PAIN

Yudiyanta
Pain Sub-Department of Neurology Department

Kasus 1
38 th 1HSMRS LBP + kedua bokong Limitasi ROM terutama pada gerakan fleksi dan rotasi. NPS 6. Neuro Exam: dbn Suhu tubuh 37.8 C. Nyeri tekan diatas vertebra lumbal 4-5 dan dibokong (+).

Diagnosis yang paling mungkin?

A. B. C. D. E. Fraktur vertebra lumbal 4-5 Spondilolistesis vertebra lumbal 4-5 Hernia Nukleus Pulposus Lumbal 4-5 Sprain Muskuler Referred Pain organ internal

Pemeriksaan Penunjang yang dianjurkan: A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu

Manakah terapi yang paling rasional?

A. Acetaminofen 3-4 x 1000 mg B. K-diclofenac 2x 50 mg C. Diazepam 3 x 2 mg D. Codein 3 x 20 mg E. Metilpredisolon 8 mg-8mg-0mg

Lumbar strain or sprain

Causes of Low Back Pain

Lumbar strain or sprain Degenerative changes Herniated disk Osteoporosis compression fractures Spinal stenosis Spondylolisthesis Spondylolysis, diskogenic LBP or other instability Traumatic fracture Congenital disease Cancer Inflammatory arthritis Infections Psychological : 70% : 10% : 4% : 4% : 3% : 2% : 2% : < 1% : < 1% : 0.7% : 0.3% : 0.01% : ?
(Stoltz, 2003)

Pemeriksaan Penunjang yang dianjurkan: A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu

Role of X-rays (Radiology)

Usually unnecessary and not helpful Plain X-ray: Age > 50 years No improvement after 6 weeks Significant Trauma MRI : After 6 weeks if have sciatica

Red Flags
Significant trauma history, or minor in older adults Nocturnal pain in supine position with history of cancer Bladder or bowel incontinence or dysfunction Constitutional symptoms:
Fever / chills Weight loss Lymph node enlargement

Risk factors for spinal infection

Recent infection IV drug use Immunosuppression

Major motor weakness

Compression fracture

Multiple-level degenerative lumbar spondylosis and spinal stenosis

Spondylolisthesis

Manakah terapi yang paling rasional?

A. Acetaminofen 3-4 x 1000 mg B. K-diclofenac 2x 50 mg C. Diazepam 3 x 2 mg D. Codein 3 x 20 mg E. Metilpredisolon 8 mg-8mg-0mg

Summary of Evidence on Medications for Acute Low Back Pain (Chou & Huffman, 2007)
Drug Net Benefit
Moderate No evidence No evidence

Effective vs. Placebo?

Unclear No evidence No evidence

Inconsistency ?
Some inconsistency No evidence No evidence

Overall Quality of Evidence

Good No evidence No evidence

Comments

Acetaminophen Antidepressants Antiepileptic drugs Benzodiazepines NSAIDs

Few data on serious adverse events Evaluated only in patients with radicular LBP No reliable data on risks of abuse or addiction. May cause serious gastrointestinal and cardiovascular adverse event. Insufficient evidence to judge benefits and harms of aspirin and celecoxib for LBP No reliable data on risks of abuse or addiction Little evidence of antispasticity skeletal muscle relaxants baclofen and dantrolene for LBP Mostly evauated in patients with radicular LBP The only trial compared tramadol with an NSAID not available in US

Moderate Moderate

Unable to determine Yes

Some inconsistency No

Fair Good

Opioids Skeletal Muscle Relaxant Systemic Corticosteroids Tramadol

Moderate Moderate

No evidence Yes

Not applicable No

Fair Good

Not Effective Unable to estimate

No No evidence

No Not applicable

Fair Poor

 Jika pada pemeriksaan ditemukan:

TD : 110/80 Ureum: 28 Creatinin : 1,1 SGOT: 30 SGPT: 28 Nyeri tekan epigastrium (+).

Pilihan NSAIDs yang paling rasional?

A. Ibuprofen 2-3 x 400 mg B. K-Diclofenac 2x50 mg C. Asam Mefenamat 3x500 mg D. Paracetamol 3x500 mg E. Celecoxib 2x200 mg

Analgesic efficacy, compared with placebo, of treatments for acute and chronic non-specific low back pain.

Machado L A C et al. Rheumatology 2009;48:520-527, SMT: spinal manipulatif therapy

Berapa lama saya bedrest?

A. 1-2 hari B. 5 hari C. 1 minggu D. 10 hari E. Tidak perlu bedrest, langsung aktifitas

Apakah boleh pijat?

A. Boleh B. Tidak boleh

Exercise & Bed Rest

Advice to stay active: There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica 1-2 days of bed rest if necessary Light activity, avoiding heavy lifting, bending or twisting

Analgesic efficacy of treatments for NSLBP of any duration.

The Author 2008. Published by Oxford University Press on behalf of the British Society for Machado L A et al. Rheumatology 2009;48:520-527 Rheumatology. All C rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

KASUS 2
Wanita 52 th dg keluhan nyeri punggung bawah menjalar ke tungkai kanan. Riwayat angkat junjung (+), riwayat trauma (-). Pada pemeriksaan nyeri terutama dirasakan saat gerakan ekstensi badan dan miring ke kiri, dan dirasakan lebih nyaman dengan posisi badan fleksi dan menekuk ke kanan. Nyeri sudah dirasakan selama 2 bulan.

Diagnosis yang paling mungkin?

A. B. C. D. E. Fraktur vertebra lumbal Spondilolistesis vertebra lumbal Hernia Nukleus Pulposus Lumbal Sprain Muskuler Referred Pain organ internal

Pemeriksaan fisik yang paling sensitif mendukung diagnosis kerja anda: A. Patrick sign B. Kontra-Patrick Sign C. Lasegue sign D. Lasegue silang sign E. Babinski sign

Pemeriksaan Penunjang yang dianjurkan:

A. Lumbal X-Ray B. Lumbal CT Scan C. Lumbal MRI D. ENMG E. Belum perlu

Role of X-rays (Radiology)

Diagnosis Disc Herniation Test CT MRI CT Myelo Spinal Stenosis CT MRI Myelogram Sensitivity 0.90 0.90 0.90 0.90 0.90 0.77 Specificity 0.70 0.70 0.70 0.80-0.95 0.75-0.95 0.70

 Pada evaluasi lebih lanjut, OS mengeluh nyeri dengan rasa kemeng dan pegal, tidak berdenyut, disertai rasa terbakar, kadang-kadang jika salah posisi nyeri seperti tersetrum sampai ujung kaki. Kesemutan dan tebal2 juga dirasakan. NPS 6.

Terapi Farmakologi yang paling rasional?

A. Paracetamol 325 mg-tramadol 37,5 mg, gabapentin 100 mg, metikobalamin 500 mcg B. Paracetamol 650 mg, amitriptilin 25 mg, gabapentin 100 mg C. Tramadol 50 mg, amitriptilin 25 mg, codein 10 mg D. Paracetamol 650 mg, tramadol 50 mg, carbamazepin 200 mg E. Celecoxib 200 mg, amitriptilin 25 mg, metilprednisolon 8 mg po

5-HT Spinal Cord

NE STT

(Kanzler et al., 2002)

DORSAL HORN

Periphery

PAF

NE 5-HT NE 5-HT 2
Glu NMDA AMPA

STT
mu 5-HT1A
GABA A/B

5-HT3 2

mu

PAF

SP NKA

NK1

Dorsal Horn Neuron

Other Dorsal Horn Neurons

GABA InterNeuron

Anterior Horn Neurons

Action of AED

Stafstrom C, 1998

Summary of Evidence on Medications for Sub Acute or Chronic Low Back Pain (Chou & Huffman, 2007)
Drug Net Benefit
Moderate Small To moderate Small to moderate Moderate Moderate

Effective vs. Placebo?

