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Complete Spinal Transaction, Hernia

Nucleus Pulposus, Sindroma Radikular,


Kompresi Medulari Akut, Sindrom Radiks
Posterior, dan Sindroma Cauda Equinal

Dr. Tutik Ermawati, Sp.S, Msi. Med


Peripheral Nerves and Nerve
Plexuses
C1
C2
Cervical plexus C3
C4
C4
C4
Brachial plexus C4 Phrenic nerve
C4
T1
T2
T3
T4
Axillary nerve
T5
T6
T7 Musculocutaneous nerve
T8
T9
Thoracic nerves
T10
T11
T12
L1
Radial nerve
Lumbar plexus L2
L3
Ulnar nerve
L4 Median nerve
L5
S1
Sacral plexus
S2
S3
S4
S5
Co1 Lateral femoral cutaneous nerve

Genitofemoral nerve
Femoral nerve

Pudendal nerve

Sciatic nerve
See ANS
lecture
Hernia Nucleus
Pulposus
Abnormal rupture of the soft
gelatinous central portion of the Typical locations of disc
disc (nucleus pulposus) through herniation
the surrounding outer ring • Central
(annulus fibrosus). In about 95% It is rare condition, it will
of all disc herniation cases, the affect multiple nerve roots,
L4-L5 or L5-S1 disc levels are patient will have back pain
Causes
involved.of disc herniation : more than leg pain and it may
1. Trauma or injury to the cause incontinence of the
disc bladder and bowel. Urgent
2. Disc degeneration surgical treatment is
3. Congenital predisposition necessary if patient presents
with neurological deficits.
• Posterolateral
Usually it is the most common
location, it involve one nerve
root (the lower one).
• Foraminal
It occurs in about 8-10% of all
cases. It involves the exiting
nerve.
Diagnosis HNP
Clinical manifestations of disc
herniation :
If the herniated disc is:
 Not pressing on a nerve, you
may have an ache in the low
back or no symptoms at all.
 Pressing on a nerve, you may
have pain, numbness, or
Tingling
weakness in the ("pins-and-needles"
area of your
sensation)
body to or numbness
which the in one leg
nerve
that can begin in the buttock or
travels.
behind the knee and extend to the
thigh, ankle, or foot.
Weakness in certain muscles in one
or both legs.
Pain in the front of the thigh.
cauda
MRI is equina
the syndrome
test of choice for
evaluation of disc disease. Its
multiplanar capabilities make it
suitable for visualizing far lateral
disc herniation as well as the
paravertebral structures.
Management of disc
herniation
Bed rest and analgesics and anti-inflammatory
drugs.

Muscle relaxants help in some. Transcutaneous


electrical nerve stimulation (TENS) helps in about 20%
of patients.

Physical therapy such as (exercise, relaxation,


massage, and hot compressors).

Surgical management : Indications for surgery


include failure of acceptable pain control by
nonoperative measures, progressive neurological
deficit. The traditional approach to lumbar discectomy
(laminectomy) usually under general anesthesia.
Cauda Equina
Syndrome
Cauda equina syndrome is caused by
any narrowing of the spinal canal that
compresses the nerve roots below the
level of the spinal cord.

Causes of cauda equina syndrome


including : disc herniation, intradural
disc rupture, spinal stenosis
secondary to other spinal conditions,
traumatic injury, primary tumors
ependymomas and schwannomas,
metastatic tumors, infectious
conditions, arteriovenous
malformation or hemorrhage, and
iatrogenic injury.
Dx: (Clinical Signs)
The symptoms of cauda equina In cauda equina syndrome, muscle
syndrome are associated with strength in the lower extremities is
corresponding signs pointing to an diminished. with the lower lumbar
LMN or UMN lesion and sacral roots more affected,
Symptoms of cauda equina syndrome leading to diminished strength in
include the following: the glutei muscles, hamstring
muscles (ie, semimembranosus,
• Low back pain semitendinosus, biceps femoris),
• Unilateral or bilateral sciatica and the gastrocnemius and soleus
• Saddle and perineal hypoesthesia muscles.
Sensation is decreased to pinprick
or anesthesia and light touch in a dermatomal
• Bowel and bladder disturbances pattern corresponding to the
• Lower extremity motor weakness affected nerve roots. This includes
and sensory deficits saddle anesthesia (sometimes
• Muscle tone in the lower including the glans penis or
extremities is decreased clitoris) and decreased sensation in
• Reduced or absent lower extremity the lower extremities in the
reflexes; Babinski reflex is distribution of lumbar and sacral
diminished or absent. nerves. Vibration sense may also
be affected. Sensation of the glans
penis or clitoris should be
examined.
Dx:
• Myelography, computed
tomography, and MRI  to
determine the level of Other lab :
pathology
Depending on the findings from the
• Bone scan may detect history and physical examination,
malignant tumor or laboratory studies can include basic
metastases and inflammatory blood tests, fasting blood sugar, and
conditions affecting the syphilis and Lyme serologies. CSF
vertebrae. examination should also be included
if signs of meningitis are present
• Due to its ability to depict the
soft tissues, MRI generally Urodynamic studies are useful to
has been the favored imaging evaluate the degree and cause of
study for assisting the sphincter dysfunction
physician in the diagnosis of
cauda equina syndrome.
Management of CES
Specific treatment is directed at the primary cause

