Abstract
Phantom limb pains in amputees require a long time until spontaneous resolution, and various treatments that have been attempted have not produced sufficient effects. We encountered a case of phantom pain of the lower limb that appeared after amputation due to traffic trauma but was improved by the administration of milnacipran. The patient was a 27-year-old male. He was admitted to the orthopedic department of our hospital due to tear of the right limb below the knee, traumatic hemopneumothorax, and atelectasis sustained in a traffic accident, and underwent right above-the-knee amputation. Hemopneumothorax and atelectasis could be managed successfully by conservative treatments. However, phantom limb pain appeared immediately after amputation with insomnia and dyspnea, which was unlikely to be due to organic causes. After the patient was administered paroxetine (20mg), he was referred to our department. At the initial examination, the patient was not depressed, but anxieties over the use of a prosthetic leg and the future were noted. In combination with supportive psychotherapy, paroxetine was increased to 40mg. This resolved the dyspnea and anxiety, but phantom limb pain persisted while it was alleviated, and bradyspermatism appeared. When the drug was replaced with milnacipran (100mg), phantom limb pain was further alleviated, and a feeling of residual urine, which appeared newly, could be managed by the administration of naftopidil. Although both paroxetine and milnacipran were effective, milnacipran was more effective and tolerable and was useful for the treatment of phantom limb pain. Although phantom limb pain in this patient is considered to have been caused by many factors, the effect of milnacipran may have been derived primarily from its direct analgesic effect by activation of both the noradrenergic and serotonergic neurons, which consist descending inhibitory nerves of the central nervous system. In addition, the early starts of pharmacotherapy and psychotherapeutic intervention were also considered to be effective.
