DISEASE OF SPINE

LUHU A. TAPIHERU

Topik
LBP HNP, Lumbar spinal stenosis Spondilitis TB

LBP (Low Back Pain)

EPIDEMIOLOGY

Life time prevalence 59% 10% leads to consultation to GP 90% improved in 1 month up to 70% patient tend to recur

Etiology

Non-specific mechanical back pain Facet joint syndrome Lumbar disc degeneration (lumbar spondylosis) Lumbar disc prolapse Spondylolisthesis Spinal stenosis Osteoporosis Sero-negative spondyl arthritis (including ankylosing spondylitis) Vertebral infection Disc space infection Malignancy secondary myeloma and primary Pagets disease, referred-visceral, pancreatic/pelvic, etc

RED FLAGS

(possible serious spinal pathology)

Age of onset : < 20 or 55 years Violent trauma, eg fall from a height, traffic accident Constant, progressive, non-mechanical pain Thoracic pain History of carcinoma Systemic steroids Drug abuse, HIV infection Systemically unwell Weight loss Persistent severe restriction of lumbar flexion Widespread neurological deficit Structural deformity

COMMON ETIOLOGY

1. 2. 3. 4. 5.

Mechanical (deformity, trauma) Inflammation Neoplasm Degenerative Psychological

MECHANICAL
Ligamentous Strain Muscle strain or spasm Facet join disruption or degeneration Intervertebral disc degeneration or herniation Vertebral compression fracture Vertebral end-plate microfractures Spondylolisthesis Spinal stenosis Diffuse idiopathic skeletal hyperostosis

SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOSIS : refers to osteoarthritis involving the articular surfaces (joints and discs) of the spine, often with osteophyte formation and cord or root compression SPONDYLOLISIS : refers to a separation at the pars articularis, which permits the vertebrae to slip. Maybe uni or bilateral

SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOLISTHESIS : May result from bilateral pars defects or degenerative disc disease. Defined as the anterior subluxation of the suprajacent vertebrae, often producing central canal stenosis : it is the slipping forward of one vertebrae on the vertebrae below.

INFECTION
Epidural abcess Vertebral osteomyelitis Septic discitis Potts disease (tuberculosis) Nonspecific manifestation of systemic illness

NEOPLASM
Epidural or vertebral carcinomatous metastases Multiple myeloma Lymphoma

DEGENERATIVE

1. Osteoarthritis 2. Rheumatoid arthritis 3. Thoracic Outlet Syndrome 4. Cervical Spondylosis 5. Lumbar disc prolaps 6. (Hernia Nukleus Pulposus (HNP) 7. Spinal Stenosis

HNP

HNP
HNP : Hernia Nukleus Pulposus Sinonim : Ruptured disk, prolapsed disk, hernia diskus intervetrebralis Penyebab NPB (Nyeri punggung bawah) / LBP (low back pain) yang penting Prevalensi 1 2% dari populasi 90% diskus intervetebralis L5 S1 aan L4 L5 Biasanya membaik 6 minggu

HNP
Definisi :
Suatu keadaan dimana sebagian atau seluruh bagian nukleus pulposus mengalami penonjolan ke dalam kanalis spinalis

HNP :
HNP servikalis HNP lumbalis HNP torakalis

The disc

Herniated disc

Patofisiologi
Diskus intervetebralis penyangga beban (Shock absorber) Terdiri dua bagian utama :
1. Anulus fibrosus : lapisan luar fibro-kolagen yang saling menyilang, bagian dalam lapisan fibro-kartilagenus 2. Nukleus pulposus : terdiri dari proteoglycan yang terdiri dari 80% air (higroskopis)

HNP Lumbalis
1. 2. L5 S1 tugas berat menyangga berat badan ( 75%) Mobilitas tinggi pada fleksi dan ekstensi. 57% aktivitas fleksi dan ekstensi dilakukan sendi L5 - S1 Daerah rawan ligamentum longitudinalis posterior hanya separuh menutupi permukaan posterior diskus arah herniasi postero lateral

3.

Derajat HNP
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.

Grade of herniated disc

Clinical symptoms
Lumbar HNP :
radicular pain abnormal vertebral posture paresthesia, parese, diminished tendon reflexes

Cervical HNP :
radicular pain, aggravated by neck extension, and reduced by abducting the arm and put it behind the head paresthesia, parese, diminished tendon reflexes

Ischialgia (sciatic)

Diagnosis
Anamnesis Neurological examination
Sensorik, motorik, reflek Lumbar HNP : Lasegue (SLR = straight leg raising) test Lasegue + provokasi Bragard Crossed Laseque (crossed SLR) test Femoral stretch (reverse SLR) test Cervical HNP : Lhermitte test Valsava test Shoulder abduction test

Diagnosis
Pemeriksaan radiologis :
Plain vertebral x-rays : limited information disc narrowing, scoliosis, lordosis lumbal Myelography CT or CT-myelography MRI EMG/NCV : 90% abnormal after 1-2 weeks

Therapy
CONSERVATIVE
bed rest analgetic, muscle relaxant, ajuvant analgentics orthopaedic mattress pelvic traction (controversial) lumbar corset

OPERATIVE Indication :
1. 2. 3. 4. 5. Fail conservative treatment Progressive motor dysfunction Recurrence Compression of cauda equina Bowel disorders

Prognosis
Sebagian besar membaik dalam 6 minggu Sebagian kecil kronik Post Op 90% membaik, rekurensi 5%