No trial in patients LBP Yes

Inconsistency ?
No No

Overall Quality of Evidence

Good God

Comments

Acetaminophen Antidepressants Antiepileptic drugs Benzodiazepines NSAIDs

Asymptomatic elevation of liver function test at therapeutic doses Only TCA have been shown effective for LBP. No evidence for Duloxetine or venlafaxine 1 trial evaluated topiramate for back pain with or w/out radiculopathy No reliable data on risks for abuse or addiction May cause serious GI and CV adverse event. Insufficient evidence to judge benefits and harms of aspirin or celecoxib for LBP No reliable data on risks for abuse or addiction Mostly evaluated in patients with radicular LBP -

Yes

Not applicable

Poor

Mixed result Yes

Some inconsistency No

Fair Fair

Opioids Skeletal Muscle Relaxant Systemic Corticosteroids Tramadol

Moderate Unable to estimate No evidence Moderate

Yes unclear No evidence Yes

No Not applicable No evidence No

Fair Poor No evidence Fair

 Hasil lab menunjukkan:

Hb 12 g% Al 7.000 SGOT: 100 SGPT : 189 Ureum: 63 Creatinin 2,7

Berdasarkan Klinis dan Hasil Lab diatas, analgetik apa yang paling anda rekomendasikan?

A. Paracetamol 650 mg B. Paracetamol 500 mg + Celecoxib 100 mg C. Paracetamol 325 mg + tramadol 37,5 mg D. Celexocib 200 mg+ meloksikam 7,5 mg E. Piroxicam 20 mg + Paracetamol 300 mg F. Asam mefenamat 500 mg + paracetamol 500 mg

Stephan A. Schug Combination analgesia in 2005a rational approach: focus on paracetamoltramadol Published online: 2 June 2006, Clinical Rheumatology 2006

Cont
safety concerns about long-term use: has demonstrated efficacy in the control of a variety of chronic pain states. long-term treatment up to 2 years duration. well-tolerated and has reduction in adverse events a useful add-on analgesic treatment if existing therapy is insufficiently effective

Pemeriksaan MRI menunjukkan hasil seperti ini:

Anda merekomendasikan tindakan operatif jika:

A. B. C. D. E. Bacaan imaging HNP Sindrome cauda equina Progressive Motor Loss Intractable Pain Klinis canalis stenosis spinalis

Pemeriksaan MRI menunjukkan hasil seperti ini:

Buldging discus - Compression Fracture

Herniated Disc

1. Kompresi mekanik langsung 2. Inflamasi biologis 3. Iskemia lokal

(Simon, 2003; Kidd dan Richardson, 2002)

BULGING

PROLAPSED

EXTRUDED

SEQUESTRATION

Spondilolisteis

SURGICAL
Indications:
Cauda Equina PROGRESSIVE Motor Loss Intractable Pain Spinal Canal Stenosis

Surgical Outcome (Weber et al)

At 1 year: 90% good outcome with Surgery as compared to 60% with NonSurgery At 4 years: Surgery is slightly better (not statistical) At 10 years: Same for both groups

Jika MRI seperti berikut:

Edukasi pada pasien ini yang paling tepat:

A. 62% herniasi diskus akan mengalami resorpsi spontan B. Respons baik dengan operasi C. Prognosis jangka panjang > 10 tahun lebih baik pada pasien yang dioperasi D. Harus minum obat seumur hidup E. Tidak akan bisa sembuh

PROGNOSIS on NON-SURGICAL
Treated the patient, not the diagnostic test Recovery:
80 % 3 days to 3 weeks, with or without treatment Up to 90 % resolved in 6-12 weeks

86-90% satisfactory outcome in one year

62% Disc Herniation Resorb Over Time

Saals et al, Bush et a

Large Compressive Discs symptomatic :

Respond well to surgery high rate of clinical improvement with non-operative treatment (Saals et al)

Other Modalities
Back Brace/Corset/Lumbar Support Traction Injections: Inconclusive evidence TENS Hot/Cold Ultrasound

Prevention
Exercise:
Aerobic, back/leg strengthening

Back braces and education about proper lifting techniques Weight loss and smoking cessation

Exercises
Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another

Injections
Epidural injections: Insufficient and conflicting evidence Facet joint injections: No improvement Local/Trigger point injections: Possibly some benefit

