Dr. Puji Pinta O.

Sinurat, SpS
Dept Neurologi FK-USU MEDAN
2014

Symptoms :
Muscle ache or shooting
Limited range of function
Inability to stand straight
Types :
Acute Vs Chronic
Lower Back Pain
Middle Back Pain
Upper Back Pain

Accidents
Arthritis
Muscle strains
Sport injuries
Nerve problems
Muscular problems
Degenerative disc disease

Age : middle age

Sex : male
Family history
Previous : Back injury, surgery
Pregnancy
Congenital spine problems
Lack of exercose
Longerm medicine that weaken bones
Poor posture
Overweight
Stress
smoking

Definisi: nyeri yang dirasakan di daerah

punggung bawah, dapat merupakan nyeri
lokal maupun nyeri radikuler atau keduanya

Incidens : 60-90% lifetime incidens

5 % annual incidens
90% LBP resolve without treatment within 612 weeks
40-50% resolves within 1 week
75% with nerve root involvement can resolve
in 6 months
LBP leading cause of disability of adults < 45
yo
Third cause of disability in >45 y o

Lumbar strain
Disc bulge/protrusion/extrusion/producing
radiculopathy
Degenerative disc disease
Spinal stenosis
Spondyloarthropathy
Spondylosis
Spondylolisthesis
Sacro-iliac dysfuntion

1.
2.
3.
4.
5.

Iritasi cabang saraf besar yang menuju

ekstremitas
Iritasi cabang saraf kecil yang mempersarafi
vertebra
Ketegangan sepasang otot punggung
(m.erector spinae)
Kerusakan tulang, ligamentum atau sendi
Ruang antar vertebra dapat menjadi sumber
nyeri

1.
2.
3.

NPB Akut
: < 6 minggu
NPB Subakut : 6 -12 minggu
NPB Khronik : > 12 minggu

I. MEKANIKAL
* Strain, sprain lumbal
* Proses degeneratif diskus dan facet
*
*
*
*
*
*

Herniasi diskus
Stenosis spinal
Fraktur kompresi osteoporotik
Spondilolistesis
Fraktur traumatik
Penyakit kongenital

II. NON MEKANIKAL

* Neoplasma
* Infeksi : osteomielitis, abses epidural,
abses
paraspinal, penyakit
Pott
* Artritis inflamatori : Ankylosing
spondylitis,
Psoriatic spondylitis,
Sindroma Reiter
* Pagets disease of the bone

INSPEKSI : gaya berjalan, simetri, perilaku

penderita
terkait keluhan nyerinya.
PALPASI : vertebra, kelompok otot paraspinal
PERKUSI : menilai adanya nyeri tekan
PEMERIKSAAN UTK MENILAI FUNGSI :
* range of motion
* SLR test
* hiperekstensi tungkai
* refleks
* fungsi motorik dan sensorik

NEUROFISIOLOGIK :
- EMG
- somatosensory evoked potential
RADIOLOGIK :
- foto polos
- mielografi, CT mielografi, CT-scan, MRI
LABORATORIUM :
- LED, CRP, DL, UL

Usia > 50 tahun

Defisit motorik (+)
BB menurun tanpa sebab yg jelas
Dugaan Ankylosing spondylitis
Penyalahgunaan obat dan alkohol
Adanya riwayat kanker
Suhu > 37,8oC
Tidak ada perbaikan dalam 1 bulan

Serious neurologic condition in which

damage to the cauda equina
Causes acute loss of function of the Lumbar
plexus, nerve roots of the spinal canal
below the termination (conus medullaris) of
the spinal cord
Is a Lower Motor Neuron Lesion

Low Back Pain/ Sciatica

Pain start in the buttocks-- travels down
the back of the thighs and legs
Severe back pain
Loss of sensation in a saddle distribution
over the genitals, anus and inner thighs
(perineal or saddle paresthesia)
Bowel and bladder disturbances

Sexual dysfunction
Lower extremitiy muscle weaakness and
loss of sensation (often paraplegia)
Lower extremity reflexes : reduced/absent

Compression
Traumatic injury compression of the
cauda equina
Disk herniation
Spinal stenosis
Spinal tumor
Inflammatory condition

Cauda equina syndrome is a surgical

emergency (surgical decompression)
Treatment underlying causes of CES
Inflammatory process antiinflammatory
agent (ibuprofen, corticosteroid
Infection antibiotics therapy
Physiotherapy and occupational theraphy

Surgical intervention with decompression

assist recovery
50-70% patient have urinary retention
30-50% incomplete syndrome

Adalah kelainan yang disebabkan perpindahan ke

depan satu corpus vertebra terhadap vertebra di
bawahnya.
Tersering pada L4-5
Sering pada : orang yang sering angkat beban
berat, pemain sepak bola, trauma
Pada semua usia, tersering pada usia tua

Berdasarkan foto polos lateral, dibagi atas

menurut derajat beratnya pergeseran :
Grade 1 : 25%
Grade 2 : 25-49%
Grade 3 : 50-74%
Grade 4 : 75-99%
Grade 5 : 100% (slip seluruhnya spondyloptosis)

Istirahat
Hindari angkat berat
Analgetik, OAINS
Operasi

Adalah kelainan degeneratif yang menyebabkan

hilangnya struktur dan fungsi normal spinal
Penyebab utama : proses penuaan
Lokasi dan percepatan proses degenerasi bersifat
individual

Konservatif (75% berhasil), meliputi :

* istirahat
* OAINS
* pelemas otot
* Pemanasan, stimulasi elektrik, lumbosakral
ortotik
* Olah raga
* Modifikasi gaya hidup
Pembedahan (jarang)

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 medulla
spinalis
Paling sering di daerah lumbal

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

HNP lumbalis (paling >>)

L5-S1 (45-50%), L4-5 (40-45%)
ok jaringan fibrokartilagonya terutama di
posterior lebih tipis dibanding diskus
intervertebralis lainnya
HNP servikalis
C6-7 (69%), C5-6 (19%)
HNP torakalis (jarang, < 1%)

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.

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.

Plain vertebral x-rays :

* limited information
* disc narrowing, scoliosis, lordosis
lumbal
Myelography
CT or CT-myelography
MRI : the best imaging study

EMG/NCV : 90% abnormal after 1-2

weeks

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 program
- soft cervical collar or lumbar corset

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 symptoms
4. Pain that has existed for more than 4 months,
has not responded to conservative treatment,
and interferes with normal function.

Adalah penyempitan kanal spinal dengan

kompresi akar saraf, dengan atau tanpa keluhan
Penyebab yang sering : hypertrophic
degenerative dari facet dan penebalan
ligamentum flavum

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

Analgetik, OAINS
Terapi fisik
Injeksi kortikosteroid epidural
Laminektomi dekompresi

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

TERIMA
KASIH