BACK PAIN

Dr. Puji Pinta O. Sinurat, SpS (K)

Dept Neurologi FK-USU MEDAN
2018
 Symptoms :
- Muscle ache or shooting
- Limite range of function
- Inability to stand straight
- The pain may be constant, Intermittent, or only occur with certain
positions or activities
- The pain may remain in one spot or refer or radiate to other areas
- It may be a dull ache or sharp or piercing or burning sensation
- The problem may be in the neck or low back but may radiate into
the leg or foot (SCIATICA), arm or hand.


 Types :
- Acute Vs Chronic
- Lower Back Pain
- Middle Back Pain
- Upper Back Pain
ETIOLOGY OF BACK PAIN
- Infection : (Sacroiliac Infections, Vertebral
Osteomyelitis, Diskitis, Pyelonephritis, Potts
disease, Spinal Epidural Abscess, Psoas Abscess)
- Inflammation
- Mechaical
- Orhtopedic
- Trauma
- Malignancy
- Systemic Disease
- Other
 Risk Factors:
Age : middle age
Sex : male
Family history
Previous : Back injury, surgery
Pregnancy
Congenital spine problems: deformitas (Kyphosis, Lordosis,
Scoliosis)
Lack of exercise
Longterm medicine that weaken bones
Poor posture
Overweight
Stress
smoking
 Nyeri Punggung Bawah (NPB)
=Low Back Pain (LBP)

 Definisi: nyeri yang dirasakan di daerah punggung

bawah, dapat merupakan nyeri lokal maupun nyeri
radikuler atau keduanya

 Nyeri yang berasal dari punggung bawah dapat

direfer ke daerah lain atau sebaliknya  disebut
REFERRED PAIN
 Epidemiologi
Incidens : 60-90% lifetime incidens
5 % annual incidens
90% LBP resolve without treatment within 6-12
weeks
40-50% resolves within 1 week
75% with nerve root involvement can resolve in 6
months
LBP leading cause of disability of adults < 45 yo
Third cause of disability in >45 y o
Differential Diagnosis
- Lumbar strain
- Disc bulge/protrusion/extrusion/producing
radiculopathy
- Degenerative disc disease
- Spinal stenosis
- Spondyloarthropathy
- Spondylosis
- Spondylolisthesis
- Sacro-iliac dysfuntion
Mekanisme timbulnya nyeri pada
vertebra:
1. Iritasi cabang saraf besar yang menuju ekstremitas
2. Iritasi cabang saraf kecil yang mempersarafi vertebra
3. Ketegangan sepasang otot punggung (m.erector spinae)
4. Kerusakan tulang, ligamentum atau sendi
5. Ruang antar vertebra dapat menjadi sumber nyeri
KLASIFIKASI NPB BERDASARKAN
LAMANYA:

1. NPB Akut : < 6 minggu

2. NPB Subakut : 6 -12 minggu
3. NPB Khronik : > 12 minggu
Penyebab NPB
I. MEKANIKAL
* Strain, sprain lumbal
* Proses degeneratif diskus dan facet
* Herniasi diskus
* Stenosis spinal
* Fraktur kompresi osteoporotik
* Spondilolistesis
* Fraktur traumatik
* Penyakit kongenital
II. NON MEKANIKAL
* Neoplasma
* Infeksi : osteomielitis, abses epidural, abses
paraspinal, penyakit Pott
* Artritis inflamatori : Ankylosing spondylitis,
Psoriatic spondylitis, Sindroma Reiter
* Paget’s disease of the bone
Red Flags NPB mengarah kelainan
patologik serius
 Onset > 55 thn
 Riwayat Trauma
 Nyeri konstan progresif dengan berbaring
 Deformitas struktur
 Riwayat keganasan
 Pemakaian steroid lama
 Pemakaian Immunosupresan
 Kelainan neurologik menetap sampai 1 bulan
 Demam
 BB menurun tanpa sebab
Pemeriksaan Vertebra
 INSPEKSI : gaya berjalan, simetri, perilaku penderita
terkait keluhan nyerinya.
 PALPASI : vertebra, kelompok otot paraspinal
 PERKUSI : menilai adanya nyeri tekan
 PEMERIKSAAN UTK MENILAI FUNGSI :
* range of motion
* SLR (Straight Leg Raise) test
* hiperekstensi tungkai
* refleks
* fungsi motorik dan sensorik
Pemeriksaan Penunjang
 NEUROFISIOLOGIK :
- EMG
- somatosensory evoked potential
 RADIOLOGIK :
- foto polos
- mielografi, CT mielografi, CT-scan, MRI
 LABORATORIUM :
- LED, CRP, DL, UL
Indikasi Foto Polos pada NPB
 Usia > 50 tahun
 Defisit motorik (+)
 BB menurun tanpa sebab yg jelas
 Dugaan Ankylosing spondylitis
 Penyalahgunaan obat dan alkohol
 Adanya riwayat kanker
 Suhu > 37,8oC
 Tidak ada perbaikan dalam 1 bulan
 CAUDA EQUINA SYNDROME
 Serious neurologic condition in which damage to
the cauda equina
 Causes acute loss of function of the Lumbar plexus,
nerve roots of the spinal canal below the
termination (conus medullaris) of the spinal cord
 Is a Lower Motor Neuron Lesion
Signs and Symptoms of CES
 Low Back Pain/ Sciatica
Pain start in the buttocks-- travels down the
back of the thighs and legs
 Severe back pain
 Loss of sensation in a saddle distribution over the
genitals, anus and inner thighs (perineal or saddle
paresthesia)
 Bowel and bladder disturbances
 Sexual dysfunction
 Lower extremitiy muscle weakness and loss of
sensation (often paraplegia)
 Lower extremity reflexes : reduced/absent
Causes of CES
 Compression
 Traumatic injury  compression of the cauda
equina
 Disk herniation
 Spinal stenosis
 Spinal tumor
 Inflammatory condition
Management
 Cauda equina syndrome is a surgical emergency
(surgical decompression)
 Treatment underlying causes of CES

