Joyce A. DeLeo

The role of neuroinflammation and neuroimmune activation in persistent pain.

Interest in neuroin ̄ammation and neuroimmune activation has grown rapidly in recent years with the recognition of the role of central nervous system (CNS) in ̄ammation and immune responses in the etiology of neurological disorders such as AIDS-associated dementia and pain, Alzheimers disease, stroke, Parkinsons disease, traumatic brain and spinal cord injury, and demyelinating diseases such as multiple sclerosis (Ruffolo et al., 1999). One approach to the treatment of these conditions is the implementation of putative anti-in ̄ammatory and/or immunosuppressant strategies, which includes the use of methylprednisolone or steroids without glucocorticoid properties (the 21 aminosteroids), and synthetic glycolipid GM-1 gangliosides that ultimately result in the protection or rescuing of neurons in the penumbral region of a pathological insult. These neuroprotective strategies (with anti-in ̄ammatory or immunosuppressant components) are presently being used to treat acute and chronic neurological diseases including: stroke, subarachnoid hemorrhage, brain and spinal cord injury, hypoxic-ischemic encephalopathy, Parkinsons, Alzheimers and Huntingtons disease, amyotropic lateral sclerosis, and diabetic and toxic neuropathies (Wood, 2000). Since some of these conditions are also associated with persistent pain states, it is possible that there is a connection between the neurodegenerative characteristics of these central disorders and the mechanisms responsible for chronic pain. An important ®rst step in understanding the role of neuroin ̄ammation and neuroimmune activation in persistent pain is to clarify terminology. Immunity, the state of protection from infectious disease and injury, is characterized by nonspeci®c (innate) and speci®c (adaptive) components. Innate immunity can be envisioned to include four types of defensive barriers: anatomic, physiologic, phagocytic and in ̄ammatory. The hallmark of the in ̄ammatory component of this innate immune response is the in®ltration and/or migration of cells to the site of injury. Therefore, neuroin ̄ammation can be de®ned as the in®ltration of immune cells into the site of injury in response to damage of the peripheral or central nervous system. Unlike innate immunity, adaptive immunity displays speci®city, diversity, memory and self/nonself recognition. These two immunological responses have an important interactive relationship. For example, perivascular macrophages, one of the ®rst cells to respond in innate immunity are intimately involved in precipitating the speci®c, adaptive immune response that involves lymphocytes and antigen-presenting cells. Broadly de®ned, neuroimmune activation involves endothelial cells, microglia and astrocytes. Activation of these cells leads to subsequent production of cytokines, chemokines, and the expression of surface antigens (to be further discussed) that enhance the immune cascade without in®ltration of immune cells to the site of injury and robust pathological sequelae. In light of the enormous interest in the etiology of CNS disorders, it is not surprising that the potential involvement of neuroin ̄ammation and neuroimmune activation has been considered to play a role in the development of acute and chronic pain (Watkins and Maier, 1999). In the case of persistent pain states, mounting evidence has shown that both neuroin ̄ammation and neuroimmune activation occur following peripheral and central injury. We will review this burgeoning area of research by highlighting recent advances with a focus on immune cells and immune mediators at peripheral and central sites of injury, and the potential modulation of this complex in ̄ammatory/immune response as a novel therapy for the treatment of persistent pain. Pain 90 (2001) 1±6

Complete Freunds adjuvant-induced peripheral inflammation evokes glial activation and proinflammatory cytokine expression in the CNS.

