Name : Dessy R Emril, MD, PhD

Date/Place of birth : Pekanbaru, 23 December 1975

Address : Jl. Kepiting no 5 Bandar Baru, Banda Aceh.
Email : dessyezzy@gmail.com,
dessyemril@unsyiah.ac.id
 
 
Educations
Medical doctor : Medical Faculty of Syiah Kuala University, 2000
Neurologist : Medical Faculty f of Indonesia University, 2006
Fellowship : Pain management center, Singapore General Hospital, 2009
Doctor (PhD) : Medical faculty of Gadjah Mada University, 2014
Certified in Interventional Pain Management from Indonesian Neurology
Collegium, 2014

Occupation
Lecturer of Neurology Department, Medical Faculty of Syiah Kuala
University/Dr Zainoel Abidin hospital (RSUZA), Banda Aceh
Consultant in Pain and Headache.
Chairman of Neurology Training Program of Syiah Kuala Medical Faculty
Chairman of The Integrated Pain Management Program in RSUZA
Organization
• Vice of Chief Indonesian Neurological Association Banda Aceh
• Vice of Chief Indonesian Medical Doctor Association, Aceh Region
• Chairman of Pain Study Group, Indonesian Neurological Association Banda Aceh
• Member of Pain Study Group, Indonesian Neurological Association Indonesia
• Member of International Association for study of pain (IASP)
Publication
• Emril D, Syafruddin, Samekto W, Lucas M, Rina S. Perbandingan Metode Crush Injury
dengan Metode Partial Sciatic Transection dalam Induksi Nyeri Neuropatik pada Hewan
Coba. Neurona Vol. 32 No. 1; 2014.
• Emril D, Basic and Advance Interventional Pain Management, ASNA Conference, Bali,
2011.
• Emril D, Interventional Pain Management in Neurology Case. INA Conference, Manado,
2011
• Emril D, Kok Yuen Ho. 2010. Treatment of trigeminal neuralgia: role of radiofrequency.
Journal of Pain Research :3 1-6
• Emril D. Management of Trigeminal Neuralgia. 2010. Neurona. April 2010
• Syahrul, Emril D, Penggunaan Skala Stroke Syiah Kuala Sebagai Metode Diagnosis yang
Cepat dan Akurat. 2010. Neurona; Vol 27 no 2: 59-65.
• Emril D. Interventional management of Trigeminal neuralgia. 2009. Jurnal Kedokteran
Syiah Kuala; 2: 83-9
• Emril D. Interventional management for chronic pain. 2009. Jurnal Kedokteran Syiah
Kuala; 3: 139-44
• Emril D, Puspitasari V, Mayza A. 2005. Elevated Blood Viscocity in People 60
Years Up. Neurona. 14: 21-23
• Emril D, JAnnis J. 2004. Diagnosis Etiologi Lesi Desak Ruang Intrakranial:
Infeksi atau Neoplasma?. Neurona. 2: 34-7
• Emril D, Jannis J, Kiemas L. 2003. Leukositosis Sebagai Salah Satu Indikator
Adanya Lesi Struktural Intrakranial Pada Penderita Cedera Kranioserebral dengan
SKG 13-15. Neurona. 21:13-9
• Emril D. Cytidine 5’-Dophosphocoline Administration Prevent Peripheral
Neuropathic Pain after Rat Sciatic Nerve Crush Injury. Journal of Pain Research
Vol. 9, p.1-5; 2015.
•  Emril D. Pain Intervention with USG Guidence. Continuing Neurology Education;
2014.
• Emril D. How to diagnose low back pain properly, Nyeri Punggung Bawah. Badan
Penerbit Universitas Diponegoro; 2013; ISBN : 978-602-097-352-4.
• Emril D. Faktir Risiko Nyeri Pinggang Bawah Kronik pada Penderita Usia Dewasa
Muda di RSUD dr. Zainoel Abidin Banda Aceh. Neurona Vol. 27 No. 4 Juli; 2012.
• Emril D. The role of interventional technique in the management of chronic pain,
50-4. Prosiding 9th Biennial Convention of ASNA Bali; 2011; ISBN : 978-602-
042.
• Emril D. Interventional Pain Management in Neurology Case. Prosiding
Neurology Update Konas Perdossi VII; 2011; ISBN : 978-979-115-138-2.
• Emril D. Treatment of Trigeminal Neuralgia: Role of Radiofrequency Abalation.
Journal of Pain Research; 2011; 3; 1-6.
• Emril D. Management of Neuralgia Trigeminal. Neurona Vol. 27 No. 4 Juli; 2010.
• Emril D. Penggunaan Skala Stroke Syiah Kuala pada Penderita Stroke sebagai
Metode Diagnosis Cepat dan Akurat. Neurona Vol. 27 No. 2 Januari; 2010; ISSN :
0216-6402.
• Emril D. Interventional Management for Chronic Pain. Jurnal Kedokteran Syiah
Kuala Vol. 9 No. 3 Desember; 2009; ISSN : 1412-1026.
• Emril D. Interventional Management of TN. Jurnal Kedokteran Syiah Kuala Vol. 9
No. 2 Agustus; 2009.
• Emril D. Elevated Blood Viscocity in People 60 Years Up. Neurona, 14: 21-23;
2005.
• Emril D. Diagnosis Etiologi Lesi Desak Ruang Intrakranial : Infeksi atau
Neoplasma?. Neurona, 2: 34-7; 2004.
• Emril D. Leukositosis sebagai salah satu indikator adanya lesi struktural
intrakranial pada penderita cedera kranioserebral dengan SKG. 13-15. Neurona,
21:13-9; 2003.
• Emril D. Continuing Neurology Education. Pain Intervention with USG Guidence.
Malang; Agustus 2014.
• Emril D. Advance Interventional Pain Management. Cervical Facet Joint Block.
Malang; Oktober 2014.
• Emril D. Neurology Update 2016. Introduction of IPM, and Interventional Pain
Management Approach in Low Back Pain. Jakarta; 2016.
 Accurate Diagnosis as
Fundamental of Appropriate
Technique and Treatment in
Low Back Pain
Dr. dr. Dessy R. Emril, SpS (K)
Pain and Headache Divison, Neurology Department
Faculty of Medicine, Syiah Kuala University.
Banda Aceh
 
• The most recent guidelines for LBP patients:
o The clinician should go through a careful diagnosis of the mechanisms that sustain acute
and/or chronic pain. Treatment has to be addressed specifically to these mechanisms.
o avoid the common mistake of making the diagnosis of “simply low back pain”, resulting
in improper treatment of a definition and not a complex disease.
o As chronic LBP could have simultaneous multiple pain generators, a multidisciplinary
diagnosis and multimodal treatment is necessary.
 How to classified etiology and
source of Pain in LBP
I. Mechanisms-based classifications
II. Etiology-based classifications
Mechanisms-based
classifications
 Mechanisms-based
classifications
• Nociceptive pain (NP)
• Peripheral neuropathic pain
• Central sensitisation (CSP)
• Mixed pain
Symptoms and signs of nociceptive pain
in patients with low back (leg) pain
• A cluster of seven clinical criteria predictive of Nociceptive
Pain , including:
o Pain localised to the area of injury/dysfunction
o Clear, proportionate mechanical/anatomical nature to aggravating and
easing factors
o Usually intermittent and sharp with movement/mechanical provocation
o May be a more constant dull ache or throb at rest
o The absence of ‘Pain in association with other dysesthesias
• Night pain/disturbed sleep
• Antalgic postures/movement patterns
• Pain variously described as burning, shooting, sharp or electric-shock-like

o Have high levels of classification accuracy

• Sensitivity 90.9%, 95% CI: 86-94.1
• Specificity 91.0%, 95% CI: 86-94.6
Fig. 1. Delphi-derived clinical indicators of
‘nociceptive’ pain
 Symptoms and signs of peripheral neuropathic
pain in patients with low back (leg) pain
• Two symptoms and one sign associated with a clinical classification
of PNP in patients with low back (leg) pain
• Pain referred in a dermatomal or cutaneous distribution, history of
nerve injury, pathology or mechanical compromise and
pain/symptom provocation with mechanical/movement tests
o e.g. Active/Passive, Neurodynamic that move/load/compress neural
tissue
• This cluster was found to have high levels of classification accuracy
(sensitivity 86.3%, 95% CI: 78.0e 92.3; specificity 96.0%, 95% CI:
93.4e97.8; diagnostic odds ratio 150.9, 95% CI: 69.4e328.1)
 Figure 2. Delphi-derived clinical indicators of
peripheral neuropathic’ pain (Smart et al., 2010)
Symptoms and signs of central sensitisation
(CSP) in patients with low back (leg) pain
• Three symptoms and one sign predictive of CSP, including:
o Disproportionate, non-mechanical, unpredictable pattern of pain provocation in
response to multiple/non-specific aggravating/easing factors
o Pain disproportionate to the nature and extent of injury or pathology
o Strong association with maladaptive psychosocial factors (e.g. negative
emotions, poor self-efficacy, maladaptive beliefs and pain behaviors)
o Diffuse/nonanatomic areas of pain/tenderness on palpation