Anti-inflammatory agents and steroids can be effective


in patients with inflammatory processes

Antibiotic therapy

Any patient with true cauda equina syndrome should


undergo no more than 24 hours of initial medical
management. If no relief of symptoms is achieved
during this period, immediate surgical decompression
is necessary to minimize the chances of permanent
neurologic injury..
Acute Medullary
Compression
Compression is caused far more
commonly by lesions outside the
spinal cord (extramedullary) than by
lesions within it (intramedullary).
Compression may be acute,
subacute, or chronic.

Acute compression develops within


minutes to hours. It is often due to
trauma (eg, vertebral fracture, acute
disk herniation, metastatic tumor,
severe bone or ligamentous injury
causing hematoma, vertebral
subluxation or dislocation). It is
occasionally due to abscess and
rarely due to spontaneous epidural
hematoma.
Dx: (Clinical Signs)
Paraparesis or These are common symptoms:
quadriparesis, 1. Pain and stiffness in the neck,
back, or lower back
hyporeflexia (when 2. Burning pain that spreads to the
acute) followed by arms, buttocks, or down into the
hyperreflexia, legs (sciatica)
3. Numbness, cramping, or weakness
in the arms, hands, or legs
Subacute or chronic 4. Loss of sensation in the feet
compression may 5. Trouble with hand coordination
begin with local back 6. "Foot drop," weakness in a foot
that causes a limp
pain, often radiating 7. Loss of sexual ability
down the distribution 8. lumbar region can also cause more
of a nerve root serious symptoms known as cauda
equina syndrome.
(radicular pain), 9. Loss of bowel or bladder control
Dx:
Spine X-rays. These may show
bone growths (spurs) that push
against spinal nerves. X-rays
may also show an abnormal
alignment of the spine.

CT or MRI scan will give a more


detailed look at the spinal cord
and the structures surrounding
it.

Other studies. These may


include a bone scan,
myelogram (a special X-ray or
CT scan taken after injecting
dye into the spinal column),
and electromyography an
electrical test of muscle
activity
Management of AMC
Medicines may include nonsteroidal anti-
inflammatory drugs (NSAIDs) that relieve
pain and swelling, and steroid injections
that reduce swelling.

Physical therapy (exercises to strengthen


the back, abdominal, and leg muscles)

Surgical treatments include removing bone


spurs and widening the space between
vertebrae.
Complete Spinal
Transection
Spinal cord injury (SCI) is an The extent of injury is defined by the
insult to the spinal cord American Spinal Injury Association (ASIA)
resulting in a change, either Impairment Scale (modified from the
temporary or permanent, in Frankel classification), using the following
the cord’s normal motor, categories :
sensory, or autonomic A = Complete: No sensory or motor
function. function is preserved in sacral
segments S4-S5
Since 2005, the most B = Incomplete: Sensory, but not
common causes of spinal motor, function is preserved
cord injury (SCI) remain: below the neurologic level and
• motor vehicle accidents extends through sacral segments S4-
(40.4%); S5
• falls (27.9%) C = Incomplete: Motor function is
• interpersonal violence preserved below the neurologic
(primarily gunshot level, and most key muscles
wounds) (15.0%) below the neurologic level have a
• sports (8.0%) muscle grade of less than 3
D = Incomplete: Motor function is
preserved below the neurologic
Dx : Clinical Sign and
Physical Ex.
• Complete bilateral loss of sensation • Injury above T6 :
or motor function below a certain Neurogenic shock;
level hypotension and/or shock

