spinal levels before terminating in the dorsal horn.

  15. 15.

    In myelinated axons, the excitable membrane that supports the propagation of action potentials found only in the intervals between adjacent segments of myelin is called:

    1. (a)

      Nodes of Ranvier

    2. (b)

      Basilar sulci

    3. (c)

      Nervus intermedius

    4. (d)

      Riopelle lipofuscin

Answers:

  1. 1.

    a

  2. 2.

    a

  3. 3.

    d

  4. 4.

    a

  5. 5.

    b

  6. 6.

    a

  7. 7.

    c

  8. 8.

    b

  9. 9.

    d

  10. 10.

    a

  11. 11.

    d

  12. 12.

    d

  13. 13.

    d

  14. 14.

    d

  15. 15.

    a

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Gould, H.J., Kaye, A.D. (2018). The Anatomy of Pain and Its Implications for Regional Anesthesiology Practice. In: Kaye, A., Urman, R., Vadivelu, N. (eds) Essentials of Regional Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-74838-2_4

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-74838-2_4

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74837-5

  • Online ISBN: 978-3-319-74838-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation