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: Amputation; Dynamic mechanical allodynia; Hyperinnervation; Neuropathic pain; Skin biopsy.

Figure 1

Area of severe dynamic mechanical allodinia from which the punch skin biopsy was taken. The area of tactile allodynia was actually larger than the illustrated one because it was partially diffused also in the dorsum of the hand.

Figure 2

The figure illustrate the higher density of epidermal nerve fibres (arrowheads) in the allodynic skin (A), when compared to contralateral normal skin (B). It also shows some abnormal patterns of nerve fibre regeneration (arrows) in the dermis of the allodynic skin. Indirect immunofluorescence method: in green, protein gene product 9.5 staining of nerve fibres; in red, type IV collagen staining of basement membrane and blood vessels.