KELAINANAN SISTEM

NEUROMUSKULOSKELETAL

Oleh:

Saifudin Zuhri, M. Kes

Tujuan Instruksional Khusus (T.I.K)
• Membaca dan memberi kesan gambaran radiologi kasus
kasus atau kelainan pada musculosceletal yang disebabkan
oleh gangguan atau kerusakan pada susunan saraf pusat
(otak dan medulla spinalis), yaitu :
– Stroke haemorrhagik
– Stroke Non haemorrhagik (infark/ischaemik)
– Hernia Nucleus Pulposus

• Membaca dan memberi kesan gambaran radiology kasus-

kasus pada musculosceletal, yaitu:
– Osteorthritis
– Rheumatoid arthritis
– Low Back Pain
• Spondilosis, Spondiloarthrosis
• Listhesis
• Axial kompressi
• Paraspinal musculospasme,Instabilitas lumbosacral
• Cauda equina, Sacralisasi, Lumbalisasi
• Scoliosis
1. STROKE
Stroke
- GPDO
- CVA
- CVD
Stroke
• Stroke is the third largest killer in the Western
World.
• It accounts for up to 6% of in-patient hospital
costs in Scotland.
• Stroke is one of the major causes of disability,
particularly in the elderly.
• Stroke patients may present with a variety of
physical, cognitive and psychosocial problems.
• Most stroke patients show signs of recovery over
time.
Sub-types Of Stroke
• Ischaemic – obstruction to one of major
cerebral arteries, brainstem strokes are less
common.
• Haemorrhage – 9% are caused by
haemorrhage to the deep parts of the brain.
Patients are usually hypertensive.
Risk Factors
OBESITY
• SMOKING
•DRUG
ABUSE
•OLD AGE
• Wee Betty lived a long and
fruitfull life, RIP Betty (1875-
1997). That’s 122 years don’t
you know!
•ALCOHOL
Penyebab Stroke
• Stroke hemoragik
- intracerebral hemoragik (ICH)
- Sub arachnoid hemoragik (SAH)
• Stroke non hemoragik
ok arteriosklerosis & sering dikaitkan dng
DM, hypercolesterolemia, asam urat dan
hiperagregasi trombosit
Tinjauan klinis infark di otak
• TIA (Transient Ischemic Attack) gejala & tanda
hilang beberapa detik – 24 jam. Defisit neurologis
dpt berupa hemiparese, monoparese, gg penglihatan,
sulit bicara.
• RIND (Reversible Ischemic Neurological Deficit) 
tanda & gejala hilang, bbrp hari – minggu
• Stroke in evolution atau progressive stroke defisit
neurologis bersifat fluktuatif, progressif ke arah
jelek, biasa disertai penyakit penyerta (DM, gg
fungsi jantung, gg fungsi ginjal dll)
• Completed stroke (stroke komplit)  defisit
neurologis bersifat permanen.
Gejala & Tanda

• Dipengaruhi oleh topis lesi & luas infark

A. Gangguan motoris
- abnormalitas tonus (flaccid atau spastik)
- parese/plegia (mono/hemi)
Patologi
1. Zona oedematosa  6 hari – 10 hari
2. Zona degenerasi  6 – 8 bulan
3. Zona nekrotik  > 8 bulan.

Neurological Improvement
1. Zona nekrotik (bersifat irreversibel, permanen)
disebut area umbra
2. Area degenerasi reversibel = zona degenerasi
disebut area penumbra
3. Area oedematosa (bersifat reversibel) disebut area
oedematosa
B. Gangguan Sensoris
1) Hemidisesthesia
2) Hemikinesthesia
Pada kondisi tertentu kelainan sensoris
terjadi tanpa kelainan motoris
C/ gambaran angiografi terjadi
obstruksi/penyempitan lumen carotis
communis, cerebre media kiri area siphon
basis cranii terjadi keluhan hemiesthesia sisi
dekstra tanpa parese.
3) Central pain (lesi korteks sensoris)
C. Gangguan saraf otonom & fungsi
luhur
1) Gg vasomotor
2) Gg aktivasi kelenjar sudorivera
3) Fungsi luhur (aphasia motoris & sensoris)
Gg lain terkait fungsi kognitif & memori, psikiatrik &
emosi
Karakteristik lesi dipengaruhi topisnya.
C/ lesi di atas brainstem  psikiatrik (suprabulbar
palsy)
- forse crying
- forse loughing
Diagnosis medis
1. Computerized Tomography Scanning (CT scan)
- Infark  lesi hipodens (lesi dengan densitas
rendah) tampak lebih hitam dibanding otak
sekitarnya
- Perdarahan  lesi hiperdens (lesi dengan
densitas tinggi) tampak lebih putih dibanding
jaringan otak sekitarnya
2. Magnetic Resonance Imaging (MRI) & Magnetic
Resonance Angiography (MRA)
- mengetahui topis kebocoran vaskuler otak
3. Positron Emision Tomography Scan (PET Scan)
Hypodense area:
• Ischemic area with edema,
swelling
• Indicates >3 hours old
• No fibrinolytics!
(White areas indicate
hyperdensity = blood)

Large left frontal

intracerebral
hemorrhage.

