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PRESENTASI KASUS BANGSAL

TETREPARESIS

Diajukan Kepada :
Dr. Gama Sita Setya P., Sp.S

Disusun Oleh :
Budi Nugraha
2007 031 0032

KEPANITERAAN KLINIK ILMU PENYAKIT SYARAF


FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH YOGYAKARTA
BPRSUD SALATIGA
2011

LEMBAR PENGESAHAN
PRESENTASI KASUS BANGSAL
TETRAPARESIS

Telah disetujui dan dipresentasikan


Pada tanggal

Februari 2010

Menyetujui :

Dokter Pembimbing

(Dr. Gama Sita Setya P., Sp.S)

BAB I
TINJAUAN PUSTAKA
TETRAPARESIS
DEFINISI
Parese adalah kelemahan/kelumpuhan parsial yang ringan/tidak lengkap atau
suatu kondisi yang ditandai oleh hilangnya sebagian gerakan atau gerakan terganggu.
Kelemahan adalah hilangnya sebagian fungsi otot untuk satu atau lebih kelompok otot
yang dapat menyebabkan gangguan mobilitas bagian yang terkena. Parese pada anggota
gerak dibagi mejadi 4 macam, yaitu:
Monoparese adalah kelemahan pada satu ekstremitas atas atau ekstremitas bawah.
Paraparese adalah kelemahan pada kedua ekstremitas bawah.
Hemiparese adalah kelemahan pada satu sisi tubuh yaitu satu ekstremitas atas dan
satu ekstremitas bawah pada sisi yang sama.
Tetraparese adalah kelemahan pada keempat ekstremitas.
Tetraparese/Quadriparese adalah kelumpuhan/kelemahan yang disebabkan oleh
penyakit atau trauma pada manusia

yang menyebabkan hilangnya sebagian

fungsi

motorik pada keempat anggota gerak, dengan kelumpuhan/kelemahan lengan lebih atau
sama hebatnya dibandingkan dengan tungkai. Hal ini diakibatkan oleh adanya kerusakan
otak, kerusakan tulang belakang pada tingkat tertinggi (khususnya pada vertebra
cervikalis), kerusakan sistem saraf perifer, kerusakan neuromuscular atau penyakit otot.
kerusakan diketahui karena adanya lesi yang menyebabkan hilangnya fungsi motorik
pada keempat anggota gerak, yaitu lengan dan tungkai. Penyebab khas pada kerusakan ini

adalah trauma (seperti tabrakan mobil, jatuh atau sport injury) atau karena penyakit
(seperti mielitis transversal, polio, atau spina bifida).
Pada tetraparese kadang terjadi kerusakan atau kehilangan kemampuan dalam
mengontrol sistem pencernaan, fungsi seksual, pengosongan saluran kemih dan rektum,
sistem pernafasan atau fungsi otonom. Selanjutnya, dapat terjadi penurunan/kehilangan
fungsi sensorik. adapun manifestasinya seperti kekakuan, penurunan sensorik, dan nyeri
neuropatik. Walaupun pada tetraparese itu terjadi kelumpuhan pada keempat anggota
gerak tapi terkadang tungkai dan lengan masih dapat digunakan atau jari-jari tangan
yang tidak dapat memegang kuat suatu benda tapi jari-jari tersebut masih bisa
digerakkan, atau tidak bisa menggerakkan tangan tapi lengannya masih bisa digerakkan.
Hal ini semua tergantung dari luas tidaknyanya kerusakan.
EPIDEMIOLOGI
Tetraparese salah satunya disebabkan karena adanya cedera pada medula spinalis.
menurut Pusat Data Nasional Cedera Medula Spinalis (The National Spinal Cord Injury
Data Research Centre) memperkirakan ada 10.000 kasus baru cedera medula spinalis
setiap tahunnya di Amerika Serikat. Angka insidensi paralisis komplet akibat kecelakaan
diperkirakan 20 per 100.000 penduduk, dengan angka tetraparese 200.000 per tahunnya.
Kecelakaan kendaraan bermotor merupakan penyebab utama cedera medula spinalis.
Cedera medula spinalis dapat dibagi menjadi komplet dan tidak komplet
berdasarkan ada/tidaknya fungsi yang dipertahankan di bawah lesi. Pembagian ini
penting untuk meramalkan prognosis dan penanganan selanjutnya. Data di Amerika
Serikat menunjukkan urutan frekuensi disabilitas neurologis karena cedera medula
spinalis traumatika sbb : (1) tetraparese inkomplet (29,5%), (2) paraparese komplet

