Transmitters involved in antinociception in the spinal cord.

The possible physiological and pathophysiological role of monoamines-adrenergic transmitter (norepinephrine), serotonin; cholinergic transmitter (acetylcholine); inhibitory (gamma-aminobutyric acid) and excitatory (glutamate) amino acids; opioid and nonopioid peptides, enkephalins, beta-endorphin and substance P, neurokinin-A, neurokinin-B, neurotensin, cytokines, calcitonine gene-related peptide, galanin, neuropeptide Y, nerve growth factor, cholecystokinin; purines; nitric oxide; vanilloid receptor agonists (capasaicin); and nociceptin-in spinal transmission of pain is reviewed. The role of substance P, neurokinin-A and neurokinin-B in the dorsal horn has been identified. These were suggested to be primary afferent transmitters mediating or facilitating the expression of nociceptive inputs. Pronociceptive modulators will be discussed later. Recent findings showing that N-methyl-D-aspartate (NMDA) receptor activation generates nitric oxide and prostanoids that enhance pain transmission whereas adenosine release acts to control these NMDA-mediated events are also mentioned. The clinical importance of centrally acting alpha2-adrenoceptor agonists (clonidine and dexmedetomidine) is also discussed. Antinociceptive and morphine-potentiating drugs are ideal adjuvants for anesthesia; their application in spinal anesthesia is highlighted. The recent development in understanding the importance of noradrenergic transmission and subtypes of alpha2-adrenoceptors (alpha2A and alpha2B) for the first time is reviewed.