Spinal stenosis

Lumbar spinal stenosis

CLINICAL SYMPTOMS :
neurogenic intermittent claudiation or pseudoclaudication (most frequent) usually bilateral, but maybe unilateral a dull, aching pain the whole lower extremity is generally affected pain provoked by walking and standing, quickly relieved by sitting or leaning forward LBP presents in 65% patients with lumbar spinal stenosis radicular pain is the least common manifestation

Most frequent causes of spinal stenosis

> 25 causes are identified The most common : 1. Idiopathic : the result of shorter than normal pedicles, thickened convergent lamina, and a convex posterior vertebral body. 2. Degenerative (50% of cases) : degenerative changes affect the facets posteriorly allowing instability and subluxation, osteophytes form and narrow the nerve root and the central canal ; and the disc anteriorly allowing the disc to bulge into the nerve root and central canal.

most frequent causes of spinal stenosis

3. Degenerative spondylolisthesis : occurs when the facets degenerate, allowing slippage of the upper vertebrae forward over the lower vertebrae. 4. Postoperative : occurs after laminectomy or spinal fusion. Stenosis is produced by bone formation and scar tissue

Indication for surgical treatment of lumbar spinal stenosis

1. 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 of sexual function.

Spondilitis TB

Spondilitis TB
Spondilitis TB, sinonim :
Tuberkulosis spinal Potts disease Tuberculosis vertebral osteomyelitis

Mr. Pervical Pott (1779) Insiden berhub fasilitas pelayanan kesehatan dan keadaan sosial

Epidemiologi Spondilitis TB
Di Asia 50% usia 1 20 tahun Keterlibatan tulang sendi pada pasien TB 10% 50 % mengenai vertebra (Vt thorakal 9 - 10), sisanya tulang panggul, lutut dan tulang kaki lainnya Penyebab paling sering paraplegia non traumatik

Patogenesis spondilitis TB
Penyebaran spondilitis TB
Hematogen Langsung nodus limfatikus para aorta dan jalur limfatikus

Sumber infeksi sistema pulmoner dan genitourinarius Penyebaran melalui :

arteri interkostal / lumbar suplai darah ke dua vertebrae yang berdekatan (setengah bagian bawah vertebra diatasnya dan bagian atas vertebra di bawahnya)

Patogenesis spondilitis TB
pleksus Batsons mengelilingi columna vertebralis menyebabkan banyak vertebra yang terkena

Tiga bentuk spondilitis TB (lokasi infeksi pada korpus)

Paradiskal Sentral Anterior : adanya scalloped = bentuk baji (erosinya bagian anterior beberapa vertebra) Atipikal

Gambaran klinis spondilitis TB

Potts paraplegia
Early onset : < 2 tahun Late onset : 2 tahun

Paraplegia :
Akibat tekanan eksternal (pd med. Spinalis dan duramater) Invasi duramater (tdp gambaran meningomielitis TB / araknoiditis TB) Disertai inkontinesia urin dan alvi, gangguan sensoris

Diagnosis spondilitis TB
Anamnesis :
Kehilangan BB, riw. batuk lama, keringat malam hari, demam intermiten, cachexia Nyeri : lesi torakal atas nyeri dada interkostal, lesi torakal bawah nyeri penjalaran ke perut Punggung kaku

Pemeriksaan fisik:
Deformitas : kifosis, gibbus, skoliosis, subluksasi, spondilolisthesis dan dislokasi Paraparesis UMN, spastisitas,

Diagnosis spondilitis TB
Pemeriksaan penunjang
Darah rutin, LED, tuberkulin/mantoux Foto Rontgen dada CT scan MRI Neddle biopsis

Manajemen terapi spondilitis TB

Konservatif
1. 2. Pemberian Nutrisi yang bergizi Pengobatan Anti tuberculosis drug/tuberkulostatika :
Isoniazid (INH) : 5-10 mg/kg/hr 300 400 mg Rifampicin (R) : 15-20 mg/kg/hr 450 600 mg Pyrazinamid (PZA) :35 mg/kg/hr 100- 1500 mg Ethambutol (E) : 25 mg/kg/hr 500-750 mg Streptomycine : 15-20 mg/kg/hr 750-1000 mg Kemudian untuk mencegah neuropati, dapat ditambahkan vit. B6

Manajemen terapi spondilitis TB

Lama pemberian ; Menurut Gilroy :
Initial treatment (2 bln) : R, INH, PZA Continued treatment (9 bln) : R, INH

Menurut Pengobatan TB paru, terbagi 2 fase

1. Fase intensif (2-3 bulan) 2. Fase lanjutan (4-7 bulan)

3. Istirahat tirah baring

Manajemen terapi spondilitis TB

Indikasi operatif

Diagnosa yang meragukan hingga diperlukan untuk melakukan biopsi Terdapat instabilitas setelah proses penyembuhan Terdapat abses yang dapat dengan mudah didrainase Untuk penyakit yang lanjut dengan kerusakan tulang yang nyata danmengancam atau kifosis berat saat ini Penyakit yang rekuren

Prognosis spondilitis TB
1. Mortalitas menurun sejak ditemukannya kemoterapi TB 2. Relaps 0% (pengawasan ketat pemberian regimen) 3. Kifosis deformitas, masalah kosmetik 4. Defisit neurologis membaik (tu. Operasi dini) 5. Usia dini prognosis lebih baik 6. Fusi tulang hal yang penting untuk pemulihan

Terima kasih