(27,3%), (3) paraparese inkomplet (21,3%), dan (4) tetraparese komplet (18,5%).
ETIOLOGI
Tabel 1. Penyebab umun dari tetraparesis :
Complete/incomplete transection of cord with fracture
Prolapsed disc
Cord contusion-central cord syndrome, anterior cord syndrome
Guillain-Barre Syndrome (post infective polyneuropathy)
Transverse myelitis Acute myelitis
Anterior spinal artery occlusion
Spinal cord compression
Haemorrhage into syringomyelic cavaty
Poliomyelitis
PATOFISIOLOGI
Tetraparese dapat disebabkan karena kerusakan Upper Motor Neuron (UMN)
atau kerusakan Lower Motor Neuron (LMN). Kelumpuhan/kelemahan yang terjadi pada
kerusakan Upper Motor Neuron (UMN) disebabkan karena adanya lesi di medula
spinalis. Kerusakannya bisa dalam bentuk jaringan scar, atau kerusakan karena tekanan
dari vertebra atau diskus intervetebralis. Hal ini berbeda dengan lesi pada LMN yang
berpengaruh pada serabut saraf yang berjalan dari kornu anterior medula spinalis sampai
ke otot.
Pada columna vertebralis terdapat nervus spinalis, yaitu nervus servikal, thorakal,
lumbal, dan sakral. Kelumpuhan berpengaruh pada nervus spinalis dari servikal dan

lumbosakral dapat menyebabkan kelemahan/kelumpuhan pada keempat anggota gerak.


Wilayah ini penting, jika terjadi kerusakan pada daerah ini maka akan berpengaruh pada
otot, organ, dan sensorik yang dipersarafinya.
Ada dua tipe lesi, yaitu lesi komplit dan inkomplit. Lesi komplit dapat
menyebabkan kehilangan kontrol otot dan sensorik secara total dari bagian dibawah lesi,
sedangkan lesi inkomplit mungkin hanya terjadi kelumpuhan otot ringan (parese) dan
atau mungkin kerusakan sensorik. Lesi pada UMN dapat menyebabkan parese spastic
sedangkan lesi pada LMN menyebabkan parese flaccid.
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Gambar 3. Lesi pada Lower motor neuron (LMN).
Lesi di Mid- or upper cervical cord
Tiap lesi di medula spinalis yang merusak daerah jaras kortikospinal lateral
menimbulkan kelumpuhan Upper Motor Neuron (UMN) pada otot-otot bagian tubuh
yang terletak di bawah tingkat lesi. Lesi transversal medula spinalis pada tingkat servikal,
misalnya C5 mengakibatkan kelumpuhan Upper Motor Neuron (UMN) pada otot-otot
tubuh yang berada dibawah C5, yaitu sebagian otot-otot kedua lengan yang berasal yang
berasal dari miotom C6 sampai miotom C8, lalu otot-otot thoraks dan abdomen serta
segenap otot kedua tungkai yang mengakibatkan kelumpuhan parsial dan defisit
neurologi yang tidak masif di seluruh tubuh. Lesi yang terletak di medula spinalis
tersebut maka akan menyebabkan kelemahan/kelumpuhan keempat anggota gerak yang
disebut tetraparese spastic.
Lesi di Low cervical cord
Lesi transversal yang merusak segmen C5 ke bawah itu tidak saja memutuskan
jaras kortikospinal lateral, melainkan ikut memotong segenap lintasan asendens dan
desendens lain. Disamping itu kelompok motoneuron yang berada didalam segmen C5
kebawah ikut rusak. Ini berarti bahwa pada tingkat lesi kelumpuhan itu bersifat Lower
Motor Neuron (LMN) dan dibawah tingkat lesi bersifat Upper Motor Neuron (UMN).
Dibawah ini kelumpuhan Lower Motor Neuron (LMN) akan diuraikan menurut

komponen-komponen Lower Motor Neuron (LMN).


