White matter reorganization of motor and affective-motivational networks in pain-indifferent carriers of the R221W mutation

Congenital insensitivity to pain (CIP) due to the R221W mutation on the nerve growth factor gene results in reduced peripheral C-nociceptor density and behavioural indifference to painful stimuli. While functional neuroimaging has revealed altered cortical and sub-cortical pain processing in R221W carriers, structural white matter changes remain unexplored and may suggest an anatomical basis of symptoms. Heterozygous R221W carriers (n = 11) and age-, sex-, education-matched controls (n = 11) diffusion tensor imaging data were compared using fixel-based analysis, and complimentary edge and node analyses using graph theory, and network-based statistics. Whole-brain and region of interest (ROI) fixel-based analyses revealed significantly reduced fibre density and fibre-bundle cross-section in brainstem motor tracts of R221W carriers, encompassing the corticospinal pathways, corona radiata, external capsule, cerebellar peduncles, and pontine crossing (p < 0.05). Graph theory analysis of pain-processing ROIs demonstrated reduced local efficiency in right anterior cingulate cortex (ACC) and altered betweenness centrality in bilateral insula and left ACC of R221W carriers. Despite R221W carriers showing higher node degrees in the somatosensory cortex and ACC, these connections had reduced efficiency and integration with cortical network regions. Network-based statistics identified a possible compensatory subnetwork with stronger connectivity from right thalamus to left ACC and left insula in R221W carriers (p < 0.019). These findings suggest that congenitally reduced peripheral nociception could lead to abnormalities in the thalamocortical and motor efferent pathway, but not sensory afferent pathways. The combination of reduced brainstem motor tract integrity and altered cortical network efficiency, alongside potentially compensatory thalamo-cortical connectivity, could support a model of R221W CIP as motor under-reactivity rather than sensory insensitivity.