Download - Medula Spinalis
![Page 1: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/1.jpg)
Medula SpinalisNeuro FK UNDIP
![Page 2: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/2.jpg)
![Page 3: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/3.jpg)
![Page 4: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/4.jpg)
4
Spinal Cord
• Extends downward through vertebral canal• Begins at the foramen magnum and terminates at the first and second lumbar vertebrae (L1/L2) interspace
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Brainstem
Spinal cord
(a) (b)
Foramenmagnum
Cervicalenlargement
Vertebralcanal
LumbarenlargementConusmedullarisCaudaequina
Filumterminale
Conusmedullaris
Lumbarenlargement
Cervicalenlargement
![Page 5: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/5.jpg)
Medula Spinalis
![Page 6: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/6.jpg)
![Page 7: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/7.jpg)
Med. Spinalis – Collumna Vertebralis
ASCENCUS MEDULORUM → topis lesi di collumna vertberalis berbeda dengan level med. Spinalis
![Page 8: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/8.jpg)
8
Structure of the Spinal Cord
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
White matter
Gray matter
Lateral funiculus
Posterior funiculus
Gray commissure
Central canal
(a)
Posterior horn
Dorsal rootof spinal nerve
Dorsal rootganglion
Ventral rootof spinal nerve
Anteriorhorn
Anteriormedianfissure
Portion ofspinal nerve
Anteriorfuniculus
Posterior mediansulcus
![Page 9: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/9.jpg)
![Page 10: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/10.jpg)
![Page 11: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/11.jpg)
Proteksi MS• MS dilindungi oleh tulang, diskus, ligamentum & otot.• Vertebra terdiri dari 33 tulang :
• Servikalis 7• Thorakalis 12• Lumbal 5• Sakral 5• Koksigeus 4
• MS lewat melalui lubang di tengah disebut kanalis spinalis dari tiap vertebra.
• Diantara vertebra terdapat diskus vertebralis yang berfungsi sebagai bantalan atau peredam kejut vertebra.
• Ligamentum dan otot membantu menjaga vertebra pada posisi yang tepat.
![Page 12: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/12.jpg)
![Page 13: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/13.jpg)
13
Functions of Spinal Cord
• Center for spinal reflexes
• Conduit for nerve impulses to and from the brain and brainstem
![Page 14: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/14.jpg)
Motorik
• Terdapat banyak lintasan atau traktus di MS.• Traktus motorik ditemukan di depan dari bagian tengah MS.• Traktus motorik menggerakkan lengan & tungkai.• Jika terdapat kerusakan di traktus motorik, terjadi kelemahan atau
kelumpuhan dibawah tingkat kerusakan.
![Page 15: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/15.jpg)
![Page 16: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/16.jpg)
Sensorik
• Traktus sensorik terdapat pada bagian depan & belakang MS.• Kerusakan pada bagian depan MS menyebabkan kehilangan perasa
nyeri & panas/dingin dibawah tingkat kerusakan.• Kerusakan di bagian belakang MS menyebabkan kehilangan
kemampuan perasa posisi pada lengan atau tungkai.