Motoneuron-motoneuron berkelompok di kornu anterius dan dapat mengalami
gangguan secara selektif atau terlibat dalam satu lesi bersama dengan bangunan
disekitarnya, sehingga di dalam klinik dikenal sindrom lesi di kornu anterius, sindrom
lesi yang selektif merusak motoneuron dan jaras kortikospinal, sindrom lesi yang
merusak motoneuron dan funikulus anterolateralis dan sindrom lesi di substantia grisea
sentralis . Lesi ini biasanya disebabkan karena adanya infeksi, misalnya poliomielitis.
Pada umumnya motoneuron-motoneuron yang rusak didaerah intumesensia servikal dan
lumbalis sehingga kelumpuhan LMN adalah anggota gerak.
Kerusakan pada radiks ventralis (dan dorsalis) yang reversibel dan menyeluruh
dapat terjadi. Kerusakan itu merupakan perwujudan reaksi imunopatologik. walaupun
segenap radiks (ventralis/dorsalis) terkena, namun yang berada di intumesensia servikalis
dan lumbosakralis paling berat mengalami kerusakan. Karena daerah ini yang mengurus
anggota gerak atas dan bawah. Pada umumnya bermula dibagian distal tungkai kemudian
bergerak ke bagian proksimalnya. Kelumpuhannya meluas ke bagian tubuh atas, terutama
otot-otot kedua lengan. Kelainan fungsional sistem saraf tepi dapat disebabkan kelainan
pada saraf di sumsum tulang belakang atau kelainan sepanjang saraf tepi sendiri. Salah
satu penyakit dengan lesi utama pada neuron saraf perifer adalah polineuropati.
Lesi di otot dapat berupa kerusakan struktural pada serabut otot atau selnya yang
disebabkan infeksi, intoksikasi eksogen/endogen, dan degenerasi herediter. Karena
serabut otot rusak, kontraktilitasnya hilang dan otot tidak dapat melakukan tugasnya.
Penyakit di otot bisa berupa miopati dan distrofi, dapat menyebabkan kelemahan di

keempat anggota gerak biasanya bagian proksimal lebih lemah dibanding distalnya. Pada
penderita distrofia musculorum enzim kreatinin fosfokinase dalam jumlah yang besar,
sebelum terdapat manifestasi dini kadar enzim ini di dalam serum sudah jelas meningkat.
akan tetapi mengapa enzim ini dapat beredar didalam darah tepi masih belum diketahui.
KLASIFIKASI
Pembagian tetraparese berdasarkan kerusakan topisnya:
Tetraparese spastik
Tetraparese spastik terjadi karena kerusakan yang mengenai upper motor neuron
(UMN), sehingga menyebabkan peningkatan tonus otot atau hipertoni.

Tetraparese flaksid
Tetraparese flaksid terjadi karena kerusakan yang mengenai lower motor neuron
(LMN), sehingga menyebabkan penurunan tonus atot atau hipotoni.
DIAGNOSIS BANDING
a. Penyakit infeksi
-

Mielitis transversa
Dapat menyebabkan satu sampai dua segmen medula spinalis rusak sekaligus,
infeksi dapat langsung terjadi melalui emboli septik, luka terbuka ditulang belakang,
penjalaran osteomielitis atau perluasan proses meningitis piogenik. Istilah mielitis tidak
hanya digunakan jika medula spinalis mengalami peradangan, namun juga jika lesinya

