Skenario

Keluhan : kebas, kesemutan, kelemahan pada kedua kakinya

Catatan medis : 3 minggu lalu berobat  diagnosis ISPA  dapat terapi amoksisilin & terapi simptomatik  sakit
membaik  1 minggu lalu mengeluh kebas & kesemutan pada kaki kemudian naik ke tungkai bawah dan paha
Rujukan ke dr saraf : 1 minggu lalu dirujuk  pasien menolak  kebas memburuk  mulai kelemahan ekstremitas
bawah bilateral  sulit berjalan  2 hari lalu jatuh di rumah
Bandingkan gejala, tanda, dan proses kejadian dengan diagnosis banding kasus tersebut
CARI KELAINAN-KELAINAN NEUROMUSKULAR :
1. Identifikasi
2. Apa kausa dan patofisiologinya
3. Bandingkan tanda dan gejalanya dengan kelainan lainnya
4. Bagaimana radiologinya
5. Tatalaksana : farmakoterapi, non farmakoterapi, bedah
6. Rehabilitasi medik

KELEMAHAN/PARALISIS WAJAH, TANGAN, DAN KAKI UNILATERAL (hemiparesis / hemiplegia)

1. Tanpa defisit sensorik (pure motor hemiparesis)
a. Locations ruled in : tractus corticospinal dan corticobulbar yang berada di bawah cortex dan di atas medulla : korona
radiata, capsula interna, basis pontis, atau middle third dari pedunkulus cereblar
b. Side of lesions : kontralateral dari weakness nya (di atas decussation pyramidal)
c. Common causes : infark lacunar pada capsula interna atau pada pons, infark pada pedunculus cerebri,
demyelination/tumor/abses pada lokasi2 tersebut.
d. Associated features : disartria(lemah otot untuk bicara) dan ataxia(gangguan keseimbangan/koordinasi)
2. Dengan tambahan deficit sensorik, oculomotor, visual
a. Locations ruled in : seluruh korteks motoric primer atau traktus kortikospinal dan kortikobulbar di atas medulla
b. Side of lesions : kontralateral dari weakness nya (di atas decussation pyramidal)
c. Associated features : aphasia (gangguan Bahasa), disartria, ataxia
d. Common causes : infark, hemorrhage, tumor, trauma, herniasi
 UNILATERAL ARM AND LEG WEAKNESS/PARALYSIS (brachiocrural plegia/paresis)
a. Locations ruled in : korteks motoric khusus arm dan leg, traktus kortikospinal dari bawah medulla sampai medulla
spinalis C5
b. Side of lesions : kortex motoric/medulla kontralateral weakness, medulla spinalis cervical ipsilateral weakness
c. Associated features : aphasia kalau lesi kortikal, loss of vibration and joint position sense pada sisi yg sama dari
weaknessnya kalau lesi di medullary medial, sindrom medullary lateral kalau lesi meluas ke medullary lateral, brown-
sequard syndrome kalau lesi di medulla spinalis, penurunan sensasi wajah kalau lesi di cervical
d. Common causes : infark, multiple sclerosis, kompresi pada medulla spinalis cervical
 BILATERAL LEG WEAKNESS OR PARALYSIS (paraparesis or paraplegia)
a. Locations ruled in : Bilateral leg areas of the primary motor cortex along the medial surface of the frontal lobes;
lateral corticospinal tracts below T1 in the spinal cord; cauda equina syndrome or other peripheral nerve or muscle
disorders affecting both legs
b. Associated features :
- Bilateral medial frontal lesions: Upper motor neuron signs may be present. confusion, apathy, grasp reflexes, and
incontinence.
- Spinal cord lesions: Upper motor neuron signs, sphincter dysfunction, and autonomic dysfunction may be present.
Asensory level or loss of specific reflexes may help determine the segmental level of the lesion.
- Bilateral peripheral nerve or muscle disorders: Cauda equina syndrome is associated with sphincter and erectile
dysfunction, sensory loss in lumbar or sacral dermatomes, and lower motor neuron signs. Distal symmetrical
polyneuropathies tend to preferentially affect distal muscles and may have associated distal “glove-stocking” sensory
loss and lower motor neuron signs. Neuromuscular disorders and myopathies often (but not always) affect proximal
more than distal muscles.
c. Common causes :
Note that spinal cord lesions are a common and serious cause of bilateral leg weakness.
- Bilateral medial frontal lesions: Parasagittal meningioma, bilateral anterior cerebral artery infarcts, cerebral palsy
(bilateral periventricular leukomalacia).
- Spinal cord lesions: tumor, trauma, myelitis, epidural abscess
- Bilateral peripheral nerve or muscle disorders: Cauda equina syndrome: tumor, trauma, disc herniation. Other
peripheral nerve or muscle disorders : The lower extremities are often clinically affected before the arms in Guillain–
Barré syndrome, Lambert–Eaton syndrome, and distal symmetrical polyneuropathies (caused by diabetes and other
toxic, metabolic, congenital, and inflammatory conditions).