![Page 17: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/17.jpg)
![Page 18: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/18.jpg)
18
Nerve Tracts of the Spinal Cord
![Page 19: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/19.jpg)
19
Peripheral Nervous System
• Cranial nerves arising from the brain• Somatic fibers connecting to the skin and skeletal muscles• Autonomic fibers connecting to viscera
• Spinal nerves arising from the spinal cord• Somatic fibers connecting to the skin and skeletal muscles• Autonomic fibers connecting to viscera
![Page 20: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/20.jpg)
Saraf Spinalis
![Page 21: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/21.jpg)
21
Spinal Nerves
• Dorsal root (aka posterior root)
• Sensory root• Axons of sensory
neurons are in the dorsal root ganglion
• Dorsal root ganglion • Aka DRG• Cell bodies of sensory
neurons whose axons conduct impulses inward from peripheral body parts
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Lateral horn
Ventral root(a)
(b)
Dorsal root
Dorsal root
Spinal nerve
Dorsal rootganglion
Posteriormedian sulcus
Posteriorhorn
Anteriorhorn
Centralcanal
Anteriormedianfissure
Dorsal branchof spinal nerveVentral branchof spinal nerve
Visceral branchof spinal nerve
Paravertebralganglion
Ventral branchof spinal nerve (ventral ramus)
Dorsal branchof spinal nerve (dorsal ramus)
Paravertebralganglion
Visceral branchof spinal nerve
Ventral root
![Page 22: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/22.jpg)
22
Spinal Nerves
• Ventral root (aka anterior root) • Motor root• Axons of motor neurons
whose cell bodies are in the spinal cord
• Spinal nerve• Union of ventral root
and dorsal roots• Hence we now have
a “mixed” nerve
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Lateral horn
Ventral root(a)
(b)
Dorsal root
Dorsal root
Spinal nerve
Dorsal rootganglion
Posteriormedian sulcus
Posteriorhorn
Anteriorhorn
Centralcanal
Anteriormedianfissure
Dorsal branchof spinal nerveVentral branchof spinal nerve
Visceral branchof spinal nerve
Paravertebralganglion
Ventral branchof spinal nerve (ventral ramus)
Dorsal branchof spinal nerve (dorsal ramus)
Paravertebralganglion
Visceral branchof spinal nerve
Ventral root
![Page 23: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/23.jpg)
23
Nerve Plexuses
• Nerve plexus• Complex networks formed by anterior branches (ventral rami) of spinal
nerves• The fibers of various spinal nerves are sorted and recombined• There are three (3) nerve plexuses:
• (1) Cervical plexus• Formed by anterior branches of C1-C4 spinal nerves• Lies deep in the neck• Supply to muscles and skin of the neck• C3-C4-C5 nerve roots contribute to phrenic nerves bilaterally
![Page 24: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/24.jpg)
24
Plexuses
C1C2C3C4C5C6C7C8T1
T2T3
T4
T5
T6
T8
T9
T10T11
T12
L1
L2
L3
L4
L5
S2S3S4S5
Co
Posterior view
Cervical plexus(C1–C4)
Lumbosacral plexus(T12–S5)
Sciatic nerve
Brachial plexus(C5–T1)
Obturator nerve
Phrenic nerve
Ulnar nerveMedian nerveRadial nerveAxillary nerve
T7
S1
Cauda equina
Musculocutaneousnerve
Femoralnerve
Intercostalnerves
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
![Page 25: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/25.jpg)
25
Brachial Plexus• (2) Brachial plexus
• Formed by anterior branches C5-T1• Lies deep within shoulders• There are five (5) branches:• 1. Musculocutaneous nerve
• Supply muscles of anterior arms and skin of forearms
• 2. Ulnar and 3. Median nerves• Supply muscles of forearms and
hands• Supply skin of hands
• 4. Radial nerve• Supply posterior muscles of
arms and skin of forearms and hands
• 5. Axillary nerve• Supply muscles and skin of
anterior, lateral, and posterior arms
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Musculocutaneous n.
Musculocutaneous n.
Humerus
Thoracodorsal n.
Lower subscapular n.
Suprascapular n.
Lateral pectoral n.
Medial pectoral n.
Axillary n.
Axillary n.
Radial n.
Radial n.
Radius
Ulna
Ulnar n.
Ulnar n.
Median n.Median n.
C5
C5
C6
C6
C7
C7
C8
C8
T1
T1
(a)
(b)
Ventral rami: C5, C6, C7, C8, T1
Anterior divisions
Posterior divisions
Trunks: upper, middle, lower
Dorsalscapular n.
78
![Page 26: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/26.jpg)
26
Lumbosacral Plexus
• (3) Lumbosacral plexus• Formed by the anterior branches
of L1-S5 roots• Can be a lumbar (L1-L5) plexus
and a sacral (S1-S5) plexus• Extends from lumbar region into
pelvic cavity• Obturator nerve
• Supply motor impulses to adductors of thighs
• Femoral nerve• Supply motor impulses to
muscles of anterior thigh and sensory impulses from skin of thighs and legs
• Sciatic nerve• Supply muscles and skin of
thighs, legs and feet
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
Sciatic n.
Saphenous n.
Femoral n.
Obturator n.
Tibial n.
Pudendal n.
(b) (c)(a)
Femoral n.
Obturator n.
Pudendal n.
Sciatic n.
L1
L2
L3
L4
L5
S1
S2
S3
S4
S5
Ventralrami
Anteriordivisions
Posteriordivisions
Lateralfemoralcutaneous n.
Superiorgluteal n.
Inferiorgluteal n.
Superiorgluteal n.
Inferiorgluteal n.