• This cluster was found to have high levels of classification

accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84-
96.4; specificity 97.7%, 95% CI: 95-99.0)

K.M. Smart et al. / Manual Therapy 17 (2012) 336e344

 Subjective :
• Disproportionate, non-mechanical,
unpredictable pattern of pain provocation in
response to multiple/non-spesific
aggravating/easing factors.
• Pain persisting beyond expected tissue
healing/pathology recovery times.
• Pain disproportionate to the nature and
extent of injury or pathology.
• Widespread, non-anatomical distribution of
pain.
• History of failed interventions
(medical/surgical/therapeutic).
• More constant/unremitting pain.
• Pain in association with high levels of
functional disability
• Pain of high severity and irratibility (i.e.
easily provoked, taking a long time to
settle).
• Strong association with maladaptive
psychosocial factors (e.g. negative
emotions, poor-self-efficacy, maladaptive
beliefs and pain behaviors, altered
family/work/social life, medical conflict).
• Unresponsive to NSAIDs and/or more
responsive to anti-epileptic /anti-
depressant (e.g. Amitriptyline)
medication).
• Resports of spontaneous (i.e. stimulus-
independent) pain and/or paroxysmal pain
(i.e. sudden recurrences and
intensification of pain).
• Night pain/disturbed sleep.
• Pain in assocoation with other
dysesthesias (e.g. burning, coldness,
crawling)
Clinical examination :
• Disproportionate, inconsistent, non-mechanical/non-anatomical pattern of
pain provocation in response to movement/mechanical testing.
• Positive findings of hyperalgesia (primary, secondary) and/or allodynia
and/or hyperpathia within the distribution of pain.
• Diffuse/non-anatomic areas of pain/tenderness on palpation.
• Positive identification of various psychosocial factors (e.g.
catastrophisation, fear-avoidance behavior, distress).
Etiology-based classifications
 Etiology-based classifications
I. Structural Etiologies
II. Neurogenic etiologies
III. Extraspinal etiologies
 Structural Etiologies
1. Lumbar intervertebral discs
a. High-intensity zones and annular tears
b. Degenerative disc disease
c. Diskitis
2. Zygapophysial joints and capsules
a. Facet joint degeneration
b. Facet hypertrophy
c. Capsular derangement and calcification
3. Sacroiliac joint
a. SI joint arthropathy
b. SI joint instability
4. Ligamentum flavum
5. Dura mater and arachnoid structures
6. Pelvic insufficiency fracture
7. Vertebral bodies
a. Vertebral fractures
b. Spondylolysis, spondylolisthesis, and pars defects
8. Musculoligamentous structure
a. Para-lumbar muscular conditions
b. Spinal ligament derangement
c. Instability of the lumbar structure
d. Piriformis syndrome
e. Myofascial etiology

9. Iatrogenic etiologies
a. Instrumentation
b. Lumbar surgery
Neurogenic etiologies of low back Pain
1. Spinal stenosis
a. Central and foraminal spinal stenosis (degenerative)
o Degenerative disc disease
o Facet hypertrophy and arthropathy
o Ligamentum flavum hypertrophy
o Vertebral fractures
o Neoplastic
o Abscess formation
o Hematoma formation
o Iatrogenic because of leaked vetebro or kyphoplasty residue
b. Congenital and developmental
o Incomplete vertebral arch closure
o Segmentation failure
o Achondroplasia
o Shortened pedicles
o Spina bifida
o Thoracolumbar kyphosis
o Apical vertebral wedging
o Osseous exostosis
 Extraspinal etiologies of low back
pain
1. Rheumatologic conditions
2. Gastrointestinal
3. Pelvic and gynecological
4. Vascular
5. Infection
6. Neoplasms
7. Psychological
Structural and neurogenic etiology
• In LBP patients with degenerative signs of the spine, several
etiologies of structural and neurologic nature appear to work
in unison to cause the pain experienced by the patient.
• An extensive understanding of the various neurologic
etiologies, in addition to the structural derangements, is
paramount to developing expertise in LBP.
 DIAGNOSTIC
PROCEDURES OF LBP
 ANAMNESIS