mengalami peradangan dan disebabkan oleh proses patologik yang mempunyai hubungan
dengan infeksi. Adakalanya reaksi imunologik timbul di medula spinalis setelah beberapa
minggu sembuh dari penyakit viral. Pada saat itu sarang-sarang reaksi imunopatologik
yang berukuran kecil tersebar secara difus sepanjang medula spinalis. Serabut-serabut
asenden dan desenden panjang dapat terputus oleh salah satu lesi yang tersebar luas,
sehingga dapat menimbulkan kelumpuhan parsial dan defisit sensorik yang tidak masif di
seluruh tubuh atau yang dikenal dengan istilah tetraparese.
Poliomielitis
Poliomielitis adalah peradangan pada daerah medula spinalis yang mengenai
substantia grisea. Jika lesi mengenai medula spinalis setinggi servikal atas maka dapat
menyebabkan kelemahan pada anggota gerak atas dan bawah . Pada umumnya kelompok
motoneuron di segmen-segmen intumesensia servikal dan lumbalis merupakan substrat
tujuan viral. Tahap kelumpuhan bermula pada akhir tahap nyeri muskular. Anggota gerak
yang dilanda kelumpuhan LMN adalah ekstremitas.
b. Polineuropati
Polineuropati adalah kelainan fungsi yang berkesinambungan pada beberapa
saraf perifer di seluruh tubuh. Penyebab karena infeksi bisa menyebabkan polineuropati,
kadang karena racun yang dihasilkan oleh beberapa bakteri (misalnya pada difteri) atau
karena reaksi autoimun, bahan racun bisa melukai saraf perifer dan menyebabkan
polineuropati atau mononeuropati (lebih jarang), kanker bisa menyebabkan polineuropati
dengan menyusup langsung ke dalam saraf atau menekan saraf atau melepaskan bahan
racun, kekurangn gizi dan kelainan metabolik juga bisa menyebabkan polineuropati.
Kekurangan vitamin B bisa mengenai saraf perifer di seluruh tubuh, penyakit yang bisa

menyebabkan polineuropati kronik (menahun) adalah diabetes, gagal ginjal dan


kekurangan gizi (malnutrisi) yang berat. Polineuropati kronik cenderung berkembang
secara lambat (sampai beberapa bulan atau tahun) dan biasanya dimulai di kaki (kadang
di tangan).
Kelainan pada saraf perifer dijumpai sebagai berikut : tiga sampai empat hari
pertama pembengkakan dan menjadi irreguler dari selubung myelin. Hari ke lima terjadi
desintegrasi myelin dan pembengkakan aksis silinder. Pada hari ke sembilan timbul
limfosit, hari ke sebelas timbul fagosit dan pada hari ketiga belas proliferasi Schwan sel.
Kesemutan, mati rasa, nyeri terbakar dan ketidakmampuan untuk merasakan getaran atau
posisi lengan, tungkai dan sendi merupakan gejala utama dari polineuropati kronik.
Nyeri seringkali bertambah buruk di malam hari dan bisa timbul jika menyentuh daerah
yang peka atau karena perubahan suhu. Ketidakmampuan untuk merasakan posisi sendi
menyebabkan ketidakstabilan ketika berdiri dan berjalan. Pada akhirnya akan terjadi
kelemahan otot dan atrofi (penyusutan otot). Kelumpuhan biasanya timbul sesudah tidak
ada panas, kelumpuhan otot biasanya bilateral dan simetris dengan tipe "lower motor
neuron dengan penyebaran kelumpuhan yang bersifat ascending yaitu mulai dari
ekstrimitas bawah yang menjalar ke ekstrimitas atas, tetapi bisa pula descending yaitu
mulai dari ekstrimitas atas yang turun ke ekstrimitas bawah.
Sindrom Guillain Barre (SGB)
Sindroma Guillain Barre (SGB) adalah suatu kelainan sistem saraf akut dan difus
yang mengenai radiks spinalis dan saraf perifer, dan kadang-kadang juga saraf kranialis,
yang biasanya timbul setelah suatu infeksi. Manifestasi klinis utama dari SGB adalah
suatu kelumpuhan yang simetris tipe lower motor neuron dari otot-otot ekstremitas,

badan dan kadang-kadang juga muka.

Sindrom Guillain Barr


Akibat suatu infeksi atau keadaan tertentu yang mendahului SGB akan timbul
autoantibodi atau imunitas seluler terhadap jaringan sistim saraf-saraf perifer. Infeksiinfeksi meningokokus, infeksi virus, sifilis ataupun trauma pada medula spinalis, dapat
menimbulkan

perlekatan-perlekatan

selaput

araknoid.