Symptom Magnification Examination:

Waddell signs: signs suggesting symptom magnification and psychological distress Superficial or non-anatomic distribution of tenderness Non-anatomic or regional disturbance of motor or sensory impairment Inconsistency on positional SLR Inappropriate/excessive verbalization of pain or gesturing Pain with axial loading or rotation of spine

Kasus 3
Anda bekerja di klinik panti jompo 65 th dg nyeri terbakar dan rasa tersetrum di dahi sebelah kiri dan di sekitar mata kiri. 3 bl timbul plenting-plenting yang nyeri pada daerah tsb namun sudah sembuh. Saat ini nyeri NPS 8, Nyeri memberat bila tersentuh, terkena sentuhan rambut atau angin.

OS hanya bersedia minum satu jenis obat. Obat mana yang paling anda rekomendasikan?

A. Meloksikam 1x15 mg B. Asam mefenamat 3x500 mg C. Metikobalamin 3x500 mcg D. Parasetamol 3x650 mg E. Amitriptilin 1x12,5 mg

Hasil EKG menunjukkan VES jarang, HHD, dan iskemik anterior. Obat mana yang anda rekomendasikan ? A. Gabapentin 2x75 mg B. Tramadol 2x50 mg C. Metikobalamin 3x500 mcg D. Parasetamol 3x650 mg E. Amitriptilin 1x12,5 mg

EFNS GUIDELINES FOR THE TREATMENT OF PHN

Recommendations: First line therapy Second line therapy Lack of or weak efficacy TCAs, gabapentin, pregabalin, and topical lidocaine (evidence level A) Strong opioids, tramadol and capsaicin (evidence level B) Mexiletine and NMDA antagonists (evidence level A)

EFNS: European Federation of Neurological Societies

What is Neuropathic pain?

Definition:
Pain arising as a direct consequence of a lesion or disease affecting the somatosensory NERVE system

Characterized by:
Pain often described as shooting, electric shock-like or burning. The painful region may not necessarily be the same as the site of injury. Almost always a chronic condition (e.g. post herpetic neuralgia, post stroke pain) Responds poorly to conventional analgesics

Perceived pain

Nerve lesion

Descending modulation

Ascending input

Nociceptive afferent fiber Spinal cord Ectopic discharges

The Inter-Relationship Between Pain, Sleep, and Anxiety / Depression

Pain

Functional impairment Anxiety & Depression Sleep disturbances

Nicholson and Verma. Pain Med. 2004;5 (suppl. 1):S9-S27

What is the Correlation Between Causes, Muscular pain, Neuro-endocrine (HPA Axis) disorders and Psychological distress
Emotional, Environmental and Genetic Predisposition Cortex-Limbic System- Hypocampus Thalamus & Hypothalamus Pituitary Adrenal, Thyroid Perception CRH, TRH, GhRH, PRF, GnRH ACTH, TSH, GH, Prolactine, FCH-LH Cortisone, Thyroid,
Prolactine, Estrogen, Progesterone

Neuro-hormonal Disfunction Sympathetic Dorsal Horn Metabolic Muscle Trauma

PAIN

Karakteristik

Post Herpetic Neuralgia Dominan terbakar, nyeri tajam Kronik + Unilateral Jarang ada -

Trigeminal Neuralgia Dominan seperti kesetrum listrik Akut, intermitten/ paroksismal +/Unilateral Selalu ada Mengunyah, menelan, berbicara

Tipe Nyeri Perjalanan Gangguan sensibilitas Lokasi Pain free interval Faktor presipitasi

Kasus 4
Laki-laki, 60 tahun penderita Ca prostat, mengeluhkan nyeri sangat hebat di tulang belakang, dirasakan seperti ditusuk-tusuk, dan kadang seperti terbakar. NPS 9. Nyeri ini muncul sejak sekitar 1 tahun yang lalu saat pasien pertama kali didiagnosis menderita keganasan prostat. Nyeri ini dirasakan hilang timbul namun semakin lama semakin berat dan konstan. Pemeriksaan neurologis didapatkan gangguan BAB dan BAK, dengan anestesi dermatom L5S1. Pemeriksaan lab menunjukkan kadar PSA 125 mg/dl dengan Ro terlampir.

