Supporting

dr. Esdras Ardi Pramudita

Definisi
Spondylodiscitis (vertebral osteomyelitis):
Infeksi pada diskus intervertebralis dan
korpus vertebra

UTI, prostatitis, endocarditis, inf paru, Inf kulit

Staphylococcus aureus, Mycobacterium

tuberculosis.

Genta, 2000
Potts paraplegia

Kelemahan anggota gerak yang

disebabkan oleh Penekanan Medula
spinalis yang terjadi pada berbagai fase
TB vertebra, akibat kompresi dari proses
inflamasi ( abses, massa kaseosa,
granulasi, sekuestrasi DIV) atau
penekanan oleh karena sekuestrasi
tulang atau jaringan fibrous.
Tuberkulosa
Micobacterium Tb
aerob
Bacillus (rod-shaped)
Non-spora
Non-motil
Cell wall mycolic acid tahan asam
Kultur tumbuh dalam 3-8 minggu pada media padat
Inkubasi 4 8 mg ( inf komplx primer )

Hart, 2008
 Epidemiologi

Indonesia Populasi TB terbesar ke 3

(China & India)

Extrapulmonary TB: 17,9-19,4% all Tb

case

TB sendi/tulang 7% Extrapulmonary
TB

Vert Thoracal >> 71% ( RSCM, 2002 )

Epidemiologi Spinal piogenik
Male : female 3 : 1
Usia rata - rata 46 th
Most common pathogen: Staphylococcus
aureus (> 50% of all spinal infection; 75 %
of all positive culture)

Hematogenous Pyogenic Spinal Infections and Their Surgical Management. Spine.

25(13):1668-1679, July 1, 2000.
 Etiologi

Hematogenous Pyogenic Spinal Infections and Their Surgical Management. Spine.

25(13):1668-1679, July 1, 2000.
Etiologi
Diagnosis ( gejala klinis )

Pucat / anemia
Lemah
berdebar debar
Nafsu makan berkurang
Penurunan BB
Keringat malam hari
Demam subfebril
Diagnosis ( Tanda lokal )

ROM terbatas
Stiffness

Fase awal: gerakan terbatas

Fase akhir: fibrosis ankylosis
Deformitas: Kerusakan tulang,

gibbus, kyphosis
Pott`s paraplegia
Diagnosis ( Tanda lokal )

Atrofi otot
Spasm otot
Pembengkakan sendi
Cold abscess formed
Nyeri ( mild pain ) sendi terutama saat
digerakkan
Sinus atau fistula
Diagnosis

Gejala >>: Nyeri tidak berkurang

dengan istirahat
Keluhan lain: Demam (minimal or -),
menggigil, berkeringat, anoreksia
Dx spondilitis tb

Bila klinis dijumpai :

- Nyeri punggung
- Kifosis / gibbus kemungkinan TBC
- Paraparesis

Bila Ro didapatkan :
- Destruksi korpus vertebra
menguatkan
- Paravertebral abses TBC

Strikland, 1991
Laboratorium
Lekosit , lymfositosis
Erythrocyte Sedimentation Rate (ESR) (active
stage) bila perbaikan/respon thd OAT
CRP
Tuberculin purified protein derivative (PPD)
history of expossure
Mantoux test
Sputum BTA TB paru aktif
Gold Dx: Kultur spinal lesion biopsy
Lab sample
Sputum
Bronchoscopic alveolar lavage
Biopsi pleura
Cairan pleura
nnll
aspirasi abses
Biopsi mesenteric
bone marrow
Otopsi
Plain Radiology
DIV menipis / menyempit
Penipisan korpus vert
Kerusakan corpus vert
Pembentukan formasi

tulang baru
Vertebral collaps
Paraspinal abscess
Soft tissue abscess
Plain Radiology

Plain film:
Dini DIV collapse
end plate mottling
Akhir - Destruksi korpus vert
anterior
- Korpus vert collapse
- Progressive kyphosis
CT Scan

