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Skin Pain and Deep Sensibility As indicated earlier, the nerve endings in each tissue are activated by different mechanisms, and the pain that results is characterized by its quality, locale, and temporal attributes Skin pain is of two types: a pricking pain, evoked immediately on penetration of the skin by a needle point, and a stinging or burning pain, which follows in a second or two Together they constitute the double response of Lewis Both types of dermal pain can be localized with precision Compression of nerve by the application of a tourniquet to a limb abolishes pricking pain before burning pain Like the sensation of a limb falling asleep, this is not due to ischemia as commonly thought The rst (fast) pain is thought to be transmitted by the larger (A- ) bers and the second (slow) pain, which is somewhat more diffuse and longer-lasting, by the thinner, unmyelinated C bers Deep pain from visceral and skeletomuscular structures is basically aching in quality; if intense, it may be sharp and penetrating (knife-like) Occasionally there is a burning type of pain, as in the heartburn of esophageal irritation and rarely in angina pectoris The pain is felt as being deep to the body surface It is diffuse and poorly localized, and the margins of the painful zone are not well delineated, presumably because of the relative paucity of nerve endings in viscera Visceral pain produces two additional sensations First, there is tenderness at remote super cial sites ( referred hyperaglesia ) and, second, an enhanced pain sensitivity in the same and in neaerby organs ( visceral hyperalgesia ) This is a restatement of Head s early observations, discussed above, and MacKenzie s mapping of the referred Head zones, where somatic and visceral sensibility overlap as discussed below The concept of visceral hyperalgesia has received considerable attention in a number of pain syndromes in reference to the transition from acute to chronic pain, particularly in headache It has been speculated that the central mechanism of these syndromes involves glutamate Referred Pain The localization of deep pain of visceral origin raises a number of problems Deep pain has inde nite boundaries and its location is distant from the visceral structure involved It tends to be referred not to the skin overlying the viscera of origin but to other areas of skin innervated by the same spinal segment (or segments) This pain, projected to some xed site at a distance from the source, is called referred pain This ostensible explanation for the site of referrral is that small-caliber pain afferents from deep structures project to a wide range of lamina V neurons in the dorsal horn, as do cutaneous afferents The convergence of deep and cutaneous afferents on the same dorsal horn cells, coupled with the fact that cutaneous afferents are far more numerous than visceral afferents and have direct connections with the thalamus, is probably responsible for the phenomenon Since the nociceptive receptors and nerves of any given visceral or skeletal structure may project upon the dorsal horns of several adjacent spinal or brainstem segments, the pain from these structures may be fairly widely distributed For example, afferent pain bers from cardiac structures, distributed through segments T1 to T4, may be projected super cially to the inner side of the arm and the ulnar border of the hand and arm (T1 and T2) as well as the precordium (T3 and T4) Once this pool of sensory neurons in the dorsal horns of the spinal cord is activated, additional noxious stimuli may heighten the activity in the whole sensory eld ipsilaterally and, to a lesser extent, contralaterally Another peculiarity of localization is aberrant reference, explained by an alteration of the physiologic status of the pools of neurons in adjacent segments of the spinal cord For example, cer-. rdlc code 128 How to Generate Code 128 Barcode in RDLC Reports
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