Imaging

Terapi yang paling anda pilih:

A. Tramadol 50 mg po B. Morfin sulfat 10 mg C. Risedronat sodium 60 mg D. Fentanil patch 25 mcg E. Ketorolac injeksi 1 amp

Primary or Metastatic Carcinoma

SPONDILITIS

Kasus 5
Wanita 25 tahun, sekretaris, mengeluhkan nyeri kedua tangan, sejak 8 HSMRS. dirasakan panas, tebal-tebal dan kemeng mulai dari sendi siku sampai dengan tangan terutama pada jari telunjuk dan jari tengah. Tidak ada rasa tebal-tebal pada kelingking. NPS ratarata 5. Rasa ini lebih parah pada saat tidur malam hari bahkan menyebabkan pasien terbangun karena nyeri. Pekerjaan mengharuskan leher sering menunduk, dan kadang-kadang merasakan nyeri leher terutama sore hari. Nyeri tekan epigastrium (-). Pemeriksaan fisik dbn.

Diagnosis yang paling mungkin?

A. HNP C5-6 B. Polineuropati C. Myelopathy D. Myalgia E. Carpal tunnel syndrome

Nasehat Pertama ?
A. Splinting position B. Tidak boleh angkat berat C. Kurangi makanan tinggi glukosa D. Tidak boleh makan tinggi kolesterol E. Minum obat secara teratur

Analgetik pilihan Anda:

A. Paracetamol 3x650 mg B. Metampiron 3x500 mg C. Tramadol 2x50 mg D. Paracetamol 325 mg + tramadol 33 mg E. Na-diclofenac 2x25 mg

Kombinasi terapi yang paling rasional?

A. Paracetamol+deksamethason B. Na-diclofenac, metilprednisolon+metikobalamin C. K-diclofenac + gabapentin + metikobalamin D. Deksamethason injeksi E. Vit B injeksi, ketorolac injeksi

Terapi non farmakologi yang anda anjurkan:

A. Operasi dekompresi B. Fisioterapi exercise C. Ultrasound dan diatermi D. Layar komputer kerja sejajar mata sehingga tidak menunduk saat kerja E. Bedrest

CTS
Normal pressure : 05mm Hg 30mm Hg at rest in CTS, and is 90mm Hg with wrist flexion or extension in patients with CTS. Classic symptoms : night pain that wakes the patient from sleep, pain with maximal wrist flexion or extension, decreased grip strength, and decreased dexterity.

Summary of Tests
Test Phalens Tinels Compression Sensitivity 75% 64% 87% Specificity 62% 71% 90%

Non-operative Treatment
Splinting (nocturnal, neutral) Oral agents
NSAIDs, Vitamin B6 (?) Neither effective in isolation

Steroid injection
80% relief short-term, ~10-20% @ 1.5 years (+) response predictive of success with surgery dexamethasone safest

Summary
CTS is a clinical diagnosis
ED are confirmatory

Non-operative treatment early Operative treatment

if denervation of APB failure of non-operative treatment

Kasus 6
Mahasiswi, 20 tahun datang dengan keluhan nyeri kepala berdenyut, sejak 3 hari yang lalu, terutama di frontal dan temporal. Pemeriksaan fisik dan neurologis tidak ditemukan abnormalitas. Gangguan penglihatan (-). Pada pemeriksaan NPS berkisar 8. Pasien merasakan silau jika melihat sinar. Pasien sedang mengalami faringitis sejak 1 hari , dan ada rasa mual.

