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W I N D A S E T Y O W U L A N
0 3 0 . 0 9 . 2 6 9
R S U D K O T A B E K A S I
MIELOPATI SERVIKAL
Pembimbing: Dr. Rudy Yunanto, Sp.BS
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PENDAHULUAN
• Cedera medula spinalis→ penyebab utama
disabilitas neurologis akibat trauma
• 10.000 kasus baru per tahun di Amerika (TheNational Spinal Cord Injury Data Research Center )
• Kecelakaan bermotor = penyebab utama!
• Mielopati servikal→ sering pada usia lanjut akibat
stenosis atau spondilosis
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ANATOMI MEDULA SPINALIS
• Terletak di dalamcanalis vertebralis
• 31 segmen:
• 8 servikal
• 12 thorakal
• 5 lumbal• 5 sakral
• 1 koksigeal
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ANATOMI VERTEBRA CERVICAL
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FISIOLOGI MEDULA SPINALIS
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PEMBAHASAN
MIELOPAT I SERVIKAL
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DEFINISI
Gangguan fungsionaldan atau anatomi
dari medula spinalis
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PATOGENESIS
Trauma
vertebra Infeksi Tumor
Kongenital Degenerasi Herniasi
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GEJALA KLINIS
• Penyebab mielopati sulit untuk dideteksi karenaperkembangannya yang lambat dan bertahap
• Gejala dari kompresi yang terjadi*:
*(tergantung segmen yang mengalami kompresi)4/9/2014 [email protected] 17
•Nyeri, parestesi
Gejala sensorik
•Kelumpuhan
Gejala motorik
•Gangguan respirasi, sirkulasi, miksi, dan defekasi
Gejala otonom
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GEJALA KLINIS
• Gejala yg biasanya dirasakan pasien:
• riwayat sakit leher atau punggung yang panjang
• perubahan dalam koordinasi gerak
•
tungkai terasa berat• kesulitan melakukan aktivitas dan tugas yang sebelumnya
mudah
• nyeri atau sensasi tersengat listrik
• paralisis
• baal atau kesemutan anggota gerak
Gejala bersifat akut, subakut, kronik progresif
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GEJALA KLINIS
•Keterampilan menurun (kesulitan
menulis), perubahan sensasi sertakelemahan lengan
Regio C3 – C6
•Sindroma spastisitas dan hilangnyaproprioseptik tungkai
Regio C6 – C8
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PEMERIKSAAN FISIK
• Kelemahan ekstremitas
• Spastic gait
• Status neurologis
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Tanda
UMN
Hipertonus
Hiperrefleks
Klonusankle (+)
Babinski (+)
Hoffman(+)
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KLASIFIKASI
• Berdasarkan ada/tidaknya fungsi yangdipertahankan di bawah lesi
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Karakteristik Lesi Komplit Lesi Inkomplit Motorik Hilang di bawah lesi Sering (+) Protopatik (nyeri, suhu) Hilang di bawah lesi Sering (+) Propioseptik (joint
position, vibrasi) Hilang di bawah lesi Sering (+)
Sacral sparing Negatif Positif Ro vertebra Sering fraktur, luksasi, atau
listesis Sering normal
MRI Hemoragi (54%), kompresi
(25%), kontusi (11%) Edema (62%),
kontusi (26%),
normal (15%)
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KLASIFIKASI
• EuropeanMyelopathy Score
• 17-18 : normal
• 13-16 : grade 1
• 9-12 : grade 2
• 5-8 : grade 3
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Score Definition Gait Function
1
2
3
4
5
Unable to walk, wheelchair
Walking of flat ground only with cane or aid
Climbing stairs only with aid
Gait clumsy, but no aid necessary
Normal walking and climbing stairs Bladder and Bowel Function
1
2
3 Retention, no control over bladder and/or bowel function
Inadequate micturition and urinary frequency
Normal bladder and bowel function Hand Function
1
2
3
4
Handwriting and eating with knife and fork impossible
Handwriting and eating with knife and fork impaired
Handwriting, tying shoelaces or a tie clumsy