Di

negara-negara

tropik

penyebabnya adalah infeksi tuberkulosis. Pada tempat-tempat tertentu perlekatan pasca


infeksi itu dapat menjirat radiks ventralis (sekaligus radiks dorsalis). Karena tidak
segenap radiks ventralis terkena jiratan, namun kebanyakan pada yang berkelompokan
saja, maka radiks-radiks yang diinstrumensia servikalis dan lumbosakralis saja yang
paling umum dilanda proses perlekatan pasca infeksi. Oleh karena itu kelumpuhan LMN
paling sering dijumpai pada otot-otot anggota gerak, kelompok otot-otot di sekitar
persendian bahu dan pinggul. Kelumpuhan tersebut bergandengan dengan adanya defisit
sensorik pada kedua tungkai atau otot-otot anggota gerak.
Secara patologis ditemukan degenerasi mielin dengan edema yang dapat atau
tanpa disertai infiltrasi sel. Infiltrasi terdiri atas sel mononuklear. Sel-sel infiltrat terutama
terdiri dari sel limfosit berukuran kecil, sedang dan tampak pula, makrofag, serta sel

polimorfonuklear pada permulaan penyakit. Setelah itu muncul sel plasma dan sel mast.
Serabut saraf mengalami degenerasi segmental dan aksonal. Lesi ini bisa terbatas pada
segmen proksimal dan radiks spinalis atau tersebar sepanjang saraf perifer. Predileksi
pada radiks spinalis diduga karena kurang efektifnya permeabilitas antara darah dan saraf
pada daerah tersebut.
Manifestasi klinis utama adalah kelumpuhan otot-otot ekstremitas tipe lower
motor neuron. Pada sebagian besar penderita kelumpuhan dimulai dari kedua ekstremitas
bawah kemudian menyebar secara asenden ke badan, anggota gerak atas dan saraf
kranialis. Kadang-kadang juga bisa keempat anggota gerak dikenai secara serentak,
kemudian menyebar ke badan dan saraf kranialis. Kelumpuhan otot-otot ini simetris dan
diikuti oleh hiporefleksia atau arefleksia. Biasanya derajat kelumpuhan otot-otot bagian
proksimal lebih berat dari bagian distal, tapi dapat juga sama beratnya, atau bagian distal
lebih berat dari bagian proksimal.
d. Miastenia Grafis
Miastenia grafis adalah penyakit neuromuskular yang menyebabkan otot skelet
menjadi lemah dan lekas lelah. Kelelahan/kelemahan ini disebabkan karena sirkulasi
antibodi yang memblok acetylcholine receptors pada post sinaptik neuromuscular
junction, stimulasi penghambatan ini berpengaruh pada neurotransmiter asetilkolin.
Manifestasi klinisnya dapat berupa kelemahan pada otot yang mengatur pergerakan mata,
kelemahan otot pada lengan dan tungkai, perubahan ekspresi wajah, disfagia, dan
disartria.

Miastenia Gravis

e. Amyotrophic Lateral Sclerosis (ALS)


Penyakit Amyotrophic Lateral Sclerosis (ALS) adalah suatu kelainan yang
progresif dari sistem saraf yang banyak terjadi pada orang dewasa dengan penyakit
motoneuron. Kondisi tersebut menyebabkan degenerasi saraf motorik bagian atas (brain)
dan saraf motorik bagian bawah (spinal cord) dengan kombinasi tanda upper motor
neuron (UMN) dan lower motor neuron (LMN). Penurunan kualitas saraf ini,
menyebabkan Kelemahan pada otot dan dapat berakhir pada kematian.

Amyotrophic Lateral Sclerosis


Proses degenerasi hanya menyerang pada neuron motorik, yaitu sel-sel saraf yang
mengatur pergerakkan otot. Akibat kelemahan itu, kemampuan tubuh untuk mengatur
gerakan otot yang disadari akan hilang secara perlahan-lahan. Misalnya, memegang,
menjentik, menggaruk, dan sebagainya. Namun penyakit ini tidak mempengaruhi saraf
sensoris (perasa) dan fungsi mental. Meskipun penyebab pasti ALS belum diketahui,
teori yang dikenal saat ini menyatakan neurotransmiter glutamat (suatu zat kimia yang
menghantarkan impuls atau sinyal ke sel-sel saraf) kemungkinan memegang peranan
sebagai penyebab matinya sel-sel saraf motorik. Zat-zat kimia lainnya, seperti molekul
radikal bebas dan kalsium kemungkinan juga ikut terlibat.
Penyakit ALS mengakibatkan sistem neuromuscular tidak berfungsi karena kedua
saraf motorik penderita ALS telah rusak. Seiring berjalannya waktu, penyakit ALS
menyebabkan sarafsaraf motorik yang berada di otak dan batang tubuh mengecil, dan
pada akhirnya menghilang. Akibatnya, otot otot tubuh tidak lagi mendapat sinyal untuk
bergerak. Karena otot yang berada dalam tubuh kehilangan pemasok nutrisinya, sehingga
otototot yang menjadi lebih kecil dan melemah. Saraf-saraf di dalam sistem

