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CEDERA

MEDULA SPINALIS
Oleh :
dr. Grace E. P. M. Sianturi, SpBS, Mkes
DEFINISI

Cedera pada medula spinalis yang


menyebabkan perubahan pada fungsi
motorik, sensorik atau otonom  fungsi
anggota tubuh yang terganggu terjadi di
bawah lesi
Perubahan ini bisa bersifat temporer atau
permanen.
Mekanisme

 Trauma langsung
 Kompresi oleh fragmen tulang / hematoma /
material diskus
 Iskemik karena kerusakan pada arteri spinal
Statistik

National Spinal Cord Injury Database


{ USA Stats }
• KLL 44.5%
• Jatuh 18.1%
• Kekerasan 16.6%
• Olahraga 12.7%

• 55% kasus terjadi pada usia 16 – 30 tahun


• 81.6% adalah pria
South African Statistics (GSH Acute Spinal Cord Injury
Unit 2007)
• KLL 56%
• Jatuh 16%
• Luka tembak 11%
• Cedera tumpul 6%
• Kecelakaan menyelam 5%
• Luka tusuk 4%
• Olahraga 3%
AnatoMI
 Medula Spinalis terletak di dalam foramen
vertebra
 Sepanjang C1 - L1
Bagian bawah membentuk konus medullaris
Gambar :
– Sistem saraf
– Vaskularisasi
Ventral:
• Fissura mediana anterior
• Sulkus mediana posterior
Segmen medula spinalis:
• Bagian dari medula yang mulai muncul saraf
spinal
31 pasang saraf spinal:
8 servikal
12 thorakal
5 lumbal
5 sakral
1 coccygeal
• Akar Dorsal – serabut sensory

• Akar Ventral – serabut motor

• Akar dorsal dan ventral akan bergabung pada


foramen intervertebral untuk membentuk
saraf spinal
FISIOLOGI
• Gray matter – serabut sensorik dan sel saraf
motorik
• White matter – traktus ascending dan
descending
• Di bagi menjadi: - dorsal
- lateral
- ventral
Traktus

1) Kolumna Posterior:

• Raba halus
• Sentuhan ringan
• Proprioseptif
2) Kortikospinal Lateral:

• Skilled voluntary movement

3) Spinotalamik Lateral:

• Sensasi nyeri dan suhu


• Traktus kolumna posterior dan kortikospinal
lateral akan menyilang pada medulla
oblongata

• Traktus spinothalamic akan menyilang pada


medula spinalis dan akan naik pada sisi yang
berlawanan
NB: mengerti defisit neurologis yang terjadi
akibat cedera
Dermatom

• Area kulit yang di inervasi oleh akson sensorik


(akar saraf segmental)
• Penting untuk menentukan level cedera
• Berguna dalam menilai perbaikan atau
penurunan gejala
Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
Myotom
• Akar saraf yang menginervasi otot
• Juga!! Penting untuk menentukan level cedera

• Ekstremitas superior:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
• Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
Klasifikasi Cedera Medula Spinalis
• Quadriplegia :
cedera pada daerah servikal
4 extremitas terkena
• Paraplegia :
cedera pada segmen thorakal, lumbal atau
sakral
2 extremitas terkena
Cedera medula spinalis:
1) Complete

2) Incomplete
Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:

i) Some function is present below site of


injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although
they are rarely pure and variations occur
Injury defined by ASIA Impairment
Scale

ASIA – American Spinal Injury Association :

A – Complete: no sensory or motor function


preserved in sacral segments S4 – S5

B – Incomplete: sensory, but no motor function


in sacral segments
C – Incomplete: motor function preserved below
level and power graded < 3

D – Incomplete: motor function preserved below


level and power graded 3 or more

E – Normal: sensory and motor function normal


Muscle Strength Grading:
• 5 – Normal strength
• 4 – Full range of motion, but less than
normal strength against resistance
• 3 – Full range of motion against gravity
• 2 – Movement with gravity eliminated
• 1 – Flicker of movement
• 0 – Total paralysis
Spinal Shock vs Neurogenic Shock

Spinal Shock :

• Transient reflex depression of cord function below level of


injury
• Initially hypertension due to release of catecholamines
• Followed by hypotension
• Flaccid paralysis
• Bowel and bladder involved
• Sometimes priaprism develops
• Symptoms last several hours to days
Neurogenic shock:
• Triad of i) hypotension
ii) bradycardia
iii) hypothermia
• More commonly in injuries above T6
• Secondary to disruption of sympathetic
outflow from T1 – L2
• Loss of vasomotor tone – pooling of blood
• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid infusion
alone
• Massive fluid administration may lead to overload
and pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
Types of incomplete injuries
i) Central Cord Syndrome

ii) Anterior Cord Syndrome

iii) Posterior Cord Syndrome

iv) Brown – Sequard Syndrome

v) Cauda Equina Syndrome


i) Central Cord Syndrome :

• Typically in older patients


• Hyperextension injury
• Compression of the cord anteriorly by
osteophytes and posteriorly by ligamentum
flavum
• Also associated with fracture dislocation and
compression fractures
• More centrally situated cervical tracts tend to
be more involved hence
flaccid weakness of arms > legs
• Perianal sensation & some lower extremity
movement and sensation may be preserved
ii) Anterior cord Syndrome:
• Due to flexion / rotation
• Anterior dislocation / compression fracture of
a vertebral body encroaching the ventral canal
• Corticospinal and spinothalamic tracts are
damaged either by direct trauma or ischemia
of blood supply (anterior spinal arteries)
Clinically:
• Loss of power
• Decrease in pain and sensation below lesion
• Dorsal columns remain intact
ii) Posterior Cord Syndrome:
Hyperextension injuries with fractures of
the posterior elements of the vertebrae

Clinically:
• Proprioception affected – ataxia and
faltering gait
• Usually good power and sensation
iv) Brown – Sequard Syndrome:
• Hemi-section of the cord
• Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
• Fractures of lateral mass of vertebrae
Clinically:
• Paralysis on affected side (corticospinal)
• Loss of proprioception and fine discrimination
(dorsal columns)
• Pain and temperature loss on the opposite
side below the lesion (spinothalamic)
v) Cauda Equina Syndrome:
• Due to bony compression or disc protrusions
in lumbar or sacral region

Clinically
• Non specific symptoms – back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia
Terapi
• Pre Hospital  mencegah cedera sekunder
(ABC-immobilisasi spine)  3-25% terjadi
cedera lanjutan saat transportasi
• Hospital  ABCDE & immobilisasi spine,
metilprednisolone, terapi terhadap komplikasi
(hipotensi,pneumonie, trombosis,dll) 
Operasi  BEDAH SARAF

• Post Hospital  Rehabilitasi Medik


Kesimpulan
Cedera medulla spinalis:
• Kerusakan temporer dan permanen
• Anatomi dan fisiologi tulang belakang
• Penanganan tepat dan cepat  hasil yang
baik
References:
1. Andrew T Raftery, et al. Applied Basic Science for Basic
Surgical Training. Second edition 2008;8:219-223
2. ATLS, et al. Student Course Manual. 7th Edition 2004;7:177-
204
3. Keith L Moore et al. Clinically Orientated Anatomy. 3rd
Edition1992;4:359-369
4. Segun T Dawodu et al. eMedicine Specialities. March 2009
5. K Frielingsdorf, R N Dunn et al. SAMJ. March 2007,Vol.
97,No. 3
Terima Kasih
Jenis Gangguan

1. Gangguan Kongenital
2. Neoplasma
3. Inflamasi
4. Trauma