Normal handwriting Proprioception and Coordination
1
2
3
Getting dressed only with aid
Getting dressed clumsily and slowly
Getting dressed normally Paraesthesia/Pain
1
2
3
Invalidity due to pain
Endurable paraesthesia and pain
No paraesthesia and pain
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KLASIFIKASI
• Nurick’s Score
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Grade Level of Neurological Involvement Grade I
Grade II
Grade III
Grade IV
Grade V
No difficulty in walking
Mild gait involvement not interfering with employment
Gait abnormality preventing employment
Able to walk only with assistance
Chairbound or bedridden
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PEMERIKSAAN PENUNJANG
Lab darah Rontgen CT scan / MRI
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KRITERIA DIAGNOSIS
Diagnostic Criteria for Cervical Spondylotic Myelopathy Characteristic symptoms (leg stiffness, hand weakness)
Characteristic signs (hyperreflexia, atrophy of hands)
MRI or CT (showing spinal stenosis and cord compression as a result of
osteophyte overgrowth, disc herniation, ligamentum hypertrophy)
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PENATALAKSANAAN
• Tujuan: meningkatkan dan mempertahankan fungsisensoris dan motoris
• Terapi konservatif:
•
Imobilisasi→ soft collar neck• Metilprednisolon high dose
30 mg/kgBB IV dalam 8 jam pertama dilanjutkan 5.4 mg/kgBB/jamselama 23 jam berikutnya
• Simptomatik→ analgetik
• Rehabilitasi medik→ fisioterapi, bladder training• Terapi okupasi→ alat bantu
• Terapi operatif
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PROGNOSIS
• American Spinal Injury Association
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Group A Complete Motor and sensory loss belowthe lesion
Group B Sensory Incomplete Some sensory preservationbelow the zone of injury
Group C Motor Incomplete Motor and sensory sparing, butthe patient is nonfunctional
Group D Motor Incomplete Motor and sensory sparing and
the patient is functional (standsand walks)
Group E Complete functional recovery Reflexes may be abnormal
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PROGNOSIS
• Sebuah penelitian prospektif selama 27 tahunmenunjukkan bahwa rata-rata harapan hiduppasien cedera medula spinalis lebih rendahdisbanding populasi normal. Penurunan rata-ratalama harapan hidup sesuai dengan beratnyacedera. Penyebab kematian utama adalahkomplikasi disabilitas neurologi yaitu: pneumonia,emboli paru, septikemia, dan gagal ginjal.
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DAFTAR PUSTAKA
1. York JE. Approach to the patient with acute nervous system trauma. Best Practice ofMedicine. September 2000.
2. Young W. Spinal cord injury levels and classification. Care Cure Community. Keek Centre forCollaborative Neuroscience. 2002.
3. Hoppenfield S. Orthopaedic neurology: a diagnosis guide to neurologic levels. JB LippincottWilliams. 1977.
4. FSIP. Spinal cord injury facts: statistics. Foundation for Spinal Cord Injury Prevention, Care andCure. 2001.
5. Pinzon R. Mielopati servikal trauma: telaah pustaka terkini. Cermin Dunia Kedokteran 154;2007: 39-42.
6. Hansen JT. Netter’s clinical anatomy. 2nd Ed. Philadelphia; Saunders Elsevier: 2010. p.60-3.7. Sherwood L. Human physiology from cells to systems. 7th Ed. California; Brooks/Cole: 2010.
p.172-7.
8. Klezl Z, Coughlin TA. Cervical myelopathy. 2013. Available at:http://www.boneandjoint.org.uk/content/focus/cervical-myelopathy. Accessed on February19, 2014.
9. Department of Neurosurgery Columbia University. Cervical myelopathy. 2014. Available at:
http://www.columbianeurosurgery.org/conditions/cervical-myelopathy/. Accessed onFebruary 20, 2014.
10. Young W. Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction inolder persons. Am Fam Physician. 2000;62(5):1064-70.
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