Kerusakan korpus vert

Soft tissue changes
Guidance of biopsy and in the planning of
operative procedures
MRI

Dx massa / penyebaran TB pada

ligamentum anterior / posterior
MRI

T2: Increase T1: Decreased

signal signal
MRI

Burrill, 2007
 Patofisiologi
MTb inhalasi

alveoli Multiplikasi

M MTb Hematogen
limfogen

MTb dlm m / granuloma

organ

dormant Khazindr, 2001

Patofisiologi
Pathogens via hematogen cartilaginous
endplate (end arteri) diskus berdampingan
(avascular) korpus vertebral yang berdekatan

Nutritional vessels

CAMPBELLS 9th edition page 3094

 Pathogenesis kyphosis

M. Tuberculosis

Anteroinferor

Anteror longitudinal ligament

kyphosis

Anterior spinal compression

Neurological sequelae
Patofisiologi

Proses hematogen Batson flexus

Anterior korpus vertebra & DIV

( jarang pada posterior vert )

Demineralisasi korpus
Vertebra collaps dan anterior wedging
Kyphosis, gibbus (+)

Burrill, 2007
Neurologic injury
Neurologic injury (12-50% kasus) disebabkan
oleh:

Tekanan abses paraspinal

Vaskulitis dengan trombosis pada pem-da spinal
Kompresi MS karena vertebra yang kolaps
Jepitan pada radiks
 Extrinsic compression

Venous out flow obstruction Mechanical injury / compression

Hypoxia PGE2

Vasogenic edema

Capillary blood flow

Ischemia

Cytotoxic edema
Neuronal death
Paraplegia
Predisposing factors

Diet inadekuat
Kelelahan
Sanitasi yang buruk
Malnutrisi
immunocompromised
Medical conditions that increase
risk for active TB:
Chronic renal failure
Diabetes mellitus

Silicosis

Leukemias/lymphomas

Carcinoma of the head/neck or lung

Weight loss > 10% of ideal body weight

Gastrectomy/jejunoileal bypass
Predisposing factors

GU tract,
subcutaneous
tissue, respiratory
tract are most often
Tipe Spondilitis TB

1) Edge type (Intervertebral type)

dewasa >>
2)Central type infeksi mulai dari
tengah korpus vert
3)Subperiosteal type
Komplikasi
Manajemen general care

Absolute bed rest

Sanatorium
Imobilisasi
Fisioterapi
Nutrisi
Antibiotik
Operasi

McKendrick, 2003
Terapi TB aktif

2 bulan pertama:
INH 300 mg
Rifampin 600 mg
PZA 15-30 mg/kg
Ethambutol 15-25 mg/kg atau

Streptomycin 15 mg/kg
4 bulan berikutnya:
INH dan rifampin
Manajemen

BTS guidelines 1999

NICE guidelines 2006

Sensitive
TB 4 drugs for 2 months
2 drugs for 4 months

Resistant TB 6 drugs for 24 months

McKendrick, 2003
Kategori I : - TB paru baru dengan BTA (+)
- TB paru BTA (-), R (+) yang sakit berat
- TB ekstra paru berat
(meningitis, milier, perikarditis, peritonitis,
pleuritis eksudativa dupleks, tulang belakang,
usus, sal. Kencing, alat kelamin)

Kategori II : - Kambuh (relaps)

- Tx gagal
- Tx lalai

Kategori III : - Os baru BTA (-) & R (+) dgn sakit ringan
- Os ekstra paru ringan
(kel limfe, pleuritis eksudatif unilateral, tulang
kecuali tl belakang, sendi, kel. adrenal)
 DEPARTEMEN KESEHATAN

TERAPI TUBERKULOSA

KATEGORI I : 2RHZE (2 bln stp hari) / 4H3R3 (4 bln

seminggu 3x)

