blok muskuloskeletal
TRANSCRIPT
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
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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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