Assalamualikum.......

PLENO PERCENTATION BY :

Among Others :

Muh. Deriyatmiko Novita Rahmawati Ninda Astari Muh. Barkah Rahmania Noor Adibah Imelda Mayasari Purba Yanwar Adi Nugraha Dwi Retno Nurhayati Azmi Rahmatullah Assiraj Reni Dian Riani Eka Putri Gladys Dwiani Tinovella T

Scenario....
A man 40 years old work such as farmer, feel paraparesis since 6 month ago. Beginning only in right foot, but after 1 week he feel paralyzed in his left foot.1 month before he feel paraparesis, he feel pain in vertebra with circle in abdomen. At examination by doctor, knows subfebris.

Key Words...

Paraparesis

Subfebris

.....................................

Questions....
Why paraparesis can happen in he foot? What caused of Subfebris? Explain anatomi of spinal cord? Explain fisiology of spinal cord? Explain neuroanatomy of spinal cord? What caused of paraparesis?

Explain relationship between pain in vertebra and paraparesis!

Mention differential diagnosis about this scenario!

Neuroanatomy in Spinal Cord

SPINAL CORD .....

terletak dalam canalis vertebralis (pinggir bawah tengkorak

yang ada lubangnya) (tulang bersifat panjang, ms menyambung dg medula oblongata) (medula spinalis hanya mengisi 1/3 bagian atas)

hanya mengisi 2/3 bagian atas ASCENSUS MEDULLAE ujung caudalnya pada level Vert. L1 2 / L2 SEGMEN MEDULLA SPINALIS :
o Ada 31 segmen medulla spinalis (8 Cervicalis + 12 Thoracalis +

5 Lumbalis + 5 Sacralis + 1 Coccygeus) o Segmen Cervicalis level For.occ.Magnum s/d V.C7

o Segmen Thoracalis level V.T1-10
(kalo tjd luka tembak pada L3, tdk ada MS yg rusak) (kalo ada luka tajam pd T10, maka yang kena adl segmen MS T12)

o Segmen Lumbalis level T10 T12 o Segmen Sacralis + Coccygeus level L1 L2

STRUKTUR DALAM MS

Struktur dalam MS terdiri dari :

o Canalis Centralis (pada bagian central) Berisi LCS Ke cranial bermuara/berhubungan dgn Ventriculus Quartus Ke caudal Buntu Ventriculus Terminalis
o Massa jaringan syaraf (di perifer), td : SUBSTANTIA ALBA (superficial) SUBSTANTIA GRISEA (profunda)

SUBSTANTIA GRISEA MS
o Suatu kumpulan Badan Sel Neuron
o Terdapat :
Commissura Grisea Ant + Post Cornu / columna Ant + Post pada segmen T, L, S Cornu /col. Lat

o Dari Cornu Post Cornu Ant 9 lamina (I-IX) o Khusus Cornu Post dikenal struktur :
SUBSTANTIA GELATINOSA ROLANDI
NUCLEUS PROPRIUS NUCLEUS DORSALIS CLARKI

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SUBSTANTIA ALBA MS
o Suatu kumpulan serabut saraf (Axon dan

Dendrit) yang Ascendens dan Descendens dalam Funiculus Ant, Lat, Post. o Makin ke cranial makin luas serabut Ascendens > Descendens

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Fisiology
Otak
SSP

Medula Spinalis

Divisi Aferen

SST

Divisi Eferen
Somatik Otonom Parasimpatis

Stimulation Sensorik

Motorik Otot Rangka

Simpatis

Otot Jantung, Kelenjar

UMN
All neuron channelling impulse motorik directly to LMN or through interneuronnya included in . the group UMN. Pursuant to difference of anatomik and fisiologik of group UMN divided into formation of piramidal and ekstrapiramidal.

Sign if there UMN Lession:

high Tonus muscle or hipertonia 2. Hipereflexia 3. Klonus 4. Patologik Reflex 5. There no atrofi at palsied muscle. 6. Refleks automatisme spinal
1.

LMN
Neuron-Neuron channelling impulse motorik at last transportation; journey shares to cell of muscle skeletal referred by Lower of motor neuron. LMN by akson is named ' final of common path' impulse motorik. LMN compile the nucleus;core of nerve of brain of motorik and nucleus;core of radiks ventralis of nerve spinal.

If there Lession in LMN:

a) All movement, both for voluntar and also which reflektorik cannot be awakened. This means that paralysis accompanied by - loss of refleks tendon ( arefleksia inexistence of refleks patologik) b) because that lesion LMN, hence part of tortous eferen of refleks, following gamma loop, do not function again, so that tonus muscle lose annihilate

C) Its his motoneuron of following by akson mean also that union motorik collapse so that atrofi muscle is quickly happened.

Meaning of Paraparesis

Paraparesis is Partial Paralisis under eksteremitas . (Dorland) Paralisis adalah malfunction of motorik because lesion nerve mechanism saraf.
(Dorland)

Paraparesis adalah lesi in spinal cord in torakal to under. (Diktat Kuliah dr. Kurnia Bintang)

....Caused of Paraparesis....
Paraparesis is a symptom because damage of motoneuron with caused by lesi. Lesi can happen because :
Trauma Spinalis Cord Tumor Spinalis Cord Infection, good infection by bactery although

virus on Spinal Cord Defitient from nutrition

Patomekanisme paraparesis
Lesion in medulla spinalis Effected to nerve

Nerve havnt O2 from vassel

Nerve bind

Paraparesis

Mechanism of fever :
Infeksi atau peradangan
+

Neutrofil
mengeluarkan

Pirogen Endogen
+

Prostaglandin

Titik Patokan suhu hipotalamus

Mengawali respon dingin

Produksi Panas

Produksi Panas

Suhu tubuh ke titik patokan yang baru = fever

Mechanism of Paraparesis
Lesi/compressi on T12-L4 medula spinalis press the nerves near it Nerves become damage inhibit passing the impuls

Effect the moving

Pain on lumbal To abdomen

Paraparesis at both of feet

Widespread to feet

Why paraparesis widespread to the left leg after one week?

