Physiol Rev 92: 193–235, 2012 doi:10.1152/physrev.00043.2010 FAST SYNAPTIC INHIBITION IN SPINAL SENSORY PROCESSING AND PAIN CONTROL Hanns Ulrich Zeilhofer, Hendrik Wildner, and Gonzalo E. Yévenes Institute of Pharmacology and Toxicology, University of Zurich, and Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland Zeilhofer HU, Wildner H, Yévenes GE. Fast Synaptic Inhibition in Spinal Sensory Processing and Pain Control. Physiol Rev 92: 193–235, 2012; doi:10.1152/physrev.00043.2010.— The two amino acids GABA and glycine mediate fast inhibitory neurotransmission in different CNS areas and serve pivotal roles in the spinal sensory processing. Under healthy conditions, they limit the excitability of spinal terminals of primary sensory nerve Lfibers and of intrinsic dorsal horn neurons through pre- and postsynaptic mechanisms, and thereby facilitate the spatial and temporal discrimination of sensory stimuli. Removal of fast inhibition not only reduces the fidelity of normal sensory processing but also provokes symptoms very much reminiscent of pathological and chronic pain syndromes. This review summarizes our knowledge of the molecular bases of spinal inhibitory neurotransmission and its organization in dorsal horn sensory circuits. Particular emphasis is placed on the role and mechanisms of spinal inhibitory malfunction in inflammatory and neuropathic chronic pain syndromes. I. INTRODUCTION 193 the spinal terminals of primary sensory fibers through post- II. MOLECULAR COMPOSITION OF FAST... 194 synaptic and presynaptic mechanisms. The function of in- III. LAMINAR ORGANIZATION OF THE... 198 hibitory dorsal horn neurons, however, extends far beyond IV. LAMINAR DISTRIBUTION OF GABAA... 200 the physiological processing of somatosensory stimuli and V. DISTRIBUTION OF PRESYNAPTIC... 201 has important implications also for the generation and VI. CORELEASE OF GABA AND GLYCINE... 201 maintenance of chronic pain states. An important role in VII. MORPHOLOGICALLY DEFINED... 203 nociceptive processing and in pain has been proposed more VIII. TRANSCRIPTION FACTORS... 205 than 45 years ago by Melzack and Wall (248) in the gate IX. EXCITATORY DRIVE ONTO INHIBITORY... 207 control theory of pain (FIGURE 1). In the original model, X. INHIBITORY NEURONS IN THE DORSAL... 208 signals arriving in the spinal dorsal horn from high-thresh- XI. SYNAPTIC TARGETS OF INHIBITORY... 208 old nociceptors and from low-threshold mechanosensitive XII. CHANGES IN DORSAL HORN SYNAPTIC... 212 fibers were proposed to interact with local inhibitory in- XIII. ENDOGENOUS MODULATORS OF... 214 terneurons to open or close the “pain gate.” Although some XIV. CHANGES IN INHIBITORY SYNAPTIC... 218 of the proposed synaptic connections were later shown to XV. RESTORING DORSAL HORN SYNAPTIC... 222 be incorrect, the pivotal role of inhibitory dorsal horn neu- XVI. CONCLUSIONS 224 rons in the spinal control of nociceptive signal propagation became firmly established, especially when the introduc- I. INTRODUCTION tion of selective blockers of GABAergic and glycinergic inhibition allowed direct proof of the contribution of the Proper processing of sensory information in the CNS de- two fast inhibitory neurotransmitters to dorsal horn pain pends critically on inhibitory synaptic transmission. The control. Today we know not only the structural, molec- contribution of GABAergic and glycinergic neurons to this ular, and neurochemical bases of this inhibition, but also process is probably best studied in the retina where the that a loss of GABAergic and glycinergic synaptic trans- neuronal circuits underlying lateral inhibition and feed-for- mission is an underlying mechanism of neuropathic and ward and feedback inhibition have extensively been char- inflammatory pain. Work from several laboratories has acterized as important mechanisms contributing to contrast discovered key elements of maladaptive plasticity in in- enhancement and to increased spatial and temporal resolu- hibitory dorsal horn circuits during different pathologi- tion. In the case of the somatosensory system, a similar cal pain states. Recent drug development programs have computation occurs first at the level of the spinal dorsal started to use this knowledge to develop new strategies horn (or in the trigeminal nucleus, the analog structure in aiming to restore proper synaptic inhibition in the spinal the brain stem). At these sites, somatosensory processing dorsal horn. Current basic research is focusing upon the involves the precise interaction of GABAergic and glyciner- precise components of neuronal circuits underlying spi- gic interneurons with other dorsal horn neurons and with nal inhibitory pain control. 