blok muskuloskeletal

BLOK MUSKULOSKELETAL :Hernia Nukleus Pulposus

Spinal StenosisSpondilitis TB

Bagian NeurologiFakultas Kedokteran UISU

2011

HERNIA NUKLEUS PULPOSUS(HNP)

Hernia Nukleus Pulposus

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 colum verteralis Paling sering di daerah lumbal

The disc

Herniated disc

KARAKTERISTIK HNP AKUT

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

Distribusi lokasi HNP

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%)

Gradasi HNP

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.

Gradasi HNP

Diagnosis HNP :Neurological examination

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.

Diagnosis HNP

RADIOLOGICAL EXAMINATION : Plain vertebral x-rays :

* limited information* disc narrowing, scoliosis, lordosis lumbal

Myelography CT or CT-myelography MRI : the best imaging studyEMG/NCV : 90% abnormal after 1-2 weeks

MRI scan shows L4-5 herniated disc

Therapy HNP : Conservative

* 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

- soft cervical collar or lumbar corset

Therapy HNP : Operative

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.

SPINAL STENOSIS

STENOSIS SPINAL

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

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

Stenosis Spinal

KARAKTERISTIK STENOSIS SPINAL

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

TERAPI STENOSIS SPINAL

Analgetik, OAINS Terapi fisik Injeksi kortikosteroid epidural Laminektomi dekompresi

INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS

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

SPONDILITIS TUBERCULOSA

INTRODUCTION

Pervicall Pott (England,1779) triad of Pott’s disease: abscess, gibbus, paraplegia

Single or multiple vertebral involvement by tuberculosis is frequently followed by spinal cord compression due to development of cold abscess in epidural space (Pott’s disease)

The most common site of infection is thoracolumbar spine, rarely cervical spine.

LOCATION

1.Paradiscal type >2. Central type3. Anterior type4. Post Facet joint5. Appendicial

1

2

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1

5

Spondilitis Tuberkulosa

Patofisiologi Spondilitis Tuberkulosa

Patofisiologi : Rute penyebaran ke vertebra

Arteri/hematogen Vena (batson plexus) Percontinuitatum

Manifestasi Klinis

Keadaan Umum : Sakit kronis, demam, keringat

malam, anorexia, Penurunan berat badan

Gejala Lokal : Nyeri lokal atau radikuler Spasme otot punggung Night cries pada anak Defisit neurologis Deformitas

Diagnostic procedure Pemeriksaan darah : LED meninggi> 100mm/jam Tuberculin skin test (Purified Protein Derivative/ PPD) biasanya positif Biopsi kelenjar leher Sputum utk BTA (+) dan kultur Mycobacterium tuberculosa Radiologi - proses spesifik di paru Thorax foto - Vertebra : gibbus dan kyphosis - CT Scan Vertebra : destruksi vertebra, soft tissue calcification, narrow

disc space, bone erosion (scalloping). - MRI vertebra: a. membedakan TB spondilitis atau pyogenic spondylitis, b. melihat adanya kompresi saraf.

X-ray in Spondylitis TB

Tuberculous spondylitis. Lateral radiograph demonstrates obliteration of the disk space (straight arrow) with destruction of the adjacent end plates (curved arrow) and anterior wedging.

X-ray in Spondylitis TB

Subligamentous spread of spinal tuberculosis. Lateral radiograph demonstrates erosion of the anterior margin of the vertebral body (arrow) caused by an adjacent soft-tissue abscess.

MRI in Spondylitis TB

Gibbus deformity secondary to tuberculous spondylitis. Sagittal T1-weighted (a) and T2-weighted (b) MR images show vertebral collapse with high signal intensity in the adjacent vertebral bodies. The vertebral collapse has resulted in a gibbus deformity and spinal cord compression.

MRI

Treatment 1. Immobilisasi, bed rest, extrafeeding, brace, korset. 2. Obat anti tuberkulosis. Berdasarkan Pedoman Penatalaksanaan TB paru termasuk kategori I ( TB diluar paru) : # 2 bln pertama : Streptomycin, INH, Rif dan PZA # Bulan 3-12 : INH dan Rifampisin 3. Operatif - Indikasi operasi pada pott’s disease: adanya defisit neurologis adanya abses paravertebra [Cold Abscess] terapi konservatif gagal severe kyposcoliosis cord/ nerve compression

PROGNOSA

Dari 100 penderita ,yang mengalami disability 2 penderita mengalami reccurence paraplegia setelah 3 tahun berobat, 1 penderita akibat granuloma ekstramedularis dan 1 orang dengan kifosis yang berat.

Angka mortalitas 20%.

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