KATEGORI II : 2HRZES / HRZE / 5H3R3E3

KATEGORI III: 2HRZ / 4H3R3

H : INH; R:Rifampicin; Z:Pirazinamid; S:Streptomycin

OAT kategori 1
OAT kategori 2
OAT kategori 3
Karakteristik OAT

Isoniazid
- Bakterisid
- membunuh 90% kuman aktif
- do harian 5 mg/kg BB
- do intermiten 10 mg/kg BB
Rifampisin
- Bakterisid
- Membunuh kuman dormant
- do harian / intermiten 10 mg/ kg BB
Pedoman Nasional TB, 2002
Karakteristik OAT
Pirazinamid
- Bakterisid
- Membunuh kuman dalam keadaan asam
- do harian 25 mg/kg BB
- do intermiten 35 mg/ kg BB
Streptomisin
- Bakterisid
- do harian 15 mg/kg BB
- do intermiten 0,75 mg/ kg BB
Pedoman Nasional TB, 2002
Karakteristik OAT

Etambutol
- Bakteriostatik
- do harian 15 mg/kg BB
- do intermiten 30 mg/ kg BB

Pedoman Nasional TB, 2002

ESO
INH:
Abdominal pain, nausea, vomiting
Dark urine
Icterus

Easy bruising/bleeding

Arthralgias

Rash

Paresthesias/weakness peripheral neuropathy is

less likely with pyridoxine

Anorexia/fatigue
ESO
Rifampin:
Ggn GI
Thrombocytopenia
Hepatitis
Flu-like syndrome
Multiple drug interactions
Orange bodily secretions due to excretion
ESO
PZA:
Ggn GI
Hepatitis
Arthralgia
Hyperuricemia acute gout uncommon

Ethambutol:
Optic neuritis: reversible decreased red-green color perception and
visual acuity
Not hepatotoxic

Streptomisin:
Ggn N. VIII, Ggn keseimbangan dan pendengaran
Steroids for TB Patients
(Pedoman Nasional Penanggulangan TB,2003)

Meningitis
MillierTB
Pleuritis exudativa TB
Pericarditis constrictiva
Keadaan umum yang berat.

Dosis:30-40 mg/daily,tapering off 5-10 mg

Problem terapi TB

Toksisitas
Multi terapi
Tx jangka panjang
Drug interactions e.g. anti HIV

McKendrick, 2003
New affordable therapy for TB

Moxifloxacin
TMC 207
OPC-67683
PA-824
LL3858

McKendrick, 2003
Manajemen

Indikasi Operasi:

1. Kegagalan tx Antibiotik
2. Progressive vertebral body collapse
3. Deformitas
4. Defisit neurologis, terutama dengan
epidural abscess
 Ambulatori awal

Hospitalisation time <<

Keuntungan Tx Bedah
recovery neurologis lebih aw

pemburukan kifosis lbh sedik

koreksi kifosis

Teknik operasi : pendekatan anterior + grafting

tulang
Pada akhir follow up hasil terapi sama
Komplikasi bedah 1 Pasien: pendekatan
anterior+posterior
teratasi recovery dalam 3 bulan
Rekomendasi terapi bedah pendekatan anterior
Stabilisasi

Sobottke, R; Seifert, H; Ftkenheuer,

G; Schmidt, M; Gomann, A; Eysel, P
Current Diagnosis and Treatment
of Spondylodiscitis
Dtsch Arztebl Int 2008; 105(10): 181-
7, DOI: 10.3238/arztebl.2008.0181
Stabilisasi

Bhojraj, 2002
Prognosis

Penyembuhan bergantung durasi &

berat gangguan. Ggn otonom prog<<.
Rychlicki, 1999 40 ps op + kompresi
MS >> cepat baik.
Achruri, 1997 7 psn post op +
immobilisasi korset + OAT 100 %
ber(-)
Abses

Epidural abses

Presakral abses
Cold abses etio

C1-2 retropharyngeal abscess

C3-T2 sternum abscess---tetraplagia
T3-T11 paraspinal abscess
T12-L4 psoas abscess-femoral triangle.
Abscess
in the groin is present, reciprocal
fluctuation may felt
Efusi Pleura