Sacralplexus
Common fibular(peroneal) n.
Posteriorcutaneous n.
Commonfibular(peroneal) n.Tibial n.
![Page 27: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/27.jpg)
Gejala lesi pada medula spinalis
• Gangguan motorik Kelumpuhan - setinggi lesi (LMN) dibawah lesi (UMN), karena terganggunya traktus kortikospinalis (traktus pyramidalis).
![Page 28: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/28.jpg)
Gejala lesi pada medula spinalis• Gangguan motorik kerusakan setinggi medula spinalis cervical
menyebabkan kelumpuhan tetraparese. Kerusakan medula spinalis thorakal s/d lumbal memberikan gejala paraparese. Kerusakan medula spinalis sacral menyebabkan gangguan miksi & defekasi tanpa para parese
![Page 29: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/29.jpg)
![Page 30: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/30.jpg)
Gejala lesi pada medula spinalis
Gangguan motorik Suatu kerusakan yang akut pada medulla spinalis,
timbul spinal shock yaitu berhentinya semua fungsi dibawah lesi. Shock dapat berlangsung sampai 6 minggu dan dalam fase shock ini timbul gejala gejala kelumpuhan berupa LMN, keadaan ini berangsur-angsur membaik bila tidak ada lesi organis.
![Page 31: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/31.jpg)
Gejala lesi pada medula spinalis
Gangguan sensibilitas :– Gangguan sensibilitas sifatnya segmental, dapat
terjadi hypestesia hingga anesthesia mulai setinggi segmen medulla spinalis kebawah.
– Bila terjadi lesi total pada medulla spinalis (lesi tranversal) maka kedua jenis sensibilitas (eksteroseptik & proprioseptik) ikut terganggu.
![Page 32: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/32.jpg)
![Page 33: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/33.jpg)
Gejala lesi pada medula spinalis
Gangguan miksi & defekasi• Bila lesi transversal diatas konus medullaris dalam stadium dini akan
timbul retensio urine, kandung kemih penuh dengan urine oleh karena serabut serabut aferen terputus. Setelah itu diikuti dengan keluarnya urine yang netes-netes disebut sebagai overflow inkontinesia.
• Bila lesi transversa ini sudah kronis maka akan terjadi kandung kemih autonom (autonomic bladder) yakni pengosongan kandung kemih secara reflektorik.
![Page 34: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/34.jpg)
Gejala lesi pada medula spinalis
• Bila lesi pada konus medullaris maka refleks miksi menghilang dan terjadi kandung kemih atonik (atonic bladder) dengan gejala-gejala retensio urine dan kemudian diikuti dengan inkontinensia, hanya disini perasaan untuk kencing masih ada. Pengosongan kandung kemih terjadi dengan menekan daerah suprapubic.
Yang penting disini ialah :• cegah infeksi saluran kemih• cegah terjadinya dekubitus.
![Page 35: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/35.jpg)
Penyebab Spinal cord injury• Trauma : KLL, jatuh, luka tembak, selam, cedera perang, dll• Tumor : meningiomas, ependymomas, astrocytomas, and metastatic
cancer. • Ischemia : oklusi a. spinalis : dissecting aortic aneurysms, emboli,
arteriosclerosis. • Developmental disorders : spina bifida, meningomyelocele• Neurodegenerative diseases : Friedreich's ataxia, spinocerebellar
ataxia • Demyelinative diseases : Multiple Sclerosis. • Transverse myelitis, : stroke, inflamasi• Vascular malformations : AVM, dural arteriovenous fistula (AVF),
spinal hemangioma, cavernous angioma & aneurisma.
![Page 36: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/36.jpg)
Patologi SCI
• 2 jenis SCI adalah Complete & Incomplete• Complete :
Tidak ada fungsi dibawah tingkat cedera :• No movement • No sharp/dull sensation • No hot/cold sensation • No vibration sensation • No sensation of light or deep touch • No sense of position of the arms or legs
![Page 37: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/37.jpg)
INCOMPLETE
• Central cord syndrome • dihubungkan dgn kelemahan ekstremitas atas yg lebih besar dibandingkan dgn
ekstremitas bawah.
• Brown-Séquard syndrome • cedera pada setengah sisi MS, menyebabkan kelemahan & gangguan
proprioseptik pada sisi cedera & gangguan nyeri & suhu pada sisi sebelahnya.