• Pulmo : Carefully evaluate


respiratory rate, chest wall
expansion, abdominal wall
movement, and chest wall and/or
pulmonary injuries (Lung injury,
such as pneumothorax,
hemothorax, or pulmonary
contusion)
 C1 or C2, vital capacity is only
5-10% of normal.
 C3 - C6, vital capacity is 20% of
normal
 T2 –T4 vital capacity is 30-50%
of normal
 With lower cord injuries,
respiratory function improves
 With injuries at T11, respiratory
dysfunction is minimal; vital
Cont...
• Arterial blood gas (ABG) measurements may be useful to
evaluate adequacy of oxygenation and ventilation
• Lactate levels to monitor perfusion status can be helpful in the
presence of shock
• Hemoglobin and/or hematocrit levels may be measured initially
and monitored serially to detect or monitor sources of blood loss
• Urinalysis can be performed to detect any associated
genitourinary injury.
• computed tomography (CT) scanning is exquisitely sensitive for
the detection of spinal fractures and is cost effective
Management of SCI
Patients with SCI usually have permanent and often
devastating neurologic deficits and disability. The most
important aspect of clinical care for the SCI patient is
preventing complications related to disability..

Depending on the level of neurologic deficit and associated


injuries, the patient may require admission to the intensive
care unit (ICU), neurosurgical observation unit, or general
ward.

The most common levels of injury on admission are C4, C5


(the most common), and C6, whereas the level for
paraplegia is the thoracolumbar junction (T12). The most
common type of injury on admission is American Spinal
Injury Association (ASIA) level A
Dorsal Root
Syndrome
Dorsal root syndrome is a group of
symptoms due to paraneoplastic ,
immune disorders , toxic , resulting
idiopathic degeneration of peripheral
sensory neurons in the posterior root
ganglia .

Some of the factors that can trigger a


sensory neuronopathy is
• HIV / AIDS.
• In patients with malignancy
• The use of drugs such as cisplatin
can also trigger the posterior root
syndrome.
• Similarly, the use of vitamin B6 is
more than 600 mg per day can
cause sensory loss
Dx
Symptoms depend on the neuronopathy sensory nerve
fibers are impaired
• Neurological deficit that seemed generally multifocal and
spread throughout the proximal and distal parts of the
limbs . The entire sensory abilities such as pain ,
temperature , sensing the position of the body , and the
vibration is generally interrupted
• Myelin plays a role in body position sense and feel the
vibrations are generally impaired in sensory neuronopathy
. This situation will result in gait ataxia and areflexia
• Some patients also experience pseudoatetotik hand
movements .
• In patients with sensory neuronopathy boasts autonomic
disorders such as tonic pupil , orthostatic hypotension ,
gastrointestinal disorders , and erectile dysfunction
Cont...
Nerve Conduction Studies ( NCS ) . According to Lauria et al
NCS is the most useful test to evaluate sensory neuronopati
suspected . NCSS can detect sensory action potential
amplitude reduction .

MRI is also a sensitive technique for diagnosing patients with


sensory neuronipati especially patients with long disease
duration . Damage to posterior root ganglion will cause
degeneration of the gracile fasciculus and cuneatus which
will give an idea of the spinal cord atrophy and gliosis .

The combination of the results of NCS and the discovery of


MRI can diagnose sensory neuronopati .

Excisional biopsy with histological analysis of the posterior


root ganglion are the gold standard diagnostic methods
neuronopati sensory examination but this is rarely done
because it is invasive measures
Management of DRS
Management neuronopati sensory associated with Sjogren's
Syndrome has not been through the test control. In a study of plasma
replacement five to nine times showed improvement in 2 of 4
patients (W. H. Chen 2001). In another study, 4 of 5 patients with
chronic diseases show improvement after three cycles of
administration of IVIG (0.4 g / kg for 5 consecutive days) were given
at intervals of 2 weeks (Takahashi Y 2003). Rituximab shows
effectiveness as a replacement for IVIG in patients with sensory
neuronopati associated with Sjogren's Syndrome. Azathioprine (2-3
mg / kg one day be effective for some patients (Martinez ARM. 2012).

In patients with pain disorder can be treated by administration of


non-opioid such as paracetamol or non-steroidal anti-inflammatory
drugs. Patients may also be given a class of opioid drugs such as
codeine, tramadol, fentanyl or morphine.