Peripheral inflammation induces central sensitization characterized by the development of allodynia and hyperalgesia to mechanical and thermal stimuli. Recent evidence suggests that activation of glial cells and a subsequent increase in proinflammatory cytokines contribute to the development of behavioral hypersensitivity after nerve injury or peripheral inflammation. In the present study, we examined mRNA and protein expression of glial markers and proinflammatory cytokines at the lumbar spinal cord, brainstem and forebrain following intraplantar administration of complete Freunds adjuvant (CFA) in rats. Gene expression studied by real‐time reverse transcriptase‐polymerase chain reaction (RT‐PCR) for microglial markers (Mac‐1, TLR4 and CD14) showed a significant increase in their expression during all phases (acute, subacute and chronic) of inflammation. Conversely, up‐regulation of astroglial markers [glial fibrillary acidic protein (GFAP) and S100B] was observed only at the subacute and chronic phases of inflammation. Increased immunoreactivity for OX‐42 (CR3/CD11b) and GFAP at various brain regions was also observed after the acute and subacute phases of the inflammation, respectively. Quantification of proinflammatory cytokines (IL‐1β, IL‐6 and TNF‐α) at the mRNA (by real‐time RT‐PCR) and protein level (by ELISA) revealed enhanced expression during the acute, subacute and chronic phases of CFA‐induced peripheral inflammation. This study demonstrates that CFA‐induced peripheral inflammation induces robust glial activation and proinflammatory cytokines both spinally and supraspinally. In addition, similar to nerve injury‐induced behavioral hypersensitivity microglial activation preceded astrocytic activation following CFA‐induced peripheral inflammation, supporting a role of microglia in the initiation phase and astrocytes in maintaining hypersensitivity. These findings further support a unifying theory that glial activation and enhanced cytokine expression at the CNS have a role in eliciting behavioral hypersensitivity.

The Effect of Site and Type of Nerve Injury on Spinal Glial Activation and Neuropathic Pain Behavior

A number of rat peripheral neuropathy models have been developed to simulate human neuropathic pain conditions. The current study sought to determine the relative importance of site versus type of peripheral nerve injury in eliciting mechanical allodynia and spinal glial responses. Rats received one of seven different surgical treatments at the L5 spinal level: spinal nerve cryoneurolysis, spinal nerve tight ligation, dorsal root cryoneurolysis, dorsal root tight ligation, dorsal root transection, ventral root tight ligation, or laminectomy/dural incision sham. Foot-lift response frequency to mechanical stimulation of the ipsilateral hindpaw was assessed postlesion on days 1, 3, 5, and 7. L5 spinal cords were retrieved for immunohistochemical analysis of microglial (OX-42) and astrocytic (anti-glial fibrillary acidic protein) responses. Both types of spinal nerve lesion, freeze and tight ligation, produced rapid and profound mechanical allodynia with intense glial responses. Dorsal root lesions also resulted in intense mechanical allodynia; however, glial responses were almost exclusively astrocytic. Ventral root tight ligation and sham provoked no marked behavioral changes and only sporadic glial responses. Direct dorsal horn communication with the dorsal root ganglion was not a crucial factor in the development of mechanical allodynia, since decentralization of the L5 DRG by complete L5 dorsal root lesion produced profound mechanical sensitization. Conversely, microglial activation responses appear to be dependent upon dorsal root ganglion-mediated signals and, contrary to behavioral responses, were robust only when the lesion was made peripheral to the cell body. Astrocytic activation was always observed following axonal injury and reliably coexisted with behavioral responses.

Intrathecal interleukin-1 receptor antagonist in combination with soluble tumor necrosis factor receptor exhibits an anti-allodynic action in a rat model of neuropathic pain.