• Anterior cord syndrome • cedera pada bagian anterior MS, menyebabkan kelemahan & kehilangan
sensasi nyeri & suhu dibawah tempat cedera tapi tetap terpelihara proprioseptik yg biasanya terletak di bagian posterior MS.
• Posterior cord syndrome / Tabes Dorsalis • Biasanya karena penyakit infeksi seperti sifilis, menyebabkan kehilangan perasa
raba & proprioseptik.
• Conus medullaris syndrome • cedera pada ujung MS yg terletak di vertebra L1.
• Cauda equina syndrome • cedera pada radiks spinalis dibawah vertebra L1.
![Page 38: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/38.jpg)
CONUS MEDULLARIS SYNDROME
![Page 39: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/39.jpg)
CONUS MEDULLARIS SYNDROME
• Conus medullaris : terminal dari MS, sekitar tingkat VL1 – VL2
• Aliran darah : 3 pembuluh darah arteri spinalis – trunkus arteri longitudinalis median anterior & 2 trunkus posterolateral. Sumber suplai darah lainnya adalah arteri radikularis cabang dari aorta, arteri sakralis lateral, arteri sakralis media, iliolumbalis & lumbal ke 5 yang mensuplai darah ke cauda equina.
• Strukturnya mengandung MS bagian distal & radiks spinalis, kombinasi UMN & LMN.
• Cauda equina : tanda & gejala LMN.
![Page 40: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/40.jpg)
Conus Medullaris Syndrome
Presentasi Mendadak & bilateral
Reflek fisiologis R patella N, R achilles menurun
Nyeri radikuler < berat
Low back pain Banyak
Tanda & gejala sensorik Hipestesi perianal; simetris & bilateral; disosiasi sensorik (+)
Kekuatan motorik Khas simetris, hiperrefleksi pada anggota gerak bawah yg paresis kurang jelas, fasikulasi mungkin ada
Impotensi Sering
Disfungsi sphinkter Retensi urin & sfinkter ani atoni menyebabkan overflow inkontinensia urin et alvi; awal perjalanan penyakit
![Page 41: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/41.jpg)
![Page 42: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/42.jpg)
Cauda Equina SyndromePresentasi Berangsur & unilateral
Reflek R patella & achilles menurun
Nyeri radikuler > berat
Low back pain Kurang
Tanda & gejala sensorik
Saddle Hipestesi; asimetris, mungkin unilateral; disosiasi sensorik (-); anestesi pada dermatom spesifik ekstremitas bawah dengan hipestesi & parestesi; mungkin hipestesi di daerah pubis, termasuk glans penis atau klitoris
Kekuatan motorik Paraplegi arefleksi asimetris lebih jelas; fasikulasi jarang; atrofi lebih sering (tanda LMN)
Impotensi Jarang; disfungsi ereksi yg termasuk ketidakmampuan ereksi, memelihara ereksi, ejakulasi & hipestesi daerah pubis (termasuk glans penis atau klitoris)
Disfungsi sphinkter
Retensi urin, akhir perjalanan penyakit
![Page 43: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/43.jpg)
43
Steroids for acute spinal cord injury
• Methylprednisolone sodium improve neurologic outcome up to one year post-injury
if administered within eight hours of injury
• The dose regimen bolus 30mg/kg over 15 minutes
• with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours
September 9, 2013Bracken MB.Cochrane Database Syst Rev. 2012 .
![Page 44: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/44.jpg)
Spondylitis tuberkulosa• Prevalensi ↑
• Tuberkulosis tulang (35% penyakit ekstra pulmoner), vertebra yang terkena 50 - 60%.
• Vertebra thorakolumbal paling sering terkena.
• Nyeri diatas vertebra, demam subfebris, menggigil & penurunan BB. Durasi gejala : 2 minggu - 3 tahun (rerata 1 tahun).
![Page 45: Medula Spinalis](https://reader035.vdocuments.mx/reader035/viewer/2022062221/563db7b1550346aa9a8d1a08/html5/thumbnails/45.jpg)
PENGOBATANBelum ada pengobatan yang diterima baik
Kausa spesifik : pengobatan yang sesuai
Methylprednisolone : 250-500 mg/12 jam, 3-7 hari, diikuti Prednison oral : 60-80 mg/hari, 7 hari
tapp. 10mg/ 4 hari Dexamethasone : 10mg iv, selanjutnya 6 x 4-6mg/ hari
Fisioterapi