Efusi terdapat pada 1 dari 4 pasien

TB
Efusi muncul 3 7 bln setelah
paparan
Unilateral
Manifestasi dari TB >>

Burrill, 2007
 Tubercles Meningitis
Tubercle bacilli from pulmonary focus milliary spread
leading to tuberculoma
Clinically

- Gradual onset of irritability, progressive headach,

anorexia followed by vomiting and seizure
- Behavioural changes common in elderly
- With progression of disease nuchal rigidity and cranial
nerves palsies
- Evidance of TB else where or past medical history of TB

Vento, 2007
 TB Meningitis cont.
Investigations
Chest Xry may be +ve for TB
Tuberculin test may be +ve
CSF finding: yellow color, increase
pressure, high protein, low glucose,
WBC 100 500 cells predominantly
lymphocyte
CT scan of head hydrocephalus

Vento, 2007
Vento, 2007
 TB meningitis cont.
Nonenhanced CT scan
shows hydrocephalus and
ependymal calcification
(arrow), which represent
sequelae of tuberculosis.
A chronic infarct of the
internal capsule
secondary to prior
tuberculous arteritis is
also shown (arrowhead).

Vento, 2007
 TB meningitis cont.
Differential diagnosis
fungal infection
neurosyphilis
Complications
seizure
cranial nerves palsies
Therapy
- same regimen for pulmonary
tuberculosis but longer duration 1 year
- Ethambutol
variable penetration into CSF -
Corticosteroid Dexamethasone 0.15mg/kg/d, 1
2 weeks then taper over 4 weeks
- supportive as indicated Vento, 2007
 Intestinal tuberculosis
Common in developing countries
Caused by both mycobacterium TB and
Bovis
< 50%of patients have active pulmonary
TB
Commonest site is the ileocecal region

Vento, 2007
 Intestinal TB cont.
Pathologically
mucosal ulceration scaring fibrosis with
narrowing of the lumen
Clinically Chronic
abdominal pain Obstructive
symptoms Weight loss
Low grade fever
Abdominal mass may be palpable
Fistula formation may be seen
Bacterial over growth with malabsorption

Vento, 2007
 Intestinal TB cont.
Differential diagnosis
Inflamatory bowel disease
Intestinal amoebiasis Carcinoma
of colon
Investigations
Chest Xry may be normal or show old TB or active TB
PPD skin test may be ve
Double cotrast barium enema mucosal
ulceration, mucosal thickening or stricture formation
Diagnosis is established by endoscopic or surgical
biopsy AFB or granulomas
Therapy
standered anti TB is effective
Vento, 2007
 Intestinal TB cont.
Ileocecal tuberculosis
in a 51-year-old man.
Anteroposterior image
from an enteroclysis
study shows thickened
folds in the cecum and
an irregular cecal
contour.

Vento, 2007
 Intestinal TB cont.
CT scan shows minimal
thickening of the cecum
with pericecal
inflammatory changes.
Mesenteric lymph nodes
are also evident (arrows).

Vento, 2007
 TB Lymphadenitis
Is relatively common disorder
Clinically present as a neck mass,
persistant adenopathy which may be fixed
with or without external drainage
Usually no constitutional symptoms
Pulmonary TB may be absent

Vento, 2007
 TB lymphadenitis cont.
Differential diagnosis
Atypical mycobacterium adenitis Staph.
Areus Sarcoidosis
Cat-scratch fever
Diagnosis fine
needle aspiration granulomatous origin. Acid fast
staining if ve aspirate for PCR
Therapy
four anti TB drugs for 2 months, then 2 drugs (INH
& Rifampcin) for 4 months more