The expression of interleukin-1beta and tumor necrosis factor has previously been shown to be up-regulated in the spinal cord of several rat mononeuropathy models. This present study was undertaken to determine whether blocking the action of central interleukin-1beta and tumor necrosis factor attenuates mechanical allodynia in a gender-specific manner in a rodent L5 spinal nerve transection model of neuropathic pain, and whether this inhibition occurs via down-regulation of the central cytokine cascade or blockade of glial activation. Interleukin-1 receptor antagonist or soluble tumor necrosis factor receptor was administered intrathecally via lumbar puncture to male Holtzman rats in a preventative pain strategy, in which therapy was initiated 1h prior to surgery. Administration of soluble tumor necrosis factor receptor attenuated mechanical allodynia, while interleukin-1 receptor antagonist alone was unable to decrease allodynia. Interleukin-1 receptor antagonist in combination with soluble tumor necrosis factor receptor, administered to both male and female rats in a preventative pain strategy, significantly reduced mechanical allodynia in a dose-dependent manner (P<0.01). The magnitude of attenuation in allodynia was similar in both males and females. Immunohistochemistry on L5 spinal cord revealed similar astrocytic and microglial activation regardless of treatment. At days 3 and 7 post-transection, animals receiving daily interleukin-1 receptor antagonist in combination with soluble tumor necrosis factor receptor exhibited significantly less interleukin-6, but not interleukin-1beta, in the L5 spinal cord compared to vehicle-treated animals. In an existing pain paradigm, in which treatment was initiated on day 7 post-transection, interleukin-1 receptor antagonist in combination with soluble tumor necrosis factor receptor attenuated mechanical allodynia (P<0.05) in male rats. These findings further support a role for central interleukin-1beta and tumor necrosis factor in the development and maintenance of neuropathic pain through induction of a proinflammatory cytokine cascade.

DISSOCIATION OF MICROGLIAL ACTIVATION AND NEUROPATHIC PAIN BEHAVIORS FOLLOWING PERIPHERAL NERVE INJURY IN THE RAT

Peripheral nerve injury commonly leads to neuropathic pain states fostered, in part, by neuroimmunologic events. We used two models of neuropathic pain (L5 spinal nerve cryoneurolysis (SPCN) and chronic constriction injury (CCI)) to assess the role of spinal glial activation responses in producing pain behaviors. Scoring of glial responses subjectively encompassed changes in cell morphology, cell density and intensity of immunoreactivity with specific activation markers (OX-42 and anti-glial fibrillary acidic protein (GFAP) for microglia and astrocytes, respectively). Glial responses were compared with tactile sensitivity (mechanical allodynia) at 1, 3 or 10 days following SPCN and with thermal hyperalgesia at 10 days in the CCI group. Neuropathic pain behaviors preceded and did not closely correlate with microglial responses in either model. Perineural application of bupivacaine prior to SPCN prevented spinal microglial responses but not pain behaviors. Spinal astrocytic responses to SPCN were early, robust and not altered by bupivacaine. The current findings support the use of bupivacaine as a tool to suppress microglial activation and challenge the putative role of microglia in initiating or potentiating pain behaviors which result from nerve injury.

Acute peripheral inflammation induces moderate glial activation and spinal IL-1β expression that correlates with pain behavior in the rat

Our laboratory has previously shown that glial activation and increased proinflammatory cytokine expression are observed in the rat spinal cord following peripheral nerve injuries that result in neuropathic pain behaviors. In the present study, we sought to determine whether acute peripheral inflammation induces changes in central glial and cytokine (Interleukin-1beta) expression similar to those seen following peripheral spinal nerve transection. Two models of peripheral inflammation were used in this study: formalin (5% solution) or zymosan (25 mg/ml) injected subcutaneously into the plantar portion of the left hind paw of male Holtzman-strain Sprague-Dawley rats. The rats were euthanized at 1 h, 6 h, and 1, 3, 7 days post-injection (n=4 or 5/group/time point). As expected, the animals treated with formalin showed a spontaneous pain response and mechanical allodynia that persisted for approximately 60 min following injection. The animals treated with zymosan exhibited mild spontaneous pain responses during the first hour and mechanical allodynia at 6 h and 1 day following injection. Immunohistochemistry for glial activation and cytokine expression was performed on L4-L5 spinal levels in all rats. Spinal sections from both formalin and zymosan treated animals exhibited microglial and astrocytic activation and increased Interleukin-1beta immunoreactivity at 1 and 6 h, respectively. Spinal glial activation and upregulation of Interleukin-1beta appear to parallel the development and maintenance of zymosan and formalin-induced mechanical allodynia. These findings support a unifying theory that glial activation and cytokine expression have a similar, if not related, role in producing hyperalgesia following either peripheral inflammation or peripheral nerve injury.

Quantitative real-time RT-PCR assessment of spinal microglial and astrocytic activation markers in a rat model of neuropathic pain.

