Dr. Puji Pinta O. Sinurat, SpSDept Neurologi FK-USU MEDAN

2014

Symptoms : - Muscle ache or shooting- Limited range of function- Inability to stand straight

Types :- Acute Vs Chronic- Lower Back Pain - Middle Back Pain- Upper Back Pain

- Accidents- Arthritis- Muscle strains- Sport injuries- Nerve problems- Muscular problems- Degenerative disc disease

Age : middle ageSex : maleFamily historyPrevious : Back injury, surgeryPregnancyCongenital spine problemsLack of exercoseLongerm medicine that weaken bonesPoor postureOverweightStresssmoking

Definisi: nyeri yang dirasakan di daerah punggung bawah, dapat merupakan nyeri lokal maupun nyeri radikuler atau keduanya

Incidens : 60-90% lifetime incidens5 % annual incidens

90% LBP resolve without treatment within 6-12 weeks40-50% resolves within 1 week75% with nerve root involvement can resolve in 6 monthsLBP leading cause of disability of adults < 45 yoThird cause of disability in >45 y o

- Lumbar strain- Disc bulge/protrusion/extrusion/producing

radiculopathy- Degenerative disc disease- Spinal stenosis- Spondyloarthropathy- Spondylosis- Spondylolisthesis- Sacro-iliac dysfuntion

1. Iritasi cabang saraf besar yang menuju ekstremitas2. Iritasi cabang saraf kecil yang mempersarafi vertebra3. Ketegangan sepasang otot punggung (m.erector spinae)4. Kerusakan tulang, ligamentum atau sendi5. Ruang antar vertebra dapat menjadi sumber nyeri

1. NPB Akut : < 6 minggu2. NPB Subakut : 6 -12 minggu3. NPB Khronik : > 12 minggu

I. MEKANIKAL* Strain, sprain lumbal* Proses degeneratif diskus dan facet * Herniasi diskus * Stenosis spinal * Fraktur kompresi osteoporotik * Spondilolistesis * Fraktur traumatik * Penyakit kongenital

II. NON MEKANIKAL * Neoplasma * Infeksi : osteomielitis, abses epidural, abses

paraspinal, penyakit Pott* Artritis inflamatori : Ankylosing spondylitis,

Psoriatic spondylitis, Sindroma Reiter

* Paget’s disease of the bone

INSPEKSI : gaya berjalan, simetri, perilaku penderita terkait keluhan nyerinya.

PALPASI : vertebra, kelompok otot paraspinal PERKUSI : menilai adanya nyeri tekan PEMERIKSAAN UTK MENILAI FUNGSI :

* range of motion* SLR test* hiperekstensi tungkai* refleks* fungsi motorik dan sensorik

NEUROFISIOLOGIK :- EMG- somatosensory evoked potential

RADIOLOGIK :- foto polos- mielografi, CT mielografi, CT-scan, MRI

LABORATORIUM :- LED, CRP, DL, UL

Usia > 50 tahun Defisit motorik (+) BB menurun tanpa sebab yg jelas Dugaan Ankylosing spondylitis Penyalahgunaan obat dan alkohol Adanya riwayat kanker Suhu > 37,8oC Tidak ada perbaikan dalam 1 bulan

Serious neurologic condition in which damage to the cauda equina

Causes acute loss of function of the Lumbar plexus, nerve roots of the spinal canal below the termination (conus medullaris) of the spinal cord

Is a Lower Motor Neuron Lesion

Low Back Pain/ SciaticaPain start in the buttocks-- travels down

the back of the thighs and legs Severe back pain Loss of sensation in a saddle distribution

over the genitals, anus and inner thighs (perineal or saddle paresthesia)

Bowel and bladder disturbances

Sexual dysfunction Lower extremitiy muscle weaakness and

loss of sensation (often paraplegia) Lower extremity reflexes : reduced/absent

Compression Traumatic injury compression of the

cauda equina Disk herniation Spinal stenosis Spinal tumor Inflammatory condition

Cauda equina syndrome is a surgical emergency (surgical decompression)

Treatment underlying causes of CESInflammatory process antiinflammatory

agent (ibuprofen, corticosteroidInfection antibiotics therapyPhysiotherapy and occupational theraphy

Surgical intervention with decompression assist recovery

50-70% patient have urinary retention 30-50% incomplete syndrome

Adalah kelainan yang disebabkan perpindahan ke depan satu corpus vertebra terhadap vertebra di bawahnya.

