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Dr. Ida Ratna Nurhidayati, Sp.

S
Bagian Ilmu Penyakit Saraf
Fakultas Kedokteran Universitas YARSI
Pendahuluan
Trauma medulla spinalis/spinal cord injury
(SCI) defisit neurologis & hendaya
permanen
Tujuan menegakkan diagnosis & memulai
terapi secepatnya mencegah defisit lanjut
(primer & sekunder)
Epidemiologi
AS, 2006
Insidens + 50 / 1 jt populasi, 14.000 ps/th (AS,
2006)
Pria : wanita = 2,5 - 3 : 1
80% pria dg SCI (spinal cord injury) berusia 18-25
th
Australia, 2006
Insidens 12 / 1 jt populasi / th
Indonesia ??
Etiologi Acute Spinal Cord Injury (ACSI)
Kecelakaan bermotor 50
Mobil
Motor
Sepeda
Jatuh 15-20
Kekerasan individual 15-20
Luka tembak
Kekerasan lain
Olahraga dan rekreasi 10-15
Menyelam (2/3 kasus dalam kategori ini)
Football dan rugby
Hoki
Senam
Gulat
Etiologi Perkiraan Persentase
Dari Keseluruhan SCI
Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.
Anatomi & Patofisiologi
Segmen servikal MS paling rentan
Thoracolumbar junction rentan (15%)

Komplit VS Inkomplit SCI
Komplit : sensoris & motorik di bawah level (-)
Inkomplit : sensoris & motorik di bawah level (+)
prognosis >>
Anatomi & Patofisiologi
Trauma MS
Primer
Deformasi lokal & transformasi energi dr kompresi akut,
laserasi, distracting, atau regangan
Sekunder
Kaskade biokimia & proses selular kerusakan /
kematian sel
Perubahan vaskular, perubahan kadar ion, akumulasi
neurotransmiter, produksi radikal bebas & lipid
peroksidase, efek opioid endogen, edema, inflamasi,
ATP
Critical Care and Resuscitation 2006;8:56-63
Neurosurgery 1999;44:1027-40
Grade A Complete No motor/sensory function is preserved in
the sacral segments S4-S5
Grade B Incomplete Sensory but not motor function is preserved
below the neurological level and extends
through the sacral segments S4-S5
Grade C Incomplete Motor function is preserved below the
neurological level, and the majority of key
muscles below the neurological level have
a muscle grade less than 3
Grade D Incomplete Motor function is preserved below the
neurological level, and the majority of key
muscles below the neurological level have
a muscle grade greater than or equal to 3
Grade E Normal Motor and sensory function are normal
ASIA (American Spinal Injury Association)/
IMSOP (the International Medical Society of Paraplegia)
Impairment Scale
Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.
Terapi
Methylprednisolone / MP (corticosteroid)
Tirilazad mesylate (corticosteroid)
Naloxone
GM-1 ganglioside
Indian Journal of Neurotrauma (IJNT) vol 4, No. 1, 2007
Methylprednisolone
Efek neuroprotektif MPSS (MP-sodium
succinate)
Menghambat lipid peroksidase
Menghambat influks kalsium
Menghambat iskemia
Efek anti inflamasi
MP in ACSI. Guidelines Department Of Surgical
Education, Orlando Regional Medical Center. 2004.
Methylprednisolone
MP (30 mg/kg IV loading dose followed by 5.4
mg/kg/h for the next 23 h NASCIS 2 regimen) may
be considered in pts w/ blunt ASCI presenting less
than 3 h after injury after considering the potential
risks & benefits to the pt
MP (30 mg/kg IV loading dose followed by 5.4
mg/kg/h for the next 47 h NASCIS 3 regimen) may
be considered in pts w/ blunt ASCI presenting
between 3 and 8 h after injury after considering the
potential risks & benefits to the pt
Steroids should not be administered to pts w/ blunt
ASCI presenting greater than 8 h after injury

Methylprednisolone
NASCIS II (1990, Class II)
Prospective, randomized, double-blind multi-center trial in 487 pts w/ ASCI
3 arms :
MPSS 30 mg/kg bolus given within 15 min, followed by 5.4 mg/kg/h infusion for 23
h
Naloxone 5.4 mg/kg bolus given within 15 min, followed by 4.5 mg/kg/h infusion
for 23 h
Placebo infusion
Naloxone improved systemic hypotension, spinal cord blood flow,
neurologic recovery in animal lab
Given within 12 h injury
Conclusion :
All primary outcome measures, including neurologic outcome & mortality, didnt
differ between the 3 groups
Post hoc subgroup analysis of fewer than 50% of those enrolled identified improved
neurologic fx in pts treated w/ MPSS within 8 h of injury.
Pts who received MPSS more than 8 h after injury demonstrated worse neurologic
fx than did the placebo group
Increased wound infection, GI bleeding, & pulmonary embolus in pts who received
MPSS although these differences were not statistically significant
Methylprednisolone
NASCIS III (1997, Class II)
Prospective, randomized, double blind multi-center trial in 499 pts w/ ASCI
All pts were administered MPSS 30 mg/kg & then randomized to 1 of 3 arms
MPSS 5.4 mg/kg/h infusion for 23 h
MPSS 5.4 mg/kg/h infusion for 47 h
Tirilizad mesylate (enhance spinal cord recovery) 2.5 mg/kg bolus q 6 h for 48 h
Treatment was initiated within 8 h in all pts
Conclusion :
Randomization didnt result in equal pt groups as 25% of Group 1 pts had normal motor fx
while only 14% of Group 2 pts had normal motor fx
Pts who received tirilizad demonstrated significantly worse motor fx than did patients who
received MPSS
Among the MPSS groups, all primary outcome measures werent different
Post hoc subgroup analysis identified that pts who received their MPSS bolus more than 3 h
post injury demostrated significantly greater motor fx if they received 48 h of MPSS rather than
24 h
This excludes almost 70% of the study pts from further analysis
Although improved motor & sensory scores were seen in the MPSS groups at 6 weeks & 6
months post-injury, no differences in motor or sensory fx were detectable at 1 year
There was 2x increase in severe pneumonia, 6x increase in mortality due to respiratory
complications in the 48 h MPSS pts when compared to 24 h MPSS pts
Methylprednisolone
Merola et al., 2002 perubahan jaringan scr
mikroskopik thd pemberian MP dosis tinggi
dilanjutkan 23 jam berikutnya pd tikus
Edema & struktur yang berkaitan dg lokasi
injuri dipertahankan
Tdk mengubah perkembangan proses nekrosis /
response sel astrosit pada lokasi injuri MS
Prognosis
Ps hidup > 18 bl angka harapan hidup 70%
(tetraplegia) & 84% (paraplegia)
5 tahun setelah SCI, mortalitas :
Septicemia 40x
Pneumonia 13x
Emboli paru 8x
Penyakit jantung 3x
Gg. berkemih 9x
Bunuh diri 2x
Prognosis
SCI segmen servikal, torakal, & torakolumbal
prognosis perbaikan neurologis incomplete >
complete
Complete (prognosis perbaikan klinis dlm 1 th)
servikal > torakal > torakolumbal (T11-T12, L1-L2)
Incomplete (prognosis perbaikan klinis dlm 1 th)
servikal = torakal > torakolumbal
Ps dg komplit SCI < 5% perbaikan
Jk komplit SCI menetap dlm 72 jam perbaikan 0
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