Activated spinal glial cells have been strongly implicated in the development and maintenance of persistent pain states following a variety of stimuli including traumatic nerve injury. The present study was conducted to characterize the time course of surface markers indicative of microglial and astrocytic activation at the transcriptional level following an L5 nerve transection that results in behavioral hypersensitivity. Male Sprague-Dawley rats were divided into a normal group, a sham surgery group with an L5 spinal nerve exposure and an L5 spinal nerve transected group. Mechanical allodynia (heightened response to a non-noxious stimulus) of the ipsilateral hind paw was assessed throughout the study. Spinal lumbar mRNA levels of glial fibrillary acidic protein (GFAP), integrin alpha M (ITGAM), toll-like receptor 4 (TLR4) and cluster determinant 14 (CD14) were assayed using real-time reverse transcription polymerase chain reaction (RT-PCR) at 4 h, 1, 4, 7, 14 and 28 days post surgery. The spinal lumbar mRNA expression of ITGAM, TLR4, and CD14 was upregulated at 4 h post surgery, CD14 peaked 4 days after spinal nerve transection while ITGAM and TLR4 continued to increase until day 14 and returned to almost normal levels by postoperative day 28. In contrast, spinal GFAP mRNA did not significantly increase until postoperative day 4 and then continued to increase over the duration of the study. Our optimized real-time RT-PCR method was highly sensitive, specific and reproducible at a wide dynamic range. This study demonstrates that peripheral nerve injury induces an early spinal microglial activation that precedes astrocytic activation using mRNA for surface marker expression; the delayed but sustained expression of mRNA coding for GFAP implicates astrocytes in the maintenance phase of persistent pain states. In summary, these data demonstrate a distinct spinal glial response following nerve injury using real-time RT-PCR.

Neuroimmune Activation and Neuroinflammation in Chronic Pain and Opioid Tolerance/Hyperalgesia:

One area that has emerged as a promising therapeutic target for the treatment and prevention of chronic pain and opioid tolerance/hyperalgesia is the modulation of the central nervous system (CNS) immunological response that ensues following injury or opioid administration. Broadly defined, central neuroimmune activation involves the activation of cells that interface with the peripheral nervous system and blood. Activation of these cells, as well as parenchymal microglia and astrocytes by injury, opioids, and other stressors, leads to subsequent production of cytokines, cellular adhesion molecules, chemokines, and the expression of surface antigens that enhance a CNS immune cascade. This response can lead to the production of numerous pain mediators that can sensitize and lower the threshold of neuronal firing: the pathologic correlate to central sensitization and chronic pain states. CNS innate immunity and Toll-like receptors, in particular, may be vital players in this orchestrated immune response and may hold the answers to what initiates this complex cascade. The challenge remains in the careful perturbation of injury/opioid-induced neuroimmune activation to down-regulate this process without inhibiting beneficial CNS autoimmunity that subserves neuronal protection following injury.

Spinal glial activation and cytokine expression after lumbar root injury in the rat.

