Referred Pain

• It is a type of pain, which is felt

away from its original site.
• It is most frequent with visceral
pain and deep somatic pain but
Cutaneous pain is not referred.
 Mechanism of referred pain 1
• Referred pain is explained by Conversion
Projection Mechanism where the afferent
pain-conducting fibers from the viscera
converge with afferent pain-conducting
fibers from the skin on one central neuron
of the paleospinothalamic tract.
• In these way impulses viscera travel in the
same central pathway as pain impulses
from the skin to reach the same final
sensory neuron in the brain.
 Mechanism of referred pain 2
• The final sensory neuron projects pain
sensation to the skin as the skin in the
place from which it usually receives pain
signals.
• This means that the pain signals from the
viscera converge to the same final
sensory neuron as the signals from the
skin, the brain projects any pain sensation
from the viscera to the skin.
 Examples
• Pain of Cholecystitis It is usually referred to the
tip of right shoulder.
• Cardiac pain: It is usually referred to the left
shoulder and inner side of the left arm.
• Renal pain: Pain in the kidneys and ureters is
referred to the testicular region.
• Appendix pain: Pain from inflamed appendix is
referred to the other area around the umbilicus.
• Gastric pain: Is referred to abdominal
structures above the umbilicus.
 Somatic Sensations from the Head
Two pathways conduct somatic sensations from the
head area:
1) From Back of head: cervical nerves 2, 3
2) From the face: Trigeminal nerve
 The Trigeminal pathway
• Sensory signals are collected from the face and upper
part of the head by the three divisions of the Trigeminal
nerve. Then the signals travel through Trigeminal
pathway in 3 order neurons:-
• 1- 1st order neurons:
• These are the central branches of unipolar nerve cells
located in the trigeminal ganglion, they enter the pons
and divided into 2 groups:-
• A) Ascending fibers:
• Carry touch sensation, vibration sense, sense of position
and sense of passive movement. These fibers end in
main sensory nucleus of the trigeminal nerve which
corresponds to the gracile & cuneate nuclei.
• B) Descending fibers:
• These transmit pain and temperature. They terminate in
spinal trigeminal nucleus.
 The Trigeminal pathway
• 2- 2nd order neuron:
• These starts at the sensory,
mesencephalic and spinal nuclei, cross to
opposite side, and ascend as the
trigeminal lemniscus → which terminate at
the thalamic vertebral posteromedial
nucleus (VPMN).
• 3- 3rd order neuron:
• These start at the thalamic nuclei (VPMN)
→ pass in the sensory radiation → and
terminate in the cortical sensory areas.
Trigeminal pathway
Lesions in the trigeminal pathway 1
• Trigeminal neuralgia
Is a painful condition which affects the
face.
The pain of trigeminal neuralgia is felt
in the territory of one or more
branches of this nerve.
It usually occurs on one side of the
face; in rare cases it can affect both
sides at the same time.
Lesions in the trigeminal pathway 2
• Trigeminal nerve injury = Trigeminal
anesthesia.
• Lesion of trigeminal ganglion =
Ipsilateral.
• Lesion of trigeminal leminscus =
Contralateral.
• Lesion of sensation from eyes = leads
to corneal inflammation & ulceration
in sever cases.
 Headache
It is a painful sensation at the head.
It may be referred from other structures.
It may be either intracranial or extracranial.
• Extracranial causes of • Intracranial causes of
headache: headache:
• - Eye disease • 1- Meningeal irritation:
• Errors of refraction. • - Alcohol headache.
• - Sinusitis. • - Space occupying lesion.
• - Constipation headache.
• - Toothache. • - Meningitis headache.
• -Otitis media and Otitis • - Lumber puncture
externa. headache.
• - Emotions and tension. • 2- Arterial distention:
• - Spasm of head and • Hypertension headache.
neck muscle. • Migraine headache.
 Somatic Sensory areas of the cerebral cortex
• All sensations of the body reach the
thalamus of the opposite side except
the olfactory sensation.
• The thalamus sends its impulses to
the sensory areas of the cerebral
cortex.
• These include the primary somatic
sensory areas and The association
somatic sensory areas
Brain areas
 Somatic sensory areas
• Primary Somatic Sensory
areas:
• Somatic Sensory Area I.
• Somatic Sensory Area II.
• Somatic Sensory Area I(SI):
• It lies in the postcentral gyrus
immediately behind the central
sulcus in the parietal lobe.
 Functions of Somatic Sensory Area I

1- It
receives the following sensations:
2- Fine touch sensations (T.L.– T.D. –
Stereognosis – Texture of material).
3- Discrimination of weight.
4- Vibration sense.
5- Discrimination of various grades of
temperature.
 Somatic Sensory Area I(SI):
It lies in the postcentral gyrus immediately behind
the central sulcus in the parietal lobe.
• It is characterized by:
• It receives sensations from the opposite side of
the body i.e. crossed representation.
• The body is represented in an inverted manner.
The head is represented in the lower part of
postcentral gyrus, while the area of the leg lies in
the upper part of the sensory area.
• The area of representation of each part is
proportional to the number of receptors in this
part, not to size.
 Somatic Sensory Area II (SII):
• It is a small area that lies posterior and inferior
to the lower end of postcentral gyrus.
• Body representation:
Bilateral representation with poor topographic
representation.
The head area is gradually in the anterior part
and the leg area is in the posterior.
• Functions:
– SII is a potentiator to SI.
- It cannot work independent of S1.