193 DORSAL HORN SYNAPTIC INHIBITION FIGURE 1 Gate control theory of pain. This model proposed that inhibitory interneurons (yellow) located in the substantia gelatinosa (SG) would determine whether nociceptive input from the periphery would be relayed through the spinal transmission system (red, T) to higher CNS areas where pain would be consciously perceived. [Modified from Melzack and Wall (248), with permission from AAAS.] II. MOLECULAR COMPOSITION OF FAST A. GABAA Receptors INHIBITORY NEUROTRANSMITTER RECEPTORS: SYNTHESIS, STORAGE, The molecular architecture of GABAA receptors has been AND REUPTAKE OF GABA AND the subject of extensive research for several decades and has GLYCINE been comprehensively reviewed elsewhere (e.g., Ref. 29). Here, we briefly summarize the molecular composition of GABAA and glycine receptors belong to the Cys loop super- GABAA receptors. Most of the data discussed here are family of ligand-gated ion channels, which also includes based on experiments performed in rodent tissue or recep- nicotinic acetylcholine receptors and ionotropic serotonin tors unless stated otherwise. (5-HT3) receptors (FIGURE 2). Members of this family are distinguished by the presence of an NH2-terminal extracel- Mammalian GABAA receptors are assembled from a reper- lular domain containing a disulfide bridge between two cys- toire of 19 subunits designated as follows: ␣1-␣6, ␤1-␤3, ␥ ␥ ␦ ␧ ␲ ␪ ␳ ␳ teine residues. Both GABAA and inhibitory (strychnine-sen- 1- 3, , , , , and 1- 3 (283) (FIGURE 3). “Additional” sitive) glycine receptors are chloride permeable, pentameric, subunits, i.e., a ␤4 subunit and a ␥4 subunit, have been transmitter-gated ion channels with four transmembrane described in chicken (31, 141). These subunits correspond domains per subunit. to the mammalian ␪ and ␧ subunits, which are conversely absent in birds (346). If one were to apply an unrestricted combinatorial approach, these 19 subunits gave rise to thousands of subunit combinations. In reality however, it is likely that no more than 50 different subunit combinations exist in relevant amounts (283). Despite this, GABAA recep- tors remain the most diverse family of neurotransmitter receptors in the mammalian nervous system. The majority of these receptors contain two ␣ subunits, two ␤ subunits, and one ␥ subunit. They are typically clustered in mem- brane spots opposing GABAergic boutons, and activated by GABA released from presynaptic terminals. These synaptic receptors have a lower affinity for GABA than the extrasyn- aptic receptors discussed below and mediate phasic inhibi- tion. In the brain, most GABAA receptors are composed of ␣1, ␤2, and ␥2 subunits. In the spinal cord, ␣2 and ␣3 are more abundant than ␣1 subunits (48), and ␤2 is replaced in ␤ the majority of spinal GABAA receptors by 3 (211, 396). The “wheel” arrangement of ␣, ␤, and ␥ subunits in these FIGURE 2 Membrane topology of Cys loop ion channels as pro- channel complexes (32, 33) is shown in FIGURE 3B. The posed by Karlin and Akabas (186). physiological activator GABA binds to an interface formed 194 Physiol Rev • VOL 92 • JANUARY 2012 • www.prv.org ZEILHOFER, WILDNER, AND YÉVENES FIGURE 3 GABAA receptor subunits and ligands. A: dendrogram of mammalian GABAA receptors. [Modified ␣ ␤ from Barnard (30).] B: wheel arrangement of the five subunits of a typical GABAA receptor containing , , and ␥ subunits seen from the extracellular side. [Data based on Baumann et al. (32, 33).] C: chemical structures of GABA and of the GABAA receptor agonist muscimol. D: chemical structures of GABAA receptor blockers. by the ␣ and ␤ subunits, which occurs twice in a typical (287), the hypothalamus, and several other hindbrain areas ␲ ␪ GABAA receptor. In addition to the physiological activator (260). The and subunit are the least well-characterized ␪ GABA, many GABAA receptors bind endogenous neuro- GABAA receptor subunits. Expression of the subunit over- modulators, such as neurosteroids, and modulatory drugs, laps with the ␧ subunit in several CNS areas (287), while the including benzodiazepines, barbiturates, alcohols, and an- ␲ subunit is generally restricted to peripheral tissues such as esthetics. The benzodiazepine binding site is generated by lung, thymus, prostate, uterus (147), pancreas (51), and ␥ ␣ the 2 subunit and by one neighboring subunit (256). respiratory epithelia (67). Receptors containing ␥1or␥3 subunits are also able to bind benzodiazepine-site agonists but with strongly reduced af- Bicuculline is the most commonly used GABA receptor ␣ ␣ A finity (38). Only receptors containing at least one 1, 2, antagonist. It blocks all ionotropic GABA receptors, with ␣ ␣ 3, or 5 subunit are potentiated by benzodiazepine-site the exception of those containing ␳ subunits, but also inhib- ␣ ␣ agonists, whereas 4 and 6 subunits are resistant to po- its certain potassium channels