Dynamic mechanical allodynia following finger amputation: Unexpected skin hyperinnervation

Abstract

The development of chronic pain after amputations is not an uncommon event. In some cases the most disabling problem is represented by the symptom called dynamic mechanical allodynia, characterized by the painful sensation evoked by gently stroking the skin. Despite the growing interest in understanding pain mechanisms, little is known about the mechanism sustaining this peculiar type of pain. We present here the case of a 53-year-old female patient who complained of severe tactile allodynia in the hand after amputation of her left second finger, resistant to several medical and surgical treatments. In order to gain information about the pain mechanism, two neurodiagnostic skin biopsies were obtained from the area of tactile allodynia and from the contralateral, normal skin area. Skin biopsies showed an unexpected increased innervation of the allodynic skin compared to the contralateral, normal skin area (+ 80.1%). Hyperinnervation has been proposed as a mechanism of pain following nerve lesions, but the increased innervation described here could be also attributed to neuronal plasticity occurring in chronic inflammatory conditions. Independently from the uncertain cause of the epidermal hyperinnervation, in this patient we tried to reduce the elevated number of epidermal nerve fibres by treating the skin with topical capsaicin (0.075%) three times a day, and obtained a persistent pain relief. In conclusion, neurodiagnostic skin biopsy might represent an useful tool for detecting derangements of epidermal innervation in patients with dynamic mechanical allodynia and can help to select an individually tailored therapeutic strategy in such difficult clinical conditions. Further studies are needed to clarify this issue and try to gain better understanding of chronic pain mechanisms in patients who underwent finger amputation.

Keywords: Neuropathic pain, Hyperinnervation, Dynamic mechanical allodynia, Amputation, Skin biopsy

Core tip: In some patients with post-amputation chronic pain dynamic mechanical allodynia (a painful sensation evoked by gentle stroking the skin) represents the most disabling problem. So far, little is known about the mechanism of this peculiar type of pain. We present here a patient who complained of severe dynamic mechanical allodynia in the hand after amputation of the left second finger. The neurodiagnostic skin biopsy showed an increased innervation of the allodynic skin compared to the contralateral, normal skin area (+ 80.1%), suggesting hyperinnervation as a possible pain mechanism. Interestingly, topical capsaicin (0.075%) relieved allodynia for a long period.