Diagnosis yang paling mungkin

A. Migraine headache B. Cluster headache C. Tension type headache D. Nyeri kepala terkait infeksi/inflamasi E. Galucoma

Classification and Diagnostic Criteria

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Migraine (7) Tension-type headache (3) Cluster headache and chronic paroxysmal hemicrania (3) Miscellaneous headaches unassociated with structural lesion (6) Headache associated with head trauma (2) Headache associated with vascular disorders (9) Headache associated with non-vascular intracranial disorder (7) Headache associated with substances or their withdrawal (5) Headache associated with non-cephalic infection (3) Headache associated with metabolic disorder (6) Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures (7) Cranial neuralgias, nerve trunk pain and deafferentation pain (8) Headache not classifiable (1)

TOTAL : 67
(Silberstein & Young, 2005)

BACKGROUND
HEADACHE

Primary

Secondary

headache condition itself is the problem, and no underlying or dangerous cause for it can be identified. The classification is based on symptom profiles

headache are related to other conditions, and a 'secondary symptom'. They are classified according to their causes (e.g. vascular, psychiatric, etc.).

Bajwa & Wootton, 209

History and examination

No gold standard tests or biologic markers exist A good history is the key to diagnosis. Examination is usually normal in patients with primary headache. A systematic case history single most important diagnosis, future work-up and treatment plan. focus the physical examination and prevent unnecessary investigation and imaging studies

Consider a diagnosis of migraine

Patients with recurrent severe disabling headaches associated with nausea and sensitivity to light, and with a normal neurological examination (C).

Consider a diagnosis of tension-type headache in patients with recurrent, non-disabling bilateral headache and a normal neurological examination (C).

Consider the diagnosis of a trigeminal autonomic cephalalgia (cluster headache, paroxysmal hemicrania, short lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)) in patients with frequent, brief, unilateral headaches in a trigeminal distribution with ipsilateral cranial autonomic features (D)

New daily persistent headache

Cresendo pattern in daily: exclude secondary causes (such as subarachnoid haemorrhage, meningitis, raised intracranial pressure, low pressure headache, giant cell arteritis) (D).

Investigation
Neuroimaging is not indicated in patients who have a clear history of migraine, no red flag features, and a normal neurological examination(D). In stable migraine only 0.2% have relevant abnormalities on neuroimaging. Both magnetic resonance imaging and computed tomography can identify incidental abnormalities that may result in patient anxiety as well as dilemmas in practical and ethical management.

For patients with a first presentation of thunderclap headache

Refer immediately to hospital for exclusion of subarachnoid haemorrhage or alternative secondary cause of thunderclap headache (such as intracranial haemorrhage, meningitis, cerebral venous sinus thrombosis) by CT brain scan, and lumbar puncture if CT brain scan is normal (D).

Investigation
The following are warning signs or red flags for potential secondary headache, based on observational studies (D): new headache in a patient aged over 50; thunderclap onset (that is, abrupt and severe); focal and non-focal symptoms; abnormal signs; headache changing with posture; valsalva headache (headache triggered by valsalva-type manoeuvres such as coughing, sneezing, bending, heavy lifting, straining); fever history of HIV; cancer

Indications for imaging studies

AAN, AAFP, ASIM: Patients with danger signs. Non-acute headache and an unexplained abnormal finding on neurologic examination. In the remaining patients remain one of clinical judgment increased severity of symptoms or resistance to appropriate drug therapy; change in characteristics or pattern of headache family history of an intracranial structural lesion

Bajwa & Wootton, 209

SUGGESTIVE INFECTION
For patients with headache and features suggestive of infection of the central nervous system (such as fever, rash), refer immediately to hospital (D).

SUGGESTIVE INCREASED of ICP

For patients with headache and features suggestive of raised intracranial pressure (such as worse lying flat, valsalva headache, focal or non-focal symptoms or signs, papillo-oedema), refer urgently for specialist assessment (D).

Consider intracranial hypotension

in all patients with headache developing or worsening after assuming an upright posture (D). Refer such patients to a neurologist or headache clinic for specialist assessment (D)

Consider giant cell arteritis

in any patient over the age of 50 presenting with a new headache or change in headache, and check erythrocyte sedimentation rate and C reactive protein levels (D).

SUMMARY
The appropriate evaluation of headache complaints includes the following: Rule out "Danger signs. Determine the type of primary headache using the patient history as the primary diagnostic tool. There may be overlap in symptoms (migraine and tension-type headache; migraine and some secondary causes of headache (such as sinus disease)). An imaging study is warranted in "Indications for imaging studies