STEP 31. Explain the anatomical of low back including the
nervous system that work there! (vertebre and spinal
cord)AnatomyYour spine is made up of 24 bones, called vertebrae,
that are stacked on top of one another. These bones connect to
create a canal that protects the spinal cord.Five vertebrae make up
the lower back. This area is called your lumbar spine.
Parts of the lumbar spine. Other parts of your spine
include:Spinal cord and nerves. These "electrical cables" travel
through the spinal canal carrying messages between your brain and
muscles.Intervertebral disks. In between your vertebrae are
flexible intervertebral disks. They act as shock absorbers when
your walk or run.Intervertebral disks are flat and round, and about
a half inch thick. They are made up of two components:
Healthy intervertebral disk (cross-section view).
2. How the pathophysiology of pain in low back?It is important
to understand that back pain is a symptom of a medical condition,
not a diagnosis itself. Medical problems that can cause back pain
include the following:Mechanical problems: A mechanical problem is
due tothe way your spine moves or the way you feel when you move
your spine in certain ways. Perhaps the most common mechanical
cause of back pain is a condition called intervertebral disc
degeneration, which simply means that the discs located between the
vertebrae of the spine are breaking down with age. As they
deteriorate, they lose their cushioning ability. This problem can
lead to pain if the back is stressed. Another cause of back pain is
the wearing down of the facet joints, which are the large joints
that connect each vertebrae to another. Other mechanical causes of
back pain include spasms, muscle tension, and ruptured discs, which
are also called herniated discs.Injuries: Spine injuries such as
sprains and fractures can cause either short-lived or chronic back
pain. Sprains are tears in the ligaments that support the spine,
and they can occur from twisting or lifting improperly. Fractured
vertebrae are often the result of osteoporosis, a condition that
causes weak, porous bones. Less commonly, back pain may be caused
by more severe injuries that result from accidents and
falls.Acquired conditions and diseases: Many medical problems can
cause or contribute to back pain. They include scoliosis, which
causes curvature of the spine and does not usually cause pain until
mid-life; spondylolisthesis; various forms of arthritis, including
osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis;
and spinal stenosis, a narrowing of the spinal column that puts
pressure on the spinal cord and nerves. While osteoporosis itself
is not painful, it can lead to painful fractures of the vertebrae.
Other causes of back pain include pregnancy; kidney stones or
infections; endometriosis, which is the buildup of uterine tissue
in places outside the uterus; and fibromyalgia, which causes
fatigue and widespread muscle pain.Infections and tumors: Although
they are not common causes of back pain, infections can cause pain
when they involve the vertebrae, a condition called osteomyelitis,
or when they involve the discs that cushion the vertebrae, which is
called discitis. Tumors, too, are relatively rare causes of back
pain. Occasionally, tumors begin in the back, but more often they
appear in the back as a result of cancer that has spread from
elsewhere in the body.Although the causes of back pain are usually
physical, it is important to know that emotional stress can play a
role in how severe pain is and how long it lasts. Stress can affect
the body in many ways, including causing back muscles to become
tense and painful. Untreated depression and anxiety can make back
pain feel much worse. Likewise, insomnia, or the lack of sleep, can
also contribute to back pain.
http://www.webmd.com/back-pain/guide/causes-of-back-painhttp://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Back_Pain/
PATOFISIOLOGIDaerah lumbal adalah daerah yang paling sering
mengalami hernisasi pulposus, kandungan air diskus berkurang
bersamaan dengan bertambahnya usia. Selain itu serabut menjadi
kotor dan mengalami hialisasi yang membantu perubahan yang
mengakibatkan herniasi nukleus purpolus melalui anulus dengan
menekan akar akar syaraf spinal. Pada umumnya harniassi paling
besar kemungkinan terjadi di bagian koluma yang lebih mobil ke yang
kurang mobil (Perbatasan Lumbo Sakralis dan Servikotoralis)
(Sylvia,1991, hal.249).Sebagian besar dari HNP terjadi pada lumbal
antara VL 4 sampai L 5, atau L5 sampai S1. Arah herniasi yang
paling sering adalah posterolateral. Karena radiks saraf pada
daerah lumbal miring kebawah sewaktu berjalan keluar melalui
foramena neuralis, maka herniasi discus antara L 5 dan S
1.Perubahan degeneratif pada nukleus pulpolus disebabkan oleh
pengurangan kadar proteinyang berdampak pada peningkatan kadar
cairan sehingga tekanan intra distal meningkat, menyebabkan ruptur
pada anulus dengan stres yang relatif kecil.
Sedang M. Istiadi (1986) mengatakan adanya trauma baik secara
langsung atau tidak langsung pada diskus inter vertebralis akan
menyebabkan komprensi hebat dan transaksi nukleuspulposus (HNP).