STUDY DESIGN This study was designed to examine the behaviorial immunohistochemical changes of spinal glial cells and spinal Interleukin (IL)-1beta expression after various nerve root injuries used as models of lumbar radiculopathy. OBJECTIVES In order to better understand the role of central inflammation in the pathophysiologic mechanisms that give rise to pain associated with lumbar radiculopathy, this research studied the relationship between pain-related behavior associated with spinal glial activation and IL-1beta expression generated by three types of nerve root injury: loose ligation with chromic gut, loose ligation with silk, and tight ligation with silk. SUMMARY OF BACKGROUND DATA An animal model of lumbar radiculopathy originally described by Kawakami and Weinstein involved loose ligation of unilateral L4-L6 nerve roots with chromic gut. Characterization and establishment of such an animal model of low back pain enables further investigation of the nature of the pathophysiologic mechanisms associated with lumbar radiculopathy in humans. METHODS Seventy-three rats were divided into four treatment groups. Chromic group (n = 25): The L5 nerve roots (dorsal and ventral) were exposed by hemilaminectomy and loosely ligated with chromic gut. Tight silk group (n = 18): The exposed L5 nerve roots were tightly ligated extradurally with 5-0 silk suture. Loose silk group (n = 15): two loose ligatures of 5-0 silk were placed around the exposed L5 nerve roots. Sham group (n = 15): the rats were subjected to laminectomy alone for exposing nerve roots. Following surgery, thermal hyperalgesia and mechanical allodynia was assessed time-dependently up to 42 days post operatively. At 1, 3, 7, 14, and 42 days postoperatively, the rats in each group were perfused with fixative. The L5 spinal cord segments was harvested and cryosectioned for glial and cytokine immunohistochemistry. RESULTS In the chromic and the tight silk group, an immediate and sustained mechanical allodynia was observed in the ipsilateral hind paw up to 35 days postoperatively. The loose silk group also showed an immediate mechanical allodynia that subsided by 14 days postoperatively. Sham-treated animals exhibited mild mechanicalallodynia for the initial 7 days after the surgery. Thermalhyperalgesia was evident in the three primary treatment groups, but not in the sham-treated rats. OX-42 expression was elevated in the gray matter of the L5 spinal section by 3 days in the chromic, the tight silk, and the loose silk groups as compared to the sham group. Astrocytic activation increased over time in all groups except the sham group. There was no direct correlation between degree of microglial response and severity of pain behaviors. In contrast, astrocytic activation demonstrated a direct relationship with the elevation of mechanical allodynia for the first 7 days. In addition, spinal IL-1beta protein expression was increased bilaterally in the superficial layer of the dorsal horn and cell nuclei of the ventral horns in the ligature treated groups as compared with the sham group. CONCLUSION Direct mechanical and/or chemical injury to lumbar roots in the rat gives rise to pain behavior suggestive of lumbar radiculopathy. The finding that glial activation and enhanced IL-1beta expression are observed in the spinal cord after root injury supports a central, neuroimmune component in the generation of lumbar radiculopathy. A further understanding of the immunologic consequences of root injury may lead to further development and the novel use of selective cytokine-inflammatory inhibitors for the treatment of low back pain associated with radiculopathy.

Cytokine and growth factor immunohistochemical spinal profiles in two animal models of mononeuropathy

Nerve injury leads to central neuroimmunologic responses that may be integral to the development and maintenance of chronic neuropathic pain in humans. Recent data have demonstrated that cytokines and growth factors may be strongly implicated in the generation of pain states at both peripheral and central nervous system sites. We utilized immunohistochemical methods to investigate this phenomenon in rat models of neuropathic pain. Specifically, we employed well-characterized models of neuropathy that result in behaviors suggestive of neuropathic pain in humans; a freeze lesion of the sciatic nerve, termed sciatic cryoneurolysis, and a chronic constriction sciatic nerve injury. We used immunohistochemistry to examine spinal localization of the cytokines, interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha) and the growth factors, basic fibroblast growth factor (bFGF), and transforming growth factor-beta1 (TGF-beta) at 3, 14, and 35 days following sciatic cryoneurolysis or 6 days following chronic constriction injury as compared with normal, unoperated rats. There was minimal, diffuse cytokine/growth factor staining in lumbar spinal tissue from the normal group. However, cell profile quantification demonstrated increases in lumbar spinal IL-1beta-, TNF-alpha- and TGF-beta-like immunoreactivity (LI) in both mononeuropathy models studied. At 3 days following sciatic cryoneurolysis, intense bFGF LI was present in the ipsilateral dorsal and ventral horn. By 14 days bFGF LI was also observed in contralateral dorsal and ventral horns. In contrast, we found no obvious staining differences in lumbar spinal cord following the chronic constriction injury. This study demonstrated increased specific cytokine and growth factor-like expression in the spinal cord following peripheral nerve injuries. It also showed a differential expression of bFGF in two distinct mononeuropathy models. These results provide further evidence that central cytokine production via a neuroimmune cascade may be involved in the development and maintenance of behaviors that mimic neuropathic pain following nerve injury.