Spesicic
Phatologogic Radicular pain or
spinal stenosis
condition

Non Spesific LBP

I
D
E
N Red Flags
T
I
F
Yellow
I Flags
C
A
T
I
O
N
Red Flags
Yellow Flags
Physical examinations
 Disc herniation
• SLR positiVe: Sens 91%, Spec 26%
• crossed SLR: Sens 29%; Spec 88%
• Centralisasi phenomen : increase
• No disc herniation in MRI: decrease
 Spinal stenosis
• 20% no symptom
• Diagnosis base on history and PE
• Neurogenic claudicatio (pseudoclaudicatio)
• Transient neurology deficits
• Decrease sensibility, muscle weakness
• wide-based gait or Romberg sign (pseudocereberal
presentatation)
 Facet Joint pain
• Degeneration process

o Spine injury
o Fracture
o Tear ligamentum
o Disc problem
• Wilde et al.
o Positive Injection diagnostic test
o Back pain unilateral and could be located,,
o Pain in palpation of facet joint or trasvrese procc
o Pain is not radiating, Decrese by flexion
o berkurang dengan gerakan fleksi, dan jika ada nyeri alih terasa di atas dari lutut.
o Refered pain above the knee
 Research
• Screen Shot 2017-03-23 at 4.56.23 AM
Scaroiliaca joint pain
Prosedure diagnostic SIJ
pain
distraction test,
Uji provokasi

compression test
• Akurasi
terbatas
thigh thrust test • Kombinasi
beberapa uji
provokasi
Patrick’s sign lebih
bermanfaat

Gaenslen’s test
Special diagnostic tools
SI join Spesifisitas dan
Moderat
validitas
Block

Radiologi Tidak terbukti

akurat
diagnostik

Bone scan Sensifitifitas Rendah/limitied

Myofascial Low Back Pain
• Quadratus Lumborum, Gluteus medius, Para iliopsoas,
Abdominis rektus.
Research
Diagnostic imaging for low back pain
• Abnormal radiology pattern is not the
role of LBP causes
• Asymptomatic patients, > 60 yr:
• 36 % have disc herniation
• 21% have spinal stenosis
• >90% have disc degeneration
 MRI Exm
WHY WE NEED?
Indications of Radiology
study for LBP
TREATMENT OF LBP
 GENERAL STRATEGIES FOR PAIN:
1. Acknowledging the client’s pain

a. Verbally acknowledge the presence of the pain

b. Listen attentively to what the client says about the
pain
c. Convey that you are assessing the client’s pain to
understand it better, not to determine whether the pain
is real
d. Attend to the client’s needs promptly

2. Assisting support persons – give info; discuss their

emotional reaction
3. Reducing misconceptions about pain

4. Reducing fear and anxiety – encouraging verbalization, being

honest and sincere, promptly attending to their needs and giving
accurate information
 EVALUATION OF PAIN
PATIENT
• Set a complete medical record
• Ask the patient for pain score of:
- Before anf after taking medc
- Static and dinamic
- other condition
• Ask the patient about any improvement or
• Ask the patient about their expectation
• Can be help by using some pain evaluation chard/methode
 PHARMACOLOGICAL PAIN MANAGEMENT:
1. Opioid/Narcotic analgesics
- Binds to Opiate receptors and
activate endogenous pain
suppression in the CNS

2. Non-narcotic analgesics
/NSAID – Acts on peripheral
nerve endings at the injury site
& decrease inflammatory
mediators

3. Adjuvant analgesic
- Developed other than for
analgesia but found to decrease
certain types of chronic pain
 NSAIDs for LBP
• The most commonly prescribed medications include nonsteroidal
anti-inflammatory drugs (NSAIDs) and muscle relaxants.
• Although NSAIDs are a chemically diverse class, their
similarities, efficacy, tolerability, and adverse effect profile have
more similarities than differences.
• The most common side effects of NSAIDs are gastrointestinal.
• Agents with cyclo-oxygenase 2 selectivity are associated with
reduced gastrointestinal bleeding, but problematic increases in
adverse cardiovascular outcomes continue to spark concern.
• Fortunately, short-term use of NSAIDs for LBP is generally both
safe and effective. 
 Summary
• LBP must always be addressed as a complex disease in which
it is mandatory that an accurate diagnosis of pain generators is
determined before starting any treatment.
• All the guidelines currently avalaible stress the importance of
a multimodal and multidisciplinary approach in order to
determine a strategy to solve the problem and not simply
alleviate symptomatic pain.
• A careful follow up is important to adapt our therapeuthic
strategies to dynamic clinical manifestations of CLBP.
• Short-term use of NSAIDs for LBP is generally both safe
and effective. 
PAIN MANAGEMENT IN
RSUD Dr. Zaionel Abidin
Banda Aceh
DIVISI NYERI DAN NYERI KEPALA
BAGIAN/SMF NEUROLOGI
FK UNSYIAH/RSUDZA
IPM Activity @ RSUD Dr. Zaionel Abidin Banda Aceh
Pain Management Team
PAIN MANAGEMENT
TRAINING
AT RSUZA TRAINING
CENTER
Manequin Hands On
IPM Patient Hands on
Thank You