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 6-12
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. Iritasi cabang saraf besar yang menuju ekstremitas
2. Iritasi cabang saraf kecil yang mempersarafi vertebra
3. Ketegangan sepasang otot punggung (m.erector spinae)
4. Kerusakan tulang, ligamentum atau sendi
5. Ruang antar vertebra dapat menjadi sumber nyeri
1. NPB Akut : < 6 minggu
2. NPB Subakut : 6 -12 minggu
3. 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
* Paget’s 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