Intraventricular
bleeding
is also present
No fibrinolytics!
Acute
subarachnoid
hemorrhage
Diffuse areas of white
(hyperdense) images

Blood visible in ventricles

and multiple areas on

surface of brain
Problematik yang dijumpai:
a. Impairment
- abnormalitas tonus (flaccid, spastis)
- gg koordinasi & keseimbangan
- hilangnya mekanisme reflek postural
normal
- kelainan sensomotoris lain akibat
komplikasi dari lamanya masa bed rest &
derajat lesi serta topis lesi: pain, stiffness,
kontraktur, DVT, ortostatik hipotensi, gg
reflek primitif dll
b. Functional limitation
Aktivitas duduk, berdiri, berjalan &
aktivitas fungsional pasien dl kegiatan
sehari-hari (ADL)

c. Participation Restriction
Pekerjaan, hobby, pendidikan dan
bermasyarakat
Physiotherapy Aims
• To normalise muscle tone
• To restore muscle function
• To control compensation strategies
• To maintain muscle length
• To re-educate balance
• To retrain walking and restore mobility
• To maximise functional ability while allowing on-
going neuromuscular recovery
Karakteristik spastisitas
1. Tahanan meningkat terhadap gerakan pasif
2. Deep tendon reflek meningkat
3. Bila berat menimbulkan clonus

Akibat spastik, koordinasi dan keseimbangan

jelek
Untung – Rugi spastisitas
• Efek braching/splinting
• Membantu posisi tegak/lurus
• Mencegah/menghambat osteoporosis

- Mobilitas turun - dekubitus

- Nyeri - fungsi menurun
- <ROM - kosmetik jelek
- Posisi terganggu - beban perawatan &
biaya
Kapan spastisitas harus diterapi?
• Bila terjadi difus
• Timbul gangguan fungsional
• Gangguan posisi
• Perawatan menjadi sulit
• Kenyamanan terganggu
Spastisitas dapat menyebabkan:
• Pola spastik (postural secara statik)
• Pola sinergis (saat gerakan dinamis)
• Reaksi asosiasi (over flow)
• Munculnya beberapa reflek primitif
• Hiperrefleksia pada tendon tertentu &
klonus
Semuanya mengakibatkan hilangnya
mekanisme reflek postural normal.
STROKE

• Penderita, laki-laki 50 th , kesadaran menurun yang terjadi tiba-

tiba, anggota gerak kanan tak dapat digerakkan
• CT Scan Kepala :
– Tampak lesi hiperdens, batas tegas, bentuk amorf di ganglia
basalis sinistra yang menyempitkan ventrikel lateralis sinistra.
• Kesan :
– Perdarahan di ganglia basalis sinistra (Intra Cerebral
Haemorrhagic)
a
b

