Decreased intracellular GABA levels contribute to spinal cord stimulation-induced analgesia in rats suffering from painful peripheral neuropathy: The role of KCC2 and GABAA receptor-mediated inhibition

Elevated spinal extracellular γ-aminobutyric acid (GABA) levels have been described during spinal cord stimulation (SCS)-induced analgesia in experimental chronic peripheral neuropathy. Interestingly, these increased GABA levels strongly exceeded the time frame of SCS-induced analgesia. In line with the former, pharmacologically-enhanced extracellular GABA levels by GABAB receptor agonists in combination with SCS in non-responders to SCS solely could convert these non-responders into responders. However, similar treatment with GABAA receptor agonists and SCS is known to be less efficient. Since K+ Cl− cotransporter 2 (KCC2) functionality strongly determines proper GABAA receptor-mediated inhibition, both decreased numbers of GABAA receptors as well as reduced KCC2 protein expression might play a pivotal role in this loss of GABAA receptor-mediated inhibition in non-responders. Here, we explored the mechanisms underlying both changes in extracellular GABA levels and impaired GABAA receptor-mediated inhibition after 30 min of SCS in rats suffering from partial sciatic nerve ligation (PSNL). Immediately after cessation of SCS, a decreased spinal intracellular dorsal horn GABA-immunoreactivity was observed in responders when compared to non-responders or sham SCS rats. One hour later however, GABA-immunoreactivity was already increased to similar levels as those observed in non-responder or sham SCS rats. These changes did not coincide with alterations in the number of GABA-immunoreactive cells. C-Fos/GABA double-fluorescence clearly confirmed a SCS-induced activation of GABA-immunoreactive cells in responders immediately after SCS. Differences in spinal dorsal horn GABAA receptor-immunoreactivity and KCC2 protein levels were absent between all SCS groups. However, KCC2 protein levels were significantly decreased compared to sham PSNL animals. In conclusion, reduced intracellular GABA levels are only present during the time frame of SCS in responders and strongly point to a SCS-mediated on/off GABAergic release mechanism. Furthermore, a KCC2-dependent impaired GABAA receptor-mediated inhibition seems to be present both in responders and non-responders to SCS due to similar KCC2 and GABAA receptor levels.

► SCS activates spinal dorsal horn GABAergic interneurons.
► SCS decreases intracellular GABA only during stimulation in responders.
► GABAA receptor levels are similar in responders and non-responders to SCS.
► KCC2 membrane levels are decreased both in responders and non-responders to SCS.
► Reduced KCC2 levels partly induce GABAA receptor-mediated disinhibition during SCS.