Nukleus yang tertekan hebat akan mencari jalan keluar, dan melalui
robekan anulus tebrosus mendorong ligamentum longitudinal
terjadilah herniasi.
3. Is there any correlation between his occupation with his
symptoms? Is there any other risk factors which can cause the
symptoms?
4. Why is the pain worsening by lifting, coghing, bending,
walking and slightly relieved by rest?PATOFISIOLOGIProtrusi atau
ruptur nukleus pulposus biasanya didahului dengan perubahan
degeneratif yang terjadi pada proses penuaan. Kehilangan protein
polisakarida dalam diskus menurunkan kandungan air nukleus
pulposus. Perkembangan pecahan yang menyebar di anulus melemahkan
pertahanan pada herniasi nukleus. Setelah trauma; jatuh,
kecelakaan, dan stress minor berulang seperti mengangkat; kartilago
dapat cedera.Pada kebanyakan pasien, gejala trauma segera bersifat
khas dan singkat, dan gejala ini disebabkan oleh cedera pada diskus
yang tidak terlihat selama beberapa bulan maupun tahun. Kemudian
pada degenerasi pada diskus, kapsulnya mendorong ke arah medula
spinalis atau mungkin ruptur dan memungkinkan nukleus pulposus
terdorong terhadap sakus dural atau terhadap saraf spinal saat
muncul dari kolumna spinal.Hernia nukleus pulposus ke kanalis
vertebralis berarti bahwa nukleus pulposus menekan pada radiks yang
bersama-sama dengan arteria radikularis berada dalam bungkusan
dura. Hal ini terjadi kalau tempat herniasi di sisi lateral.
Bilamana tempat herniasinya di tengah-tengah tidak ada radiks yang
terkena. Lagipula, oleh karena pada tingkat L2 dan terus ke bawah
sudah tidak terdapat medula spinalis lagi, maka herniasi di garis
tengah tidak akan menimbulkan kompresi pada kolumna
anterior.Setelah terjadi hernia nukleus pulposus sisa duktus
intervertebralis mengalami lisis sehingga dua korpora vertebra
bertumpang tindih tanpa ganjalan.
5. Why in physical examination revealed a positive straight leg
raise at 450 with pain radiating to the left buttock and posterior
thigh?
6. Why the patient complains of 1 month history of left-side low
back pain radiating to buttock, leg and great toe?Ada penonjolan
diskus pada L4-L5 yang merupakan segmentasi nervus femoralis dan
nervus ischiadicus. Pada saat lesi di lumbal 4 nyeri radikuler yang
menjalar mulai dr panggul, paha posterolateral, betis lateral,
maleolus latera, punggung kaki, jari kaki 1,2,3 (terutama ibu
jari)
n. ischiadicus dermatom dari L4-S4.Persarafan yg paling besar
yang terdiri dri pars ant (n. Tibialis) dan post (n.peroneus
communis) berjalan dri pelvis foramen ischiadica mayor gluteus
berjalg dgn nervus gluteus superior dan mengakhiri perjalanan di
poplitea.
Nyeri radikuler : karena adanya tarikan, rangsangan, penekanan,
desakan thd akar saraf spinal dalam perjalanannya di canalis
vertebralis atau menjelang foramen intervertebralis. Bisa disertai
dgn hilangnya gangguan fungsi motorik.
7. Pain spot at back low?
8. Why does the patient feel numb on his left leg?Di posterior
vertebra terdapat jaras sensorik, bila ada penonjolan NP maka jaras
tersebut terhambat shg impuls tidak bisa disampaikan ke otak.
9. Why in MRI scanning shows a bulging at the disc located
between L4-L5 vertebrae?Penonjolan tsb akibat dari FR shg kandungan
air di intervertebralis berkurang mengakibatkan penonjolan NP
(annulus fibrosus masih intak) bila tekanan semakin berat dan
terus-menerus annulus robek, NP keluar dan menekan saraf bila
penekanan ke arah lateral ada symptom, bila ke medial tidak ada
keluhan karena tidak ada serabut saraf yang tertekan.
10. What are the DD?LBP Akut : < 6 minggu Kronik : 6-12
minggu
Mechanical : congenital degenerative, trauma. (caused by muscle
in ligamentum, muscle so the NP bulge)Non-mechanical : inflamation,
tumor.Visceral : disease in visceral organ and pelvic area.
HNP (lumbal disc disease)RF : lifting MOAE, MOAI, MTA contract,
increase the pressure in abdominal bulging in lumbal.
11. What is the definitive treatment for the patient?
12. What are the Clinical examinations that are needed?
13. Therapy for the patient?
14. The complication of this scenario? Kronis : timbul HNP
annulus fibrosus robek
STEP 4
