Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 18. Spinal disorders are among the most common medical conditions with significant impact on health related quality of life, use of health care resources and socio-economic costs. Spinal surgery is still one of the fastest growing areas in clinical medicine. | Pathways of Spinal Pain Chapter 5 145 ceptive stimuli before transmission to the somatosensory cortex perception . Neuroplasticity. Alterations in the physiological function of pain pathways as a result of tissue damage or neural injury are referred to as neuroplasticity. Injured tissue can release inflammatory mediators which activate and sensitize receptor channels in the peripheral terminal of the nociceptor. High-threshold and silent nociceptors are activated by a decrease in their threshold and show an increase in the responsiveness peripheral sensitization . Tissue damage may also result in transcriptional changes in the dorsal root ganglion. Similarly pain transmission is facilitated and inhibitory influences are attenuated by distinct neurobiological alterations of the receptor channels in the dorsal horn central sensitization . Afferent nociceptive signals from the periphery to the brain are modulated by a well balanced interplay of excitatory and inhibitory neurons which can be disturbed as a result of an injury. Disinhibition is the disturbance of this balance with relief from inhibitory neuronal mechanisms. Genetic predisposition and biopsychosocial factors have a significant influence on the modulation of the afferent sensory input. Clinical assessment. The clinical assessment of pain encompasses a detailed medical history sophisticated quantitative sensory testing neurophysiological studies imaging studies and pharmacological tests. The clinical differentiation of persistent inflammatory pain and neuropathic pain remains difficult because of the lack of an objective test for neuropathic pain the missing gold standard . It is important to note that not all persistent pain is neuropathic. The diagnosis of neuropathic pain should be based on the presence of negative and positive sensory symptoms and signs. General treatment concepts. The pharmacological treatment of acute pain must be aggressive multimodal and preemptive to reduce the likelihood of pain
