PLACE AND DATE OF BIRTH Curriculum Vitae

Payakumbuh, September 20th 1980

EDUCATION
Neurology, Andalas University, 2014
Magister of Biomedical Science, Andalas University, 2014
M.D. Faculty of Medicine, Andalas University, Padang 2005

TRAINING
Workshop EMG
Workshop EEG
Workshop Neurointensive
Workshop Evidence Based Medicine

WORKING EXPERIENCE
Neurolgist EKA HOSPITAL, Pekanbaru, 2015 – now
RSUD Arifin Achmad, Pekanbaru, 2015 – now
Lecture in Faculty of Medicine, Riau University, 2006 - now

Dr Yossi Maryanti
Maryanti,, SpS
SpS,, M.Biomed
M.Biomed..
Dr. Yossi Maryanti, M.Biomed, SpS
 BACKGROUND
• Very common
• 85% of population will have neck and low back pain
at some point
• 2.6 million people consult their GP about back pain
per year
• Majority settle with no intervention within a few
weeks
• Acute back pain’ = <6 weeks
• If present for >12 months few return to normal
function/work
• Only 5% will have serious cause
ANATOMY
CAUSES
Clinical Features
 HISTORY TO ASK
• Pain Constitual symptoms
- Onset - Fever
- Duration - Anoreksia
- Location - Weight loss

• Trauma? Co-morbidoty condition

• Associted symptoms
- Stiffness
- Deformity
- Neurologic complaints
 Sign and Symptoms
• RADICULAR PAIN
• A type of pain raduates into the lower
extremity directly along the course of spnal
neve root.
• Sharp, burning, intense pain that radiatesto
trapezius, periscapular area or down the arm
• Weakness or paresthesias may develop weeks
after pain onset
• MYELOPATHY PAIN
• Neck pain that progress insidiously
• Clumsy hands, gait disturbance and sexual or
bladder dysfunction
• Due to sinal cord lession, stenosis or
compression.
PAIN EVALUATION
PHYSICAL EXAMINATION
 MOVEMENTS

• Forward flexion
• Extension
• Right and lateral flexion
• Rotation to each side
Spurling’ sign
Lhermitte’s sign
Shoulder Abduction test
Hoffman’s sign
Sign of Meningism
Signs of Thoracic Outlet
Obstruction
Neurovascular examination
Neurovascular examination
 TEST
• Lab: useful only in infective pathology.