Inflammatory process antiinflammatory agent

(ibuprofen, corticosteroid
Infection antibiotics therapy
Physiotherapy and occupational theraphy
Prognosis
 Surgical intervention with decompression  assist
recovery
 50-70% patient have urinary retention
 30-50% incomplete syndrome
 SPONDILOLISTESIS
 Adalah kelainan yang disebabkan perpindahan ke depan satu
corpus vertebra terhadap vertebra di bawahnya.
 Tersering pada L4-5
 Sering pada : orang yang sering angkat beban berat, pemain
sepak bola, trauma
 Pada semua usia, tersering pada usia tua
Gradasi Spondilolistesis
Berdasarkan foto polos lateral, dibagi atas
menurut derajat beratnya pergeseran :
Grade 1 : 25%
Grade 2 : 25-49%
Grade 3 : 50-74%
Grade 4 : 75-99%
Grade 5 : 100% (slip seluruhnya  spondyloptosis)
Terapi Spondilolistesis
 Istirahat
 Hindari angkat berat
 Analgetik, OAINS
 Operasi
 SPONDILOSIS
 Adalah kelainan degeneratif yang menyebabkan hilangnya
struktur dan fungsi normal spinal
 Penyebab utama : proses penuaan
 Lokasi dan percepatan proses degenerasi bersifat individual
Terapi Spondilosis
 Konservatif (75% berhasil), meliputi :
* istirahat
* OAINS
* pelemas otot
* Pemanasan, stimulasi elektrik, lumbosakral
ortotik
* Olah raga
* Modifikasi gaya hidup
 Pembedahan (jarang)
 HERNIA NUKLEUS PULPOSUS
(HNP)
 HNP adalah protrusi atau ekstrusi nukleus pulposus bersama
sebagian annulus fibrosus ke dalam kanalis vertebralis atau
foramen intervertebralis
 Insidens : 1-2 % populasi
 Dapat terjadi dimana saja sepanjang medulla spinalis
 Paling sering di daerah lumbal
Karakteristik HNP Akut
 Umur 30-50 tahun
 Lokasi nyeri : pinggang ke tungkai bawah
 Rasa nyeri : nyeri terbakar, parestesi di tungkai
 Faktor yang memberatkan : meningkat dengan membungkuk
atau duduk, berkurang dengan berdiri
 Tanda klinis : SLR (+), kelemahan, refleks asimetri
Distribusi Lokasi HNP
 HNP lumbalis (paling >>)
L5-S1 (45-50%), L4-5 (40-45%)
ok jaringan fibrokartilagonya terutama di
posterior lebih tipis dibanding diskus
intervertebralis lainnya
 HNP servikalis
C6-7 (69%), C5-6 (19%)
 HNP torakalis (jarang, < 1%)
Gradasi 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.
Diagnosis HNP
Neurological Examination

Lumbar HNP :
* Lasegue (straight leg raising) test.
A positive SLR test is a sensitive indicator of
nerve root irritation (sensitivity 95%).,
May be positive with disc protrussion, intraspinal
tumor or inflammatory radiculopathy
* Crossed Laseque (crossed SLR) test.
Less sensitive but highly specific.
* Femoral stretch (reverse SLR) test.
May detect an L2-4 root or femoral nerve
irritation.
Radiological Examination

 Plain vertebral x-rays :

* limited information
* disc narrowing, scoliosis, lordosis lumbal

 Myelography
 CT or CT-myelography
 MRI : the best imaging study

EMG/NCV : 90% abnormal after 1-2 weeks

Terapi HNP: Conservative
bed rest : max 2 days recommended
* Pharmacotherapy :
- NSAID
- short course of corticosteroid for acute
herniated disc (controversial)
- muscle relaxant
- for neuropathic pain : gabapentin, 5% lidocaine
patch, tramadol, TCA.
* Nonpharmacologic therapy :
- heat, ice, massage, stress reduction, activity
limitation, postural modification, physical
therapy program
- soft cervical collar or lumbar corset
Terapi Operative:
The few absolute indications :
1. Marked muscular weakness pertaining to a nerve
root or roots.
2. Progressive neurologic deficits.
3. Cauda equina syndrome with urinary symptoms
4. Pain that has existed for more than 4 months, has not
responded to conservative treatment, and interferes with
normal function.
 STENOSIS SPINAL
 Adalah penyempitan kanal spinal dengan kompresi akar
saraf, dengan atau tanpa keluhan
 Penyebab yang sering : hypertrophic degenerative dari facet
dan penebalan ligamentum flavum
Karakteristik Stenosis Spinal
 Usia > 50 tahun
 Neurogenic intermittent claudiation or
pseudoclaudication (most frequent)
 Radicular pain is the least common manifestation
 Lokasi nyeri : pinggang sampai tungkai bawah,
seringkali bilateral
 Sifat nyeri : menusuk, seperti menikam, rasa seperti
ditusuk jarum
 Faktor yang memperberat : bertambah bila jalan,
berkurang bila duduk
 Tanda klinis : sedikit penurunan ekstensi vertebra
Terapi Stenosis Spinal
 Analgetik, OAINS
 Terapi fisik
 Injeksi kortikosteroid epidural
 Laminektomi dekompresi
Indication for Surgical Treatment of
Lumbar Spinal Stenosis
1. Severe and disabling pain (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 and bowel, or sexual function.
4. Poor response to at least 4 weeks of conservative
treatment