Antidepressants such as amitriptyline can work to help the process of


pain tolerance. Anticonvulsant drugs such as phenytoin,
carbamazepine, lamotigrin can reduce pain in patients through its
effect on pain modulation process.
Radicular Syndrome
Definition:

a combination of changes usually seen with


compromise of a spinal root within the
intraspinal canal; these include neck or back
pain and, in the affected root distribution
dermatomal pain, parasthesia or both decreased
deep tendon reflex, occasionally myotomal
weakness
Radicular Syndrome
Arises due to compression or
herniation of the
nerve roots are branching of the spinal
cord that
transmits signals throughout the body
Radicular
at every Syndrome Symptome
level along
Leads theand
to pain spine
other signs like lack
of
sensation, tingling and a sense of
weakness felt
in the upper or lower regions of the
body like
Radicular Syndrome Symptomes

Sensory-related symptomes are more


prevalens
as compared to motor-related
symptomes, and
muscular weakness is generally as
indicator
The nature of
and kind of pain could
the increased
differ ranging severity of nerve
compression
from dulling, throbbing pain and
complex to
localize , and even sharp-shooting and
burning
Radicular pain:
Less common than somatic pain
The hallmark of radiculopathy, any
pathologic condition affecting the nerve
roots
Arises from the nerve roots or dorsal
root ganglia
Herniated disk is by far the most
common cause
Radicular pain:
usually radiates down the limbs
Associated symptoms of paresthesias are very
helpful determining the identity of the
involved nerve root better than site of pain
Symptoms of weakness and objective findings of
sensory loss, weakness and reflex loss may occur
Radicular pain:
Inflammation is important as a pain
mechanism:
Phospholipase A and E, NO, TNF, other pro-
inflammatory mediators are released by a
herniated disk
The dura surrounding the ventral and dorsal nerve
root is bathed in this exudate
Inflammation or prior injury to nerve root is
necessary to cause compression to generate
continued pain
Types of peripheral
nerve injury:
Neurapraxia: Segmental loss of myelin coating
on nerve root/nerve
Weakness, but no atrophy

Axonotmesis: Loss of axons and myelin but at


least some supporting structures are preserved
Weakness and muscle atrophy if severe

Neurotmesis: Loss of axons, myelin, and


complete disruption of supporting structures
(transection) weakness and atrophy
Dermatome
• Each nerve root
supplies cutaneous
sensation to a
specific area of
skin, known as a
dermatome

Overlaps somewhat, so won’t lose


All sensation, but will feel paresthesia
Myotome
• If radicular pain sever
could affect myotome
• Each nerve root
supplies motor
innervation to certain
muscles,
known as a myotome
In the cervical spine:
Nerve roots exit above
their named vertebral
body
I.e., C7 exits below C6
and above C7-so lateral
disk herniation here gets
C7

In the lumbar spine:


Spinal cord ends at L1 or
L2
Nerve roots travel long
distances then exit below
their named vertebral
body
The lumbosacral nerve
roots are susceptible to
1. Cervical Radiculopathy
C7 most common
Dx
• Plain radiography is to detect underlying structural
serious pathological condition .
• More advisable to use MRI than CT scanning
because detect soft- tissue pathology such as disc
herniation .
• American College of Radiology recommends regular
MRI as the most appropriate imaging study in
patients with chronic back pain and neck who have
neurological signs or symptoms but normal
radiographs . MRI can detect disturbances
ligaments and discs , which can not be shown by
other imaging studies . The entire spinal nerves ,
nerve roots , and axial skeleton can be visualized
Management
• The initial treatment aims to reduce pain and inflammation: cold
compresses, NSAIDs, relative rest (avoid positions that improve the
symptoms of the arm or neck to do manual traction and if necessary
traction mechanics. In addition, collar neck can be used for the
convenience of the patient and some support. A neck pillow at night
can help in keeping the neck in a neutral position and limit the
position of the head that causes the deterioration of narrowing the
neural foramen. Kuijper et al proved that patients with cervical
radiculopathy using a neck collar and rest for 3- 6 weeks experienced
a decrease in pain of the neck and hands.
• American Society of Interventional Pain Physicians find moderate
evidence that cervical interlaminar epidural steroid injections may
provide short-term fixes long term. These studies have shown up to
60% good results with corticosteroid injections translaminar and
transforaminal epidural.

• Evidence-based treatment guidelines from the Board of Acupuncture


and Oriental Medicine Association recommends acupuncture and
electroacupuncture suitable for patients with cervical radiculopathy .

• Most sources agree on urgent indication for surgical intervention in


patients with lumbosacral radiculopathy is a significant motor deficits /
severe and progressive, cauda equina syndrome with bowel and
bladder dysfunction.
• 5 surgical treatment options are as follows:
1. simple discectomy
2. discectomy plus fusion
3. chemonucleolysis
4. percutaneous discectomy microdiscectom