Vento, 2007
 TB Pericarditis
Is caused by direct lymphatic or hematogenous spread
pulmonary TB is commonly absent but pleural
effusion is common
Clinically Subacute,
low grade fever, night sweating, fatigue, FUO
Pericardial effusion if large tamponade
Diagnosis
Pericardiocentesis for AFB yield is low Pericardial
biopsy high yield Pericardiectomy may be
needed for both diagnosis and theraptic reasons
Therapy
Anti TB for 9 12 months + steroid

Vento, 2007

TB Peritonitis
Relatively common in developing countries Common in HIV patients
Clinically
Non specific low grade fever, weight loss and abdominal pain with
distension then ascitis in > 95%
Investigations
Ascitic aspiration protein>2.5g/dl,
LDH> 90 units/l, mononuclear leukocytosis > 500
This give 70 80% sensitivity, but non
specific Sensitivity decline with liver cirrhosis
Smear for acid fast bacilli is rarely +ve
Peritoneal culture in only 20% (4-6 wks )
Laparoscopy definitive test for diagnosis > 90%
characteristic peritoneal nodules are visible, granuloma is seen in
peritoneal biopsy
PPD skin test +ve in 50%
CXR is abnormal in 70 80% of patients
Therapy
Ant TB medication up to one year
Vento, 2007
 TB peritonitis
Peritoneal tuberculosis (wet
type) in a 27-year-old woman
with ileocecal tuberculosis.
CT scan shows a high-
attenuation, loculated fluid
collection and mesenteric
lymph nodes (arrow) with fine
nodular irregularity of the
mesenteric surface. Marked
thickening of the cecum and
terminal ileum is also shown.
The diagnosis was confirmed
with culture of peritoneal fluid.

Vento, 2007
 Renal TB
Microscopic pyuria without bacteruria and
with or without hematouria
Progression of the disease urine culture
may be +ve for tubercle bacilli
Cavitation of renal parenchyma may be
seen
Standered anti TB therapy

Vento, 2007
Vento, 2007
 Ovarian TB
Fallopian tubes are affected in 94% of
women with genital tuberculosis. Salpingitis
caused by hematogenous dissemination is
almost always bilateral
A tubo-ovarian abscess that extends through
the peritoneum into the extraperitoneal
compartment suggests tuberculosis

Vento, 2007
 Ovarian
Tuberculous tubo-ovarian
TB
Tuberculous tubo-ovarian
abscess in a 21-year-old
woman with lower
abdominal pain and fever.
(a) Contrast-enhanced CT
scan shows a multiloculated
mass with peripheral
enhancement around
centers of low, soft-tissue
attenuation. The lesion
extends to the iliac muscle
(arrow). (b) Coronal T2-
weighted MR image
(7,200/90) shows the
abscess (arrows). The
diagnosis was confirmed
with culture of a US-guided
aspiration sample. Vento, 2007
Anatomi Tulang Belakang
Intervertebral
foramen

Intervertebral
disc

Spinal nerve
Jaringan Peka Nyeri :

Lig spinal (lig longitudinal anterior & posterior)

Kapsul dari sendi apophyse
Periosteum
Dinding pembuluh darah
Akar saraf
Otot yang spasme
Facet articuler cartilago
Lapisan synovia dari facet
Tempo of Spinal Cord Disease
Acute Subacute Chronic

Trauma X

Mass lesion X X

Infectious X X X

Inherited X

Vascular X X X

Autoimmune X X

Nutritional X
DD Pasien
Tanda dan gejala Spondilitis TB Pasien Tumor MS
Umur Semua umur 40 th <20 or >50
Onset Sub akut/Kronis Sub akut progresif Kronis progresif
prog
Kontak penderita + - -
TB
Anemia + - +
Batuk lama, batuk + - -
darah
Riw penurunan + - +
berat badan
Demam malam +/- - -
hari
Onset nyeri Lambat Awal Awal
Intensitas nyeri Ringan-sedang Ringan-sedang Berat
Lokasi lesi Thoracal >> Thoraco-lumbal Thoracal >>
Diskripsi lesi > 1 vertebra, Vert Th XI-XII-L1-L2 >1 vertebra
berdekatan
Kondisi vertebra Pedikel intak; Pedikel intak; Pedikel (+/-)
korpus bagian korpus bagian
anterior rusak anterior rusak
 DD of spinal cord disease
Congenital/ developmental Neoplastic
Neural tube defects Intramedullary
Syringomyelia Extramedullary
Spinal stenosis (intradural and extradural)
Carcinomatous meningitis
Paraneoplastic
Trauma
Fractures
Syringomyelia Vascular
AVM or AVF
Compromise of spinal canal
Cervical spondylosis/stenosis Infarct
Acute disc herniation Vasculitis
Tethered cord Epidural hematoma
DD of Spinal Cord Disease (cont)
Infections
Epidural abscess
Intraparenchymal infxn
(viral, bacterial, fungal)
Lyme disease
Vitamin deficiency (B12, E)
Inflammatory diseases
MS
Post-Infectious myelitis
SLE injury
Sarcoid
Degenerative disorders
Spinocerebellar degeneration
Familial spastic paraparesis
ALS
Toxins & physical agents
Contrast materials
(arachnoiditis)
Spinal anesthesia
Radiation and electrical
Nitrous oxide
Symptom and Sign
Sign & Tuberculosis Spinal Cord OPLL
symptom spondylitis tumor
Age of onset Any age <20 or >50 Old

Time of onset Chronic Chronic Chronic

progressive progressive
Contact with Present Absent Absent
TB sufferer
Anemia Present Present Absent

Night sweating Present Absent Absent

Fever Absent Absent Present

Symptom and Sign
Pain at onset Late Early Late

Intensity of Mild -moderate Severe Mild

pain
Description Increase: Increase at Stationer
of pain activities Reduce: night
inactive
Location of Thoracal Thoracal Cervical >>
lesion
Description More than 1 More than 1 More than 1
of lesion vert. affected vert. affected vert. affected
Condition of Lytic: anterior Lytic & Thickening PLL
aspect,corpus, sclerotic:pedicle &
vertebra narrowing DIV corpus, no
narrowing DIV

Tumor Absent Present Absent

dd/ abses epidural
Item Spondilitis TB Abses epidural Tumor medula
spinal
Onset Semua usia t.u Usia 45-70 rerata Cancer age <20
dekade tiga 60 th thn/>50 th

Riw.kontak TBC Berhubungan Tdk berhubungan Tdk berhubungan

Paru

Anemia Sering Jarang Sering

Demam Dpt disertai / tdk Selalu disertai Tidak disertai

demam demam demam

Def neurologis Nyeri mendahului Nyeri dominan Nyeri mendahului

(ggn sensorik) & mendahului (ggn (ggn sensorik) &
motorik sensorik) & motorik
motorik
intramedullary or extramedullary
tumor
Intramedullary
Astrocytoma
Ependymoma
Extramedullary-Intradural
Meningioma
Nerve sheath tumors
(schwannomas, neurofibromas)
Filum terminale ependymoma
Extradural-Extramedullary
(Vertebral Column Tumors)
Metastasis
Ostegenic sarcoma
Osteoid osteoma
Tumor Spinal

Duus, 1996
Tumor Spinal
 Tabel 1. Tipe Tumor Jaringan Saraf
Tumor Persentase
Glioma (41%)
Glioblastoma multiforme 20
Astrocytoma 10
Ependymoma 6
Medulloblastoma 4
Oligodendrocytoma 5
Meningioma (17%) 15
Pituitary adenoma (13%) 7
Neurinoma (Schwannoma) (12%) 7
Metastatic carcinoma 6
Craniopharyngioma, dermoid, epidermoid, teratoma 4
Angioma 4
Sarcoma 4
Unclassified (mostly glioma) 5
Miscellaneous (pinealoma, chordoma, granuloma, lymphoma) 3
Total 100

Sumber: Victor & Ropper, 2002.

MEKANISME TANDA KLINIK TUMOR

1. Kompresi pd jaringan neuronal

2. Infiltrasi / invasi langsung pd jar neuronal
3. Gangguan pembuluh darah
4. Gangguan eksitabilitas
5. Penekanan efek massa
6. Gangguan sirkulasi aliran LCS

(Spencer, 1989)
CORTICOSTEROID

Primarily to treat vasogenic cerebral

edema
Effective in tumors, meningitis, other
cerebral lesion that increase BBB
permeability
CORTICOSTEROID

Reduction in peritumor edema :

decreased endothelial cell permeability by
stabilizing the endothelial cell membrane
Increased clearance or resolution of
cerebral edema
Inhibition of tumor cell growth
 Decrease vascular permeability
Decrease tumor cytotoxic effect
Prevent tumor growing
Decrease CSF production

Reduce pain & improve neurologic

deficit

Black,2001
 Dexamethasone

Initail dose 10 mg followed by 4mg/6hr

Loading dose (100 mg bolus followed by 16 mg/6
hr) : reduce pain better
Solu Medrol (30 mg/kg loading dose followed by
5,4/mg/kg for 23 hrs) especially in patient with rapid
and progressive deterioration or during surgery
Ranitidin
Bekerja pada reseptor histamin H2, yaitu berkompetitif dan menghambat aksi
histamin.
Efek pada sekresi asam:
* Menghambat sekresi asam lambung pada siang
dan malam hari
* Tidak mempengaruhi sekresi pepsin
* Tidak mempengaruhi sekresi faktor intrinsik
* Sedikit atau tidak mempengaruhi gastrin serum
puasa dan setelah makan

(Par Pharma)
Indikasi Ranitidin
Ulkus duedonum aktif
Terapi pemeliharaan ulkus duedonum
Kondisi patologis hipersekresi
Ulkus gaster aktif
Terapi pemeliharaan ulkus gaster
Esofagitis erosif

(Par Pharma)
 Primer Frekuensi Primer Frekuensi
(%) (%)

Pulmo 17 Sarcoma 8

Mammae 16 Lymphoma 6

Prostat 11 GI tract 6

Ginjal 9 Thyroid 6

Unknown site 9 Melanoma, multiple 15

myeloma dll
Metastasis

Cancer metastasis: lung, liver, bone

bone metastasis origin: lung, breast, prostate,
renal, thyroid
Spine is the most common site of bone
metastasis
L-spine: most common
Batsons plexus
Pathway of Metastasis:
arterial,
direct extension
epidural venous plexus
Batsons plexus

Batsons venous plexus

From Essential of Skeletal Radiology p977
Metastasis
Pathway of Metastasis:
arterial, direct extension, lymphatic,
venous
epidural venous plexus--Batsons plexus
cancellous bone micro-environmental
necessary
cortical bone invasion secondarily
 Metastatic Disease

The spine and it surrounding

elements have a generous
blood supply, draining many
of the structures of the lower
abdominal cavity via a system
of veins called Batson's
Plexus. This venous plexus is
felt to be the reason that
certain intra-abdominal and
pelvic tumors have a tendency
to spread to the spine.
Batsons venous plexus
Patophysiological Mechanism of Spinal
Metastases

Majority : metastase to extradural spinal axis by

hematogenic spread
- via arterial emboli to the abundan bone marrow of the VBs &
subsequently into ant. or post. extradural space through venous
channels
- via retrograde spread through the valveless extradural
Batson`s venoous plexus
Another mechanism : direct invasion extension of tumor
into the epidural space
lymphoma
Cascade of Metastasis
metastatic vertebral deformity
Type IA Type IB Type IIIA Type IIIB cervical

Type IIA Type IIB Type IIIC lumbar Type IV

Asdourian 1990
Erosi Pedikel

Paraspinal shadow

Fraktur Kompresi

Fraktur dislokasi
Definisi Nyeri