neuromuscular yang memberi nutrisi ke otot-otot tersebut terlokalisir, sehingga


menyebabkan tumbuhnya jaringan yang rusak mengantikan sarafsaraf yang normal.
f. Spondilosis servikalis
merupakan suatu penyakit yang menyerang usia pertengahan dan usia lanjut, dimana
diskus dan tulang belakang di leher mengalami kemunduran (degenerasi).

Spondilosis Servikalis
Spondilosis servikalis menyebabkan menyempitnya kanal spinalis (tempat lewatnya
medula spinalis) di leher dan menekan medula spinalis atau akar saraf spinalis, sehingga
menyebabkan kelainan fungsi. Gejalanya bisa menggambarkan suatu penekanan medula
spinalis maupun kerusakan akar sarafnya. Jika terjadi penekanan medula spinalis, maka

pertanda awalnya biasanya adalah perubahan pada cara berjalan. Gerakan kaki menjadi
kaku dan penderita berjalan dengan goyah. Leher terasa nyeri, teutama jika akar sarafnya
terkena. Kelemahan dan penciutan otot pada salah satu atau kedua lengan bisa terjadi
sebelum

maupun

sesudah

timbulnya

gejala

penekanan

medula

spinalis.

g. Spondilitis Tuberkulosa
Tuberkulosis tulang belakang atau dikenal juga dengan spondilitis tuberkulosa
merupakan peradangan granulomatosa yang bersifat kronik destruktif yang disebabkan
oleh mikobakterium tuberkulosa. Spondilitis tuberkulosa dikenal juga sebagai penyakit
Pott, paraplegi Pott. Spondilitis ini paling sering ditemukan pada vertebra T8-L3 dan
paling jarang pada vertebra C1-2.(1,2,3,4). Spondilitis tuberkulosa merupakan 50% dari
seluruh tuberkulosis tulang dan sendi. Tuberkulosis tulang belakang merupakan infeksi
sekunder dari tuberkulosis di tempat lain di tubuh, 90-95% disebabkan oleh
mikobakterium tuberkulosis tipik (2/3 dari tipe human dan 1/3 dari tipe bovin) dan 5-10%
oleh mikobakterium tuberkulosa atipik. Kuman ini berbentuk batang, mempunyai sifat
khusus yaitu tahan terhadap asam pada pewarnaan. Oleh karena itu disebut pula sebagai
Basil Tahan Asam (BTA). Kuman TB cepat mati dengan sinar matahari langsung, tetapi
dapat bertahan hidup beberapa jam di tempat yang gelap dan lembab. Dalam jaringan
tubuh kuman ini dapat dorman, tertidur lama selama beberapa tahun.
Basil TB masuk ke dalam tubuh sebagian besar melalui traktus respiratorius. Pada saat
terjadi infeksi primer, karena keadaan umum yang buruk maka dapat terjadi basilemia.
Penyebaran terjadi secara hematogen. Basil TB dapat tersangkut di paru, hati limpa,
ginjal dan tulang. 6 hingga 8 minggu kemudian, respons imunologik timbul dan fokus
tadi dapat mengalami reaksi selular yang kemudian menjadi tidak aktif atau mungkin

sembuh sempurna. Vertebra merupakan tempat yang sering terjangkit tuberkulosis


tulang. Penyakit ini paling sering menyerang korpus vertebra. Penyakit ini pada
umumnya mengenai lebih dari satu vertebra. Infeksi berawal dari bagian sentral, bagian
depan, atau daerah epifisial korpus vertebra. Kemudian terjadi hiperemi dan eksudasi
yang menyebabkan osteoporosis dan perlunakan korpus. Selanjutnya terjadi kerusakan
pada korteks epifise, discus intervertebralis dan vertebra sekitarnya. Kerusakan pada
bagian depan korpus ini akan menyebabkan terjadinya kifosis yang dikenal sebagai
gibbus. Berbeda dengan infeksi lain yang cenderung menetap pada vertebra yang
bersangkutan,

tuberkulosis

akan

terus

menghancurkan

vertebra

di

dekatnya.