• Imaging- Acute ( day to week)- NO

IMAGING
Uncomplicated
Non radicular
Non myelopathic
A traumatic
 Imaging
• Chronic ( week-month) neck pain with or
without a history of trauma.
• Neck pain and priorhistory of malignancy
• Preexisting spinal disorders such rheumatoid
arthritis, ankylosing spondilytis.
• MRI : chronic neck pain with neurologic signs
or symptoms regardless of the plain
radiographic finding
• CT Myelography: if MRI contraindication
 Differential diagnosis
Neck pain
• Cervical spondylosis
• Cervical disc disease
• Cervical facet joint disease
• Cervical radiculopathy
• Cervical myelopathy
• Fracture
• Inflammatory spondyloarthropathy
• Infection
• Malignancy
 Differential Diagnosis
Neck pain
• Mechanical neck disorder
• Cervical disc herniation
• Cervical spondylosis and stenosis
• Cancer of cervical spine
• Cervical myofascial syndrome
• Other condition
Mechanical Disorders
• Hyperextension strain
• Acceleration-deceleration injury
• Hyperextension-hyperflexion injury
• Neck strain
• Neck sprain
• Whiplash
Cervical Disc Herniation
• Cervical disk herniations occur as the nucleus
pulposus protrudes through the posterior
annulus fibrosis, producing an acute
radiculopathy or, occasionally, a myelopathy.
• Direct posterior rupture-Progressive
myelopathy
• Posterior lateral herniation-Radiculopathy
• Most frequent- C5-6 or C6-7
Cervical Spondylosis and Stenosis
Degenerative disk disease or osteoarthritis
• Progressive, degenerative condition
• Loss of cervical flexibity
• Neck pain
• Occipital neuralgia
• Radicular pain
• Occasionally progressive myelopathy
• Progressive degeneration of the disks, ligaments,
facet joints (zygapophyseal joints) and uncovertebral
joints (joints of Luschka)
Cervical Spondylosis
Radiographic diagnosis
If any one of three findings is present :
• Osteophytes
• Disk space narrowing
• Facet disease
Cervical Spondylosis
• Osteophytic spurs
– Encroach posteriorly on the spinal canal
cervical myelopathy
– Laterally on the intervertebral foramen
cervical radiculopathy
– Anteriorly on the esophagus dysphagia
• Spurious osteophytes
• Horner’s syndrome
• Vertebrobasilar symptoms
• Severe radicular symptoms without associated neck pain
• Painless upper extremities myotome weakness
• Chest pain mimicking angina
Stenosis
• Cervical spinal stenosis as the diameter of the
spinal canal is reduced to less than 13 mm
 Cancer Cervical Spine
• Metastatic cancers
• Unremitting night pain
• Lung, breast, and prostate cancers
• Multiple myeloma & lymphoma
• MRI is the standard for the detection of spinal epidural metastatic
disease and cord compression
• Cancer patients with radiographic evidence of bone or disk margin
destruction should undergo MRI
Cancer Myofascial Syndrome
• Chronic neck pain
• Confused with radiculopathy
• Myofascial pain symptoms may present or exacerbate acutely,
especially after trauma
• Psychological distress & specific personality traits are risk
factors
• Pain in the neck, scapula, and shoulder with or without non-
dermatomal radiation into the upper extremity
• Trigger point
• Neurology exam normal
• Imaging nonspesific
 Cervical Myelopathy
• Cervical spondylotic myelopathy causes the greatest
degree of impairment and disability
• Myelopathy is the most common cause of spastic
paraparesis in patients older than 55 years of age
• Prompt neurosurgical or spinal orthopaedic
consultation
• Decompression surgery
• Additional therapeutic considerations (e.G. Steroids
and radiation in spinal epidural metastases)
Cervical Radiculopathy
Without Myelopathy
• Conservative activity modification to prevent symptoms
exacerbation injury
• Oral medications
• Immobilization with a soft or hard cervical collar is
controversial without clear evidence for against its use
• Encourage to a neurosurgical or orthopedic spine specialist
• Electrodiagnostic evaluation
• Rehabilitation interventions

Oral medications may include NSAIDs, opioid analgesics, and

muscle relaxants. A 7 to 10 days cours of oral steroids (e.g.
methylprednisolone or prednisone)
Cervical Radiculopathy
Other treatment options in chronic cases
• Epidural steroid injection
• Surgery
Indication for hospital admission
1. Progressive upper extremity weakness, especially in the C7
distribution
2. Acute or progressive symptoms or signs of myelopathy
3. Intractable radicular pain unresponsive to treatment
Other causes
Infectious and inflammatory causes
• Epidural abscess
• Osteomyelitis
• Transverse myelitis
Non infectious
• Epidural hematoma
• Ischemic heart disease
• Peripheral nerve involvement- Carpal tunnel syndrome
(radiculopathy)
• Multiple sclerosis, amyotrophic lateral sclerosis, subacute
combined degeneration and syrinx (myelopathy)
Differential diagnosis
Back pain
• Lumbar sprain
• Herniated disc
• Spinal facet joint disease
• Radicular low back pain (sciatica)
• Spinal stenosis
• Compression fracture
• Inflammatory spondyloarthropathy
• Infection
• Malignancy
Red Flags
Red Flags
Yellow Flags
• Attitudes and beliefs about back pain
• Belief that back pain is bad or harmful
• Behaviours
• Activity avoidance, very high VAS scores,
• Emotions
• Fear/depression/anxiety
• Over protective partner/spouse –
• Manual job/low socioeconomic
status/unhappy at work
Treatment
 Treatment
• Uncomplicated pain
• NSAID
• Muscle relaxants
• Short course opioids
• Soft collar
• Advice: “ACT AS USUAL”
Conservative Treatment
Modalities
• Physiotherapy
• Acupuncture
• Electrotherapy
• Manipulation
• Traction
• Thermotherapy
• Medicinal and injection therapies
• Exercises
2. Cervical Radiculopathy
• Advice : activity modification
• Oral NSAID, muscle relaxants, opioid
• Steroid
• Follow up with neurosurgery/orthopaedic

3. Cervical myelopathy
• Follow up with neurosurgery
• Decompressive surgery