Tersering pada L4-5 Sering pada : orang yang sering angkat beban berat, pemain

sepak bola, trauma Pada semua usia, tersering pada usia tua

Berdasarkan foto polos lateral, dibagi atasmenurut derajat beratnya pergeseran :Grade 1 : 25%Grade 2 : 25-49%Grade 3 : 50-74%Grade 4 : 75-99%Grade 5 : 100% (slip seluruhnya spondyloptosis)

Istirahat Hindari angkat berat Analgetik, OAINS Operasi

Adalah kelainan degeneratif yang menyebabkan hilangnya struktur dan fungsi normal spinal

Penyebab utama : proses penuaan Lokasi dan percepatan proses degenerasi bersifat individual

Konservatif (75% berhasil), meliputi :* istirahat* OAINS* pelemas otot* Pemanasan, stimulasi elektrik, lumbosakral

ortotik* Olah raga* Modifikasi gaya hidup

Pembedahan (jarang)

HNP adalah protrusi atau ekstrusi nukleus pulposus bersama sebagian annulus fibrosus ke dalam kanalis vertebralis atau foramen intervertebralis

Insidens : 1-2 % populasi Dapat terjadi dimana saja sepanjang medulla spinalis Paling sering di daerah lumbal

Umur 30-50 tahun Lokasi nyeri : pinggang ke tungkai bawah Rasa nyeri : nyeri terbakar, parestesi di tungkai Faktor yang memberatkan : meningkat dengan membungkuk

atau duduk, berkurang dengan berdiri Tanda klinis : SLR (+), kelemahan, refleks asimetri

HNP lumbalis (paling >>)L5-S1 (45-50%), L4-5 (40-45%)ok jaringan fibrokartilagonya terutama di posterior lebih tipis dibanding diskus intervertebralis lainnya

HNP servikalisC6-7 (69%), C5-6 (19%)

HNP torakalis (jarang, < 1%)

Protruded Disk : penonjolan nukleus pulposus tanpa kerusakan annulus fibrosus

Prolapsed Disk: nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus.

Extruded Disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis posterior.

Sequestrated Disk : nukleus telah menembus ligamentum longitudinalis posterior.

Lumbar HNP :* Lasegue (straight leg raising) test.

A positive SLR test is a sensitive indicator of nerve root irritation (sensitivity 95%).,

May be positive with disc protrussion, intraspinal tumor or inflammatory radiculopathy* Crossed Laseque (crossed SLR) test.

Less sensitive but highly specific.* Femoral stretch (reverse SLR) test.

May detect an L2-4 root or femoral nerve irritation.

Plain vertebral x-rays :* limited information* disc narrowing, scoliosis, lordosis lumbal

Myelography CT or CT-myelography MRI : the best imaging study

EMG/NCV : 90% abnormal after 1-2 weeks

bed rest : max 2 days recommended* Pharmacotherapy :

- NSAID- short course of corticosteroid for acute herniated disc (controversial)- muscle relaxant- for neuropathic pain : gabapentin, 5% lidocaine patch, tramadol, TCA.

* Nonpharmacologic therapy :- heat, ice, massage, stress reduction, activity

limitation, postural modification, physical therapy program

- soft cervical collar or lumbar corset

The few absolute indications :1. Marked muscular weakness pertaining to a nerve root or roots.2. Progressive neurologic deficits.3. Cauda equina syndrome with urinary symptoms4. Pain that has existed for more than 4 months, has not

responded to conservative treatment, and interferes with normal function.

Adalah penyempitan kanal spinal dengan kompresi akar saraf, dengan atau tanpa keluhan

Penyebab yang sering : hypertrophic degenerative dari facet dan penebalan ligamentum flavum

Usia > 50 tahun Neurogenic intermittent claudiation or

pseudoclaudication (most frequent) Radicular pain is the least common manifestation Lokasi nyeri : pinggang sampai tungkai bawah,

seringkali bilateral Sifat nyeri : menusuk, seperti menikam, rasa seperti

ditusuk jarum Faktor yang memperberat : bertambah bila jalan,

berkurang bila duduk Tanda klinis : sedikit penurunan ekstensi vertebra

Analgetik, OAINS Terapi fisik Injeksi kortikosteroid epidural Laminektomi dekompresi

1. Severe and disabling pain (persistent intolerable pain)

2. Limitation of walking distance or standing endurance to a degree that compromises necessary activities

3. Severe or progressive muscle weakness or disturbed bladder and bowel, or sexual function.

4. Poor response to at least 4 weeks of conservative treatment

TERIMAKASIH