Apa diagnosis diferensial nyeri pinggang ?

Differential diagnosis of low back pain

Mechanical (97%) Non mechanical (1%) Visceral disease

(2%)
Lumbar strain/sprain Neoplasia (0.7%) Disease of pelvic
(70%) organ
Degenerative disks and Infection (0.01%) Renal disease
facets (10%)
Herniated disk (4%) Inflammatory arthritis Aortic aneurysm
(0.3%)
Spinal stenosis (3%)
Osteoporotic fr (4%)
Spondylolisthesis (2%)
Traumatic fr (1%)
Congenital disease (1%)
 ‘Red flags’ for possible serious low back pain
consider prompt referral (less than 4 weeks)

HISTORY
• Pain worse at rest or at night
• Prior history of cancer
• History of chronic infection
• History of trauma
• Age <20 or > 55 years
• Duration of pain > 1 month
• Intravenous drug use
• Corticosteroid use
• Change in bladder
habits/urinary retention
EXAMINATION
• Unexplained fever
• Unexplained weight loss
• Straight leg raising sign
• Percussion tenderness over
lower spine or costovertebral
angle, thoracic pain
• Abdominal, rectal, or pelvic
mass
• Focal neurological deficit,
particularly if progressive
 Low Back Pain: What the history suggests
CAUSE ONSET OF PAIN OTHER SYMPTOMS
Spinal stenosis Insidious Pain in either or both lower extremities;
is greater with walking and eases with
sitting
Vertebral stress Acute Pain is usually constant, localized, and
fracture severe; worsen with minimal
movement; often no relief in lying

Metastatic Acute/insidious Night pain and weight loss may be

disease/tumor signs, lying in fetal position does not
provide relief
Infection Acute/insidious Lying in fetal position does not relief;
fever and weight loss often present
Regional back Acute Has a radicular component in 5 to 10%
pain of patients; muscle spasm and
tenderness may be present
Cauda equina Acute Bilateral lower extremity pain,
syndrome unilateral or bilateral siatica, and
urinary retention
 Penatalaksanaan Pasien Nyeri Pinggang

Risiko rendah Risiko sedang Risiko tinggi

Faktor risiko + , pemeriksaan Tanda korda atau Cauda equina
normal Atau Ada panas dan dugaan abses
Atau faktor risiko +,pemeriksaan: epidural atau hematoma
lesi pleksus atau akar saraf Atau Retensi urin

Tidak perlu
pemeriksaan Urgen MRI
radiologi (< 24 jam)

Emergensi MRI
MRI negatif. MRI positif (dalam beberapa jam)
Follow-up; Terapi dan
Konsultasi Konsultasi

Edukasi pasien
Penjelasan, penentraman
Prognosis baik MRI (atau radiologi lain) MRI (atau radiologi lain)
negatif. positif.
Terapi analgesik non-narkotik, Konsultasi untuk Terapi dan Konsultasi
muscle relaxant Menentukan etiologi yang sesuai untuk
Pertimbangkan terapi fisik diagnosis
panas, dingin Follow-up
 Common messages of most international
guidelines : Recommendations for assessment

• Diagnostic triage ( nonspecific LBP, radicular

syndrome, serious pathology)
• History taking and physical examination to exclude
”red flags”
• Physical examination for neurological screening
( including SLR test)
• Consider psychosocial factors if there is no
improvement
• X rays and MRI are not useful for nonspecific LBP
Kasus 1.
Seorang pria,56 tahun, BMI 20.1 kg/m2,tambah kurus
mengeluh nyeri pinggang yang menjalar ke paha dan nyeri
tulang-tulang sejak 3 bulan yl, nyeri lebih terasa waktu tidur.

Apakah nyeri pinggang pasien serius?

Apa rencana selanjutnya?
 The plan

• Identifying neurologic abnormalities, signs of

serious low back pain and signs of systemic
disease
• Plain radiography
• Immediate additional imaging studies in cauda
equina syndrome, a progressive neurologic
deficit, tumor or infection
Pada pemeriksaan laboratorium ditemukan Hb 8.6
g/dl dan BUN 69 mg/dl.
Hasil radiografi seperti berikut.
Apa diagnosis pasien ?
Kasus 2

Seorang pria,36 tahun, BMI 27.6 kg/m2, mengeluh nyeri

pinggang yang kadang-kadang menjalar ke paha sejak 1
bulan yl, hilang timbul tak menentu terutama kalau
bergerak. Tak ada riwayat penyakit lain.
Apa rencananya?
The plan

Identifying neurologic abnormalities, signs

of serious low back pain and signs of
systemic disease
 Diagnosis ?
• Presentation between ages 20 - 55
• Lumbosacral, buttocks and thighs
• Pain ‘Mechanical’ in nature
– varies with physical activity
– varies with time
• Patient well

