Case Report SessionRadiculopathy

1) Classification of pain• Pain has been classified into two major types: fast pain

and slow pain

• Fast pain = felt within about 0.1 second • Slow pain = after 1 second or more and then increases

slowly over many seconds and sometimes even minutes.

• Fast pain is also described by many alternative names, such as sharp pain, pricking pain, acute pain, and electric pain. Usually on the surface of skin.

• Slow pain also goes by many names, such as slow burning pain, aching pain, throbbing pain, nauseous pain, and chronic pain. It can occur both in the skin and in almost any deep tissue or organ.

• Referred pain is pain in a part of the body that is fairly remote from the tissue causing the pain.

• For instance, pain in one of the visceral organs often is referred to an area on the body surface.

In the figure, branches of visceral pain fibers are shown to synapse in the spinal cord on the same second-order neurons (1 and 2) that receive pain signals from the skin. When the visceral pain fibers are stimulated, pain signals from the viscera are conducted through at least some of the same neurons that conduct pain signals from the skin, and the person has the feeling that the sensations originate in the skin itself.

• Visceral Pain = Essentially all visceral pain that originates in the thoracic and abdominal cavities is transmitted through small type C pain fibers and, therefore, can transmit only the chronic-aching-suffering type of pain.

• Causes of True Visceral Pain • Ischemia • Chemical Stimuli • Spasm of a Hollow Viscus • Overdistention of a Hollow Viscus • Insensitive Viscera

• Pain from the viscera is frequently localized to two surface areas of the body at the same time because of the dual transmission of pain through the referred visceral pathway and the direct parietal pathway.

Pain impulses pass first from the appendix through visceral pain fibers located within sympathetic nerve bundles, and then into the spinal cord at about T-10 or T-11; this pain is referred to an area around the umbilicus and is of the aching, cramping type.

Anatomy

Disc space L3-4 L4-5 L5-S1 C4-5 C6-7 C7-T1

Root affected

L4 L5 S1 C5 C7 C8

Muscles affected

Quadriceps Peroneals, anterior tibial, extensor hallucis longus

Gluteus maximus, gastrocnemius, plantar flexor of toes

Deltoid, biceps

Triceps, wrist exrensors

Intrinsic hand muscles

Area of pain and sensory loss

Anterior thigh, medial shin

Great toe, dorsum of foot

Lateral foot, small toe

Shoulder, anterior arm, radial forearm

Thumb, middle fingers

Index, fourth fifth finger

Reflex affected

Knee jerk Posterior tibial Ankle jerk Biceps Triceps Triceps

Straight leg raising

Many not increase pain

Aggravates root pain

Aggravates root pain

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Struktur peka nyeri vertebra• Kulit, jaringan subkutan

adiposa• Otot, kapsul dan sendi

ligamentum vertebrae• Lapisan luar anulus

fibrosus• Durameter dan jaringan

epidural fibroadiposa• Dinding vaskuler dan saraf

Nyeri Punggung Bawah• Definisi• Nyeri yang dirasakan di daerah punggung bawah. Dapat

berupa nyeri local,nyeri radikuler atau keduanya. Nyeri terasa di antara tepi iga terbawah dan lipat bokong bawah yaitu di daerah lumbal atau lumbosacral dan sering disertai dengan penjalaran nyeri kearah tungkai dan kaki

• Klasifikasi berdasarkan waktu onset1. NPB akut <6 minggu2. NPB subakut 6-12 minggu (bisa 4 minggu)3. NPB kronis >12 minggu

Klasifikasi berdasarkan triage klinis: *untuk menghindarkan pemeriksaan penunjang yang tidak perlu dan penanganan lebih terarah4. NPB dengan kelainan kelainan patologik serius (red-flags)5. NPB non spesifik6. NPB dengan sindroma radikuler

• Red Flags:

• Awitan NPB usia>55th

• Riwayat trauma (ringan, atau potensi osteoporosis)

• Nyeri konstan progresif memburuk dengan berbaring

• Deformitas structural• Riwayat keganasan• Kecanduan obat (suntikan)• Pemakaian steroid lama• Pemakaian imunosupresan• Luasnya gejala tanda neurologic

(gang. BAK, saddle anesthesia, loss sesibilitas progresif atau tanpa loss motoric sesuai radiks saraf)

• Kelainan neurologic menetap 1 bulan

• Restriksi fleksi lumbal berat <5cm• Demam

• YellowFlags

• Negative attitude that backpain is harmful

• Reduced activity level• Tendency depression• Social financial

problems

• Faktor resiko1. Umur 35-55 thn2. Jenis kelamin3. BMI4. Pekerjaan5. Aktivitas6. Posisi tubuh

• Etiologi1. Degeneratif (spondilosis,

HNP, stenosis spinalis, OA)2. Inflamasi (RA)3. Osteoporosis 4. Kongenital5. Gangguan sirkulasi

(aneurysma aorta abdominalis)

6. Tumor (Osteoma, paget’s disease,hemangioma)

7. Infesi (spondilitis TB)8. Psikoneurotik

• Patogenesis

Agen inflamasi menstimulasi reseptor

nyeri pada jaringan

Bradikinin, prostaglandin,leukot

rien

Ujung saraf nociceptor,

teraktivasi,impuls menjalas melalui spinal cord dan

melepaskan neuropeptida

Extravasasi pemb.darah dan aktivasi sel mast

Histaminpembengkakan jaringan

• Gejala klinis• Nyeri punggung bawah (sementara,lokal,atau

menjalar, dangkal atau dalam)• Nyeri lokal: bisa karena terkilir atau keseleo, sakit bila

dipalpasi, bisa ada spasme otot, bertambah atau berkurang bila berubah posisi• Nyeri menjalar: karena penekanan pangkal saraf• Referred pain

• Diagnosis• X-ray• Ct scan•Myelography•MRI

• Diagnosis banding• Cedera tendon achilles• Kompresi lumbal e.c fraktur

Penatalaksanaan Radikulopati

• Informasi dan edukasi• Farmakoterapi• Akut : asetaminofen, NSAID, muscle relaxant, opioid (nyeri berat), injeksi epidural.• Kronik : analgesic adjuvan• antidepresan trisiklik (amitriptilin), opioid (kalau sangat diperlukan), SSRE, anti dopamin

• Terapi nonfarmakologik• Akut : imobilisasi (lamanya tergantung kasus),

pengaturan berat badan, posisi tubuh dan aktivitas, modalitas termal (terapi panas dan dingin), masase, traksi (tergantung kasus), alat bantu (antara lain korset, tongkat).• Kronik : terapi psikologik, modulasi nyeri

(akupunktur, modalitas termal), latihan kondisi otot, rehabilitasi vokasional, pengaturan berat badan, posisi tubuh dan aktivitas.

• Invasif nonbedah• Blok saraf dengan anestetik lokal.• Injeksi steroid (metilprednisolon) pada epidural

untuk mengurangi pembengkakan edematous sehingga menurunkan kompresi pada radiks saraf.

• Bedah• Indikasi operasi pada HNP :• Skiatika dengan terapi konservatif selama lebih dari 4

minggu : nyeri berat / intractable / menetap / progresif.• Defisit neurologik memburuk.• Sindroma kauda.

• Stenosis kanal : setelah terapi konservatif tidak berhasil.• Terbukti adanya kompresi radiks berdasarkan

pemeriksaan neurofisiologik dan radiologik.