• Laki-laki, 46 tahun dengan keluhan tiba-tiba anggota gerak kiri tak

dapat digerakkan. Hasil Pemeriksaan CT Scan :
• a. CT Scan kepala:
– Tampak lesi hipodens di lobus parietalis dextra, ukuran ?
• Kesan : Infark cerebri di lobus parietalis dextra (a)
• b.CT Scan kepala
– Tampak lesi hipodens di paraventriculer dextra dan lobus parietalis
dextra, ukuran ?
• Kesan : Infark cerebri di paraventrikuler dextra dan lobus parietalis
dextra (b)
2. HNP
Herniated Nucleus Pulposus
• Degenerasi disk progresif,
atau peristiwa traumatik,
dapat menyebabkan
kegagalan anulus untuk
mempertahankan nucleus
pulposus
• This is known as herniated
nucleus pulposus (HNP)
or a herniated disc
Herniated Nucleus Pulposus
• Symptoms
– Back pain
– Leg pain
– Dysthesias
– Anesthesias
Herniated Nucleus Pulposus
• Varying degrees
• Disc bulge
– Mild symptoms
• Usually go away with
nonoperative treatment
– Rarely an indication
for surgery
• Extrusion (herniation)
– Moderate/severe symptoms
• Nonoperative treatment
Herniated Nucleus Pulposus
• Diagnosis
– Magnetic resonance
imaging (MRI)/patient
exam
• Nonoperative Care
– Initial bed rest
– Nonsteroidal anti-
inflammatory (NSAID)
medication
– Physical therapy
• Exercise/walking
– Steroid injections
Herniated Nucleus Pulposus
• Surgical care
– Failure of nonoperative
treatment
• Minimum of 6 weeks in
duration
– Can be months
– Discectomy
• Removal of the herniated
portion of the disc
• Usually through a small
incision
• High success rate
Herniated Nucleus Pulposus
• Cauda Equina Syndrome
– Caused by a central disc
herniation
– Symptoms include bilateral
leg pain, loss of perianal
sensation, paralysis of the
bladder, and weakness of
the anal sphincter
– Surgical intervention in
these cases is urgent
• Laki-laki, 42 tahun dengan nyeri pada daerah panggul yang
dirasakan semakin bertambah, terutama bila dipakai untuk
mengangkat barang dan posisi membungkuk
• Myelografi/MRI/CT Scan lumbalis:
– Tampak penonjolan discus intervertebralis masuk ke dalam
medulla spinalis
• Kesan : HNP
Sampai ketemu pada
pertemuan berikutnya...
3. NYERI SENDI
• ARTHRITIS
• RHEUMATOID ARTHRITIS
• OSTEOARTHROSIS
Rheumatoid Arthritis

• Penderita dengan keluhan nyeri pada tangan kanan kiri disertai

bengkak pada persendian
• Foto Manus dextra et sinistra:
– Tampak lesi litik (cyst) pada metacarpophalangeal, interphalanx
manus dextra et sinistra disertai soft tissue swelling (+).
– Tampak joint space menyempit dengan deformitas (+)
• Kesan : mendukung Rheumatoid Arthritis pada kedua manus
 Key Features
• Symmetric, inflammatory polyarthritis
• Autoimmune
• Females > Males
• Symptoms > 6 wks
• Morning stiffness > 1 hr
• > 3 joints involved
• Spares:
 Thoracolumbar spine
 DIP of fingers
www.cks.nhs.uk/.../rheumatoid_arthri
tis_arc
Rheumatoid Nodule
Stage I:
Acute: penebalan sinovial, terbatas pada kapsul sendi
Stage II:
Persistent inflammation  c/c pain, joint damage
Stage III:
Peradangan dan kerusakan membatasi fungsi sendi
Stage IV:
Permanent joint damage and deformity  disability
Joint Involvement

• 1 medium-large joint (0 points)

• 2-10 medium-large joints (1 point)
• 1-3 small joints (2 points)
• 4-10 small joints (3 points)
• More than 10 small joints (5 points)
Radiologic progression
Differential Diagnosis
• Spondyloarthropathies
• CTD’s
• Gout
• CPPD
• Viral infections
• Fibromyalgia
• Lyme disease
• Rheumatic fever
References

• Saag K.G., Teng G.G. American College of Rheumatology 2008

recommendations for the use of nonbiologic and biologic disease-
modifying antirheumatic drugs in rheumatoid arthritis . Arthritis
&Rheumatism2008; Vol. 59, No. 6 : p 762-784)

• Rindfleisch J.A. Diagnosis and Management of Rheumatoid Arthritis.

the American Family Physician; September 15, 2005 ; Volume 72, Number 6

• Family Practice News Feb 15, 2010

• www.medscape.com
OSTEOARTHRITIS
Osteoarthritis

• Kasus : wanita, 60 tahun, nyeri pada persendian, terutama : lutut,

panggul dan tangan

• Foto Polos pada articulatio genue, coxae dan manus :

– tampak joint space menyempit
– tampak lesi scelorotic pada daerah subchondral os tibia proksimal
dan os femur distal, caput femoris dan lesi litik pada bagian
proximal dan distal metacarpal dan phalanx pada manus dextra et
sinistra
• Kesan : Osteorthritis pada genue, coxae dan manus
 Osteoarthritis