Because compressi of medula spinalis on T12-L4 press the radix, but the right radix has pressed firstly so the right leg feels paraparesis, then the left leg feels parapaaresis too. It takes one week because this process is chronic, so it takes many times to make paraparesis.And this paraparesis has the character of late progressive.

Neuromuscular Junction........

Relation pain in vertebra with paraparesis

TRAUMA

LETION

PAIN

T4 L1

LATERAL MEDIAL EXTREMITAS INFERIOR

SPREAD TO STOMACH

IMPULS NERVE

PARAPARESIS

Relationship between age, sex and work.......

Age : 60% < 20 tahun, with old age

Sex : male = female, but more like in male Occupation : trauma, economy and working around

SPONDILITIS TBC
DEFINITION:
Spondilitis TBC is a infection disease caused by mycobacterium tuberculosis Etiology: Caused by mycobacterium tuberculosis. Spread through sufferers cough, sneeze, sputum (droplet) or speak that released to air. Mycrobacterium get into humans respiration

Epidemiology:
Male > Female Adult > children Can cause death The most in develop state Eight million society in the world attacked TB with death 3

million every year (WHO, 1993)

Pathogenesis:
Basil TB get into human trough tractus respiratorius primer infection basilemia can caught in lungs, liver, spleen and bone 8 weeks more appear imunologic respon focus experience cellular reaction inactive or heal

Basil TB attack corpus vertebrae corpus vertebrae broken discus intervertebralis become sekuesterisasi abscess paravertebralis columna anterior vertebrae colaps gibbus

Clinical Manifestation:
- Subfebris fever - fever is experienced at night with sweat - Weight - Desire to eat - Weak body - Pain vertebrae - Pain radicular that surround chest or stomach followed paraparesis - Sometimes influenza - Cought > 3 weeks (can be participated blood) - Malaise

Examination:
1. Anamnesis 2. Physical examination Pathologic Reflex: Babinski 3. Support examination - Torax Photo and Photo AP-Lateral - CT Scan - MRI - Mielograph - Laboratory examination: LED Tubeculin test Lumbal punction

THERAPY:
Antituberculosis

- Isoniasid
- Rifamisin - Pirasinamid - Streptomisin - Etambulol

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Differential diagnosis
mielitis
D E F E N I s I E P I D E M I O L O G I

Trauma medula spinalis

Trauma medulla spinalis is trauma in vertebrae,there are fraktur in vertebrae ,ligamentum longitudainalis posterior and duramater can torn,and can stick canalis vertebralis, arteri and venous

Mielitis is inflamation proses wich attack substansia alba and substansia glriseria medulla spinalis. Transversal spread. Contains of acute,subacute and kronic Happen in development country

AS Database report that happen 11 thousand case every years. trauma medulla spinalis in AS is 247 thousand people.

 found 90% in child < 5 years old while in > 6 years old found seldom

E T I O L O G y

substansia griseria that infection is called poliomyelitis, and if infected substansia alba is called leukomielitis

Fraktur vertebrae happened cause hiperflexion, hiperekstention, compression, or vertebrae rotation ,and accident.

Ruptur in one of or some of vertebrae discus Secunder abnormality in bone marrow Infection and tumor Abnormality blood vessel (malformation arteriveniosa )
P A T O G E N I S I S

Virus enter to body via mouth and than reproduction in tonsil and enter intestine and brought by blood to all of the body which will cause sick but if virus brought direct by blood to nervus system cause paralysis

In normal medulla spinalis protect by kolumna spinalis that have structure like bone but because something so that happened pressure to medulla spinalisand disturb normal function.

Effect of medulla spinalis pressure ,motoric nerve corticospinal,ascending dorsal which bring sensation vibration and ipsilateral posision which crossing above medulla spinalis is disturb too. Spinothalamic which send temperature sensasion and touchn sensasion from contralateral side body

Gamb aran klinik

Flu ( headache, fever, malaise, influenza, mialgia ) atau faringitis , gastroenteritis ( vommiting nausea, kontsipasion,diare and anoreksia).

Symptoms depend of location Weakness and loss of sensation Paresis in some day or week

examina Lumbal pungsi tion rontgen of columna vertebralis and thorac CT-Scan and MRI

Anamnenis phisic examination support examination laboratoryum examination CT Scan MRI Biopsi Angiography Mielogram

therapy

glukokortikoid prednisone oral 1 mg/kg bw/hari

Therapy depend of cause infeksion antibiotic.

 unknown cause antiotic Inflamation combination between penisilin and kloramfenikol.

happened abses throw pussh kortikosteroid. surgery.

Refferent.....
Mardjono,Mahar,dkk.Neurologi Klinik Dasar.Dian Rakyat.2008. Duus,Peter.Neurology.

M.Noor,Busjra.Diktat Kuliah Fisiologi.2008.

Harsono. Kapita Selekta Neurologi. Yogyakarta: Gadjah Mada University Press.2007.

Mardjono, Mahar dan Priguna Sidharta. Neurologi Klinis Dasar.

Jakarta: DIAN Rakyat. 1988. Price, Sylvia A dan Wilson, Lorraine M. Patofisiologi Konsep Klinis Proses-proses Penyakit. Edisi 6. Volume 2. Jakarta: EGC. 2005.

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And......
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Wassalam....

Thanks For Attention