Dr. Puji Pinta O.

Sinurat, SpS
Dept 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 age
Sex : male
Family history
Previous : Back injury, surgery
Pregnancy
Congenital spine problems
Lack of exercose
Longerm medicine that weaken bones
Poor posture
Overweight
Stress
smoking
 Definisi: nyeri yang dirasakan di daerah
punggung bawah, dapat merupakan nyeri
lokal maupun nyeri radikuler atau keduanya
Incidens : 60-90% lifetime incidens
5 % annual incidens
90% LBP resolve without treatment within 6-
12 weeks
40-50% resolves within 1 week
75% with nerve root involvement can resolve
in 6 months
LBP leading cause of disability of adults < 45
yo
Third 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
ekstremitas
2. Iritasi cabang saraf kecil yang mempersarafi
vertebra
3. Ketegangan sepasang otot punggung
(m.erector spinae)
4. Kerusakan tulang, ligamentum atau sendi
5. Ruang antar vertebra dapat menjadi sumber
nyeri
1. NPB Akut : < 6 minggu
2. NPB Subakut : 6 -12 minggu
3. 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
* Pagets 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/ Sciatica
Pain 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 CES

Inflammatory process antiinflammatory

agent (ibuprofen, corticosteroid
Infection antibiotics therapy
Physiotherapy 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 atas
menurut 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 servikalis
C6-7 (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 symptoms
4. 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
TERIMA
KASIH