• Kegagalan articular cartilage disebabkan oleh

interaksi yang kompleks dari faktor genetik,
metabolisme, biokimia, dan biomekanik
• With secondary components of inflammation
• Mekanisme kerusakan dimulai pada tulang rawan
artikular normal oleh kekuatan fisik (macrotrauma
atau microtrauma berulang)
• Not necessarily normal consequence of aging
Risk Factors
• Age
• Female versus male sex
• Obesity
• Lack of osteoporosis
• Occupation
• Sports activities
• Previous injury
• Muscle weakness
• Proprioceptive deficits
• Genetic elements
• Acromegaly
• Calcium crystal deposition disease
Idiopathic Osteoarthritis
• Localized or generalized forms
• Localized OA most commonly affects the
hands, feet, knee, hip, and spine
• Other joints less commonly involved
– shoulder, temporomandibular, sacroiliac, ankle,
and wrist joints
• Generalized OA
– three or more joint sites
Patterns of Presentation
• Monoarticular in young adult
• Pauciarticular, large-joint in middle age
• Polyarticular generalized
• Rapidly progressive
• Secondary to trauma, congenital
abnormality, or systemic disease
Secondary Osteoarthritis
• Trauma
• Congenital or developmental disorders
• Calcium pyrophosphate dihydrate deposition
disease (CPPD)
• Other bone and joint disorder
– osteonecrosis, rheumatoid arthritis, gouty arthritis,
septic arthritis, and Paget disease of bone
• Other diseases
– diabetes mellitus, acromegaly, hypothyroidism,
neuropathic (Charcot) arthropathy, and frostbite
 Clinical Features

• Age of Onset > 40 years

• Commonly Affected Joints
– Cervical and lumbar spine
– First carpometacarpal joint
– Proximal interphalangeal joint
– Distal interphalangeal joint
– Hip
– Knee
– Subtalar joint
– First metarsophalangeal joint
Uncommonly Affected Joints
• Shoulder
• Wrist
• Elbow
• Metacarpophalangeal joint
• TMJ
• SI
• Ankle
 Clinical Diagnosis
• Symptoms
– Pain
– Stiffness
– Gelling

• Physical examination
– Crepitus
– Bony enlargement
– Decreased range of motion
– Malalignment
– Tenderness to palpation

• The more features, the more likely the diagnosis

Differential Diagnosis
• Rheumatoid Arthritis
• Gout
• CPPD (Calcium pyrophosphate crystal
deposition disease)
• Septic Joint
• Polymyalgia Rheumatica
Synovial fluid analysis
• Severe, acute joint pain is an
uncommon manifestation of OA

• Clear fluidWBC <2000/mm3

• Normal viscosity
Radiographic Features

• Joint space narrowing

• Subchondral sclerosis
• Marginal osteophytes
• Subchondral cyst
Joint Space Narrowing

• OA typically asymmetrical

Paget’s disease
 Subchondral Sclerosis

• Peningkatan kepadatan tulang atau penebalan

dalam lapisan subchondral
Osteophytes
• Bone spurs
 Subchondral Cysts

• Kantung berisi cairan di tulang subchondral

OA of the Knee: Classic Criteria
1. Greater than 50 years of age
2. Morning stiffness for less than 30 minutes
3. Crepitus on active motion of the knee
4. Bony tenderness
5. Bony enlargement
6. No palpable warmth

• 3 of 6 criteria give sensitivity of 95% and

specificity of 69%
OA of the Knee: Addition of X-rays
• ACR Criteria of:
1. knee pain
2. radiographic evidence of osteophytes
3. one of three additional findings:
• age greater than 50 years of age
• morning stiffness of less than 30 minutes
• crepitus

– Sensitivity and specificity for OA of 91 and

86%
Hand Osteoarthritis
• Diagnosis by hand pain
• Plus at least three of the following four features:
1. Hard tissue enlargement of 2 or more of 10 selected joints.
• The 10 selected joints are the second and third distal
interphalangeal (DIP) joints, the second and third
proximal interphalangeal (PIP) joints, and the first
carpometacarpal (CMC) of both hands
2. Hard enlargement of two or more DIP joints
3. Fewer than three swollen metacarpophalangeal (MCP)
joints
4. Deformity of at least 1 of the 10 selected joints

• Sensitivity and Specificity for hand OA of 94 and 87%

Hip Osteoarthritis Diagnosis
• Use history, physical, laboratory, and
radiographic features (ACR)
• Hip Pain, plus at least two of the following
three features:
1. ESR of less than 20 mm/h
2. Radiographic osteophytes
3. Joint space narrowing on radiography
• Sensitivity of 89 percent and a specificity of
91 percent
Typical OA work-up
• History
• PE
• Consider following (especially if OA of
knees or hips)
– Erythrocyte sedimentation rate (ESR)
– Rheumatoid factor titers
– Evaluation of synovial fluid
– Radiographic study of affected joints
Goals of Treatment
• Control pain and swelling
• Minimize disability
• Improve the quality of life
• Prevent progression
• Education
• Chronic Condition and Management
Non-pharmacologic Treatment
• Weight Loss
– Ten-pound weight loss over 10 years decreased the
odds for developing knee OA by 50%
– Even a modest amount of weight loss may be beneficial
• Rest
– Short period of time, typically 12-24 hours
– Prolonged rest can lead to muscle atrophy and
decreased joint mobility
Non-pharmacological Treatment
• Physical Therapy
– “Manual therapy" may be more beneficial than
exercise programs that focus on muscle
strengthening, endurance training, and
improved coordination
– May be more beneficial in those with mild OA
– Ultrasound therapy may have some benefit
based on 2009 Cochrane Review
Tens
• SOR B
• Safety/Tolerability: High
• Efficacy: Medium
• 20 points more effective on scale of 100
compared to placebo
• Few long term studies
• Price: Low to medium
Non-pharmacologic Treatment
• Knee Braces/Shoe Inserts - SOR C
– Cochrane reports a “sliver of benefit”
– 73% taping for 3 weeks reported improvement (elastic knee
sleeve)
– Price: Low $30
• Acupuncture
– Cochrane January 2010
– Very small improvements in pain and physical function after 8
weeks and 26 weeks
– A lot seems to be placebo effect due to incomplete blinding
– Price: Medium to high, 1000$ over 3-4 months
– Reasonable to offer if patient resistant to conventional treatment
and wants to try alternative therapies
Non-pharmacological Treatment
• Exercise – focus on low load exercise
– Tai Chi
– Yoga
– Swimming
– Biking
– Walking
– Most important aspect to counsel patients for prevention and
treatment
– Cochrane Review 2009 compares efficacy to NSAIDs in short-
term benefits

• Heat and Cold

– Lack of convincing data despite being commonly used
• Penderita dengan keluhan nyeri pada lutut kanan kiri.
• Foto genue Dextra et Sinistra
– Tampak osteofit di eminentia interchondiloidea os tibia
dextra et sinistra.
• Kesan : Osteoarthrosis genue dextra et sinistra
LOW BACK PAIN (Nyeri Pinggang)

• Spondilosis (deg diskus intervertebralis)

• Spondiloartrosis
• Spondilolisthesis
• Instabilitas lumbosacral
• Paraspinal musculospame
• Axial kompressi
• Sacralisasi (seharusnya sacral tumbuh ke ala ossis
sacri, tetapi malah ke promontorium), lumbalisasi,
cauda equina sindrom (pemadatan atau
penyempitan yang simultan dari radik saraf lumbosacral
multipel di bawah konus medullaris)
• Foto Lumbosacral, lateral:
– Tampak osteofit pada corpus V.Lumbales

• Kesan : Spondilosis lumbales

• Kasus : laki-laki 46 tahun
sering merasa nyeri pada
daerah punggung, terutama
bila untuk berdiri, berjalan
atau mengangkat benda
• Foto Lumbalis dengan
myelografi:
– Tampak penyempitan
Ductus intervertebralis
– Tampak listhesis grade II
pada V.L 2 terhadap V.L.3
– Kesan : Spondilolisthesis
grade II V.L.2 terhadap
V.L.3
• Kasus :
– Laki-laki, 52 tahun dengan
nyeri pada punggung yang
dirasasemakin berat,
terutama bila untuk berdiri
atau berjalan
– Riwayat trauma (+)

• Foto lumbosacral, lateral:

– Tampak deformitas
(kompressi dan sclerotic
pada Vertebra Lumbal 3,4)
• Wanita 43 tahun
dengan nyeri pada
panggul
• Foto Lumbosacral AP,
lateral:
– Kompressi V.L.3,4
– Spondilolisthesis V.L.5
terhadap 4
– DIV V.L 3-4, 4-5
menyempit
KESAN : Discitis
lumbales
Penderita laki-laki usia 73 tahun dikirim dengan
cervical syndrome
Foto Cervical, AP, lateral kanan-kiri dan oblique:
-Spondiloarthrosis cerfvicalis
-Spondilolisthesis
Kelainan Bentuk (Deformitas) Vertebra

a. Foto lumbal, AP:

- Scoliosis ringan vertebra lumbalis
- Spondiloarthrosis lumbales
b. Foto Thoracolumbal, AP:
Scoliosis berat vertebra thoracolumbal
 Wassalam
Terimakasih

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