Kemudian eksudat (yang terdiri atas serum, leukosit, kaseosa, tulang yang fibrosis serta
basil tuberkulosa) menyebar ke depan, di bawah ligamentum longitudinal anterior dan
mendesak aliran darah vertebra di dekatnya. Eksudat ini dapat menembus ligamentum
dan berekspansi ke berbagai arah di sepanjang garis ligament yang lemah.
Pada daerah servikal, eksudat terkumpul di belakang fasia paravertebralis dan menyebar
ke lateral di belakang muskulus sternokleidomastoideus. Eksudat dapat mengalami
protrusi ke depan dan menonjol ke dalam faring yang dikenal sebagai abses faringeal.
Abses dapat berjalan ke mediastinum mengisi tempat trakea, esophagus, atau kavum
pleura. Abses pada vertebra torakalis biasanya tetap tinggal pada daerah toraks setempat
menempati daerah paravertebral, berbentuk massa yang menonjol dan fusiform. Abses
pada daerah ini dapat menekan medulla spinalis sehingga timbul paraplegia. Abses pada
daerah lumbal dapat menyebar masuk mengikuti muskulus psoas dan muncul di bawah
ligamentum inguinal pada bagian medial paha. Eksudat juga dapat menyebar ke daerah
krista iliaka dan mungkin dapat mengikuti pembuluh darah femoralis pada trigonum

skarpei atau region glutea.


DIAGNOSIS
Diagnosis ditegakkan berdasarkan :
Anamnesis (Riwayat penyakit sekarang, riwayat penyakit dahulu dan riwayat penyakit
keluarga).
Pemeriksaan penunjang :
Foto vertebrae servikal/lumbaluntuk mengetahui adanya trauma, penyempitan
maupun pergeseran susunan tulang belakang.
Fungsi lumbaluntuk menyingkirkan beberapa penyakit pembanding seperti
sindrom guillain barradanya peningkatan protein sito albumin yang disertai
peningkatan jumlah selnya.
Elektromiografimenunjukan adanya fibrilasi, fasikulasi, atrofi dan denervasi (pada
penyakit ALS)
MRI
PENATALAKSANAAN
Penatalaksanaan dilakukan berdasarkan penyebabnya. Namun dapat dilakukan terapi
umum sebagai berikut:
Medikamentosa
Kortikosteroid untuk mengurangi nyeri, juga dipercaya dapat menghasilkan

perbaikan neurologis.
Antidiabetika pada kasus-kasus yang diperburuk oleh penyakit diabetes mellitus.
Terapi konservatif
a.Tirah baring (bed rest)
b. Memberi korset yang mencegah gerakan vertebra /membatasi gerak vertebra
c. Memperbaiki keadaan umum penderita
3. Fisioterapi :
Program : Infra Red, ROM (range of motion) dan meningkatkan kekuatan otot
ekstremitas atas dan bawah.
Terapi Okupasi
Problem : agak kesulitan melakukan pekerjaan yang biasanya dilakukan sendiri karena
terlalu lama berbaring.
Assesment: Pasien mengalami deconditioning syndrome.
Program :
Melatih pasien untuk latihan bekerja, seperti apa yang biasanya dilakukan sendiri,
melatih kekuatan duduk, berdiri dan berjalan.
Melakukan kegiatan sehari-hari sendiri, dan tanpa bantuan orang lain, misalnya
berpakaian, makan, dan rawat diri.
AKS/ADL secara luas berkaitan dengan aspek psikologis, komunikasi, sosial.
I. PROGNOSIS
Prognosis penderita dipengaruhi oleh pengobatan terhadap penyebab tetraparesis
itu sendiri. Diagnosis sedini mungkin dan dengan pengobatan yang tepat, prognosisnya
baik meskipun tanpa tindakan operatif. Penyakit dapat kambuh jika pengobatan tidak
teratur atau tidak dilanjutkan setelah beberapa saat.