Diagnosis : Simple backache:

Is radiography of vertebra useful?
What is the prognosis ?
Features of non-specific ‘mechanical’/simple LBP

Site (one or more of the following) Character

• Discomfort across lower back • Episodic or cyclical pain in the

• Central pain, usually over L5
• Leg pain and/or paraesthesia
within ‘sciatic’ distribution
• Uni or bilateral buttock or
lateral back pain
• Presentation : ages 20 - 55
middle years of life
• Arises from L3-S1
• Early morning stiffness/pain
eases when up and
• Relationship to posture
 Prognosis : Simple backache:
• prognosis good
• 90% recover from acute attack in 6 weeks
 Kasus 3

• Seorang pria,42 thn, BMI 29.4 kg/m2,mengeluh nyeri paha

kanan bagian belakang dan pantat. Nyeri menyebar ke
tungkai kanan bawah disertai rasa kesemutan. Tes SLR
positiv.
• Apa kemungkinan diagosis yang paling mendekati ?
• Apa rencananya ?
• Unilateral leg pain worse than LBP
• Pain generally radiates to foot or toes
• Numbness & paraesthesia in the same distribution
• Nerve irritation signs
– reduced SLR which reproduces leg pain
• Localized neurological signs

Nerve root pain

Bagaimana prognosis pasien ?
 Nerve root pain

• Prognosis reasonable
• 50% recover from acute attack within 6 weeks
Kasus 4

• Pasien pria,25 tahun, BMI 24.3 kg/m2 mengeluh

nyeri sejak kurang lebih 6 bulan yl
• Nyeri dan kekakuan tulang belakang berkurang
dengan aktivitas
• Sering mengeluh nyeri tumit juga
• Schober tes positiv
• Apa kemungkinan diagnosisnya?
• Younger age at onset of pain (peak 26 years)
• Pain and early morning stiffness of the spine
• Improvement with exercise / activity
• Insidious in onset
• Symptoms lasting longer than 3 months
• Spinal mobility and deep breathing may be
restricted

Inflammatory back pain

Pemeriksaan fisik
Hasil pemeriksaan radiographi seperti berikut
 Spondyloarthropathies
AS Ps A Re A Ent A
Frequency 0.1% 0.1% 0.05% 0.05%
M:F 3:1 1:1 9:1 1:1
Axial arthritis 100% 20% 20% 15%
Sacroiliitis Bilateral Unilateral Unilateral Bilateral
Peripheral artrhitis 25% 60-95% 90% 20%
Uveitis 30% 15% 15-20% - 5%
Dactylitis Uncommon -25% 30-50% Uncommon
Cutaneous None spec Psoriasis Oral Erythema
Onycholisis ulceration nodosum
Nail pitting Keratoderm Pyoderma
blenorrhag. gangren.

HLA B27 positive 90% 40-50% 50-90% 30-50%

 AS : modified New York criteria
• Low back pain of ≥ 3 months’ duration improved by
exercise and not relieved by rest
• Limitation of lumbar spine in sagital and frontal
planes
• Chest expansion decreased relative to normal values
for age and sex
• Bilateral sacroilitis, grade 2-4
• Unilateral sacroilitis, grade 3-4

• Definite AS if unilateral grade 3 or 4 bilateral grade 2-1 sacroilitis and

any clinical criteria
Management
 Management of Low Back Pain
• No single form of therapy is effective for all forms of
low back pain
• The vast majority of patients have low back pain on
mechanical basic
• In most circumstance, the mechanical disorder
causing the symptoms cannot be identified
• Only 1 – 2% of patients with low back pain will
undergo lumbar spine surgery
General approach to management of LBP

Phase Resolve at 6 Approach

months
Acute > 95% Usual activities
( 0- 4 weeks) Minimal tests and intervention
Address risk factors for
recurrence

Subacute 70% Above plus intensive physical

(4-12 weeks) therapy to strengthen and
recondition
Work conditioning

Chronic <50% Above plus multidisciplinary

( > 12 weeks) functional restoration program
 European spondyloathropathy study
group criteria
1. Inflammatory spinal pain
2. Synovitis (symmetric or predominantly lower limbs)
One or more of the following (in addition to criterion 1 or
2) :
# Alternate buttock pain
# Sacroiliitis
# Positive family history
# Psoriasis
# IBD
# Urethritis / cervicitis / diarrhea < 1 month prior
 Radiography ?
• Plain radiography is rarely useful (except in
suspect of tumor, infection, fracture,
spondylolisthesis or sacroiliitis)
• Immediate additional imaging studies in cauda
equina syndrome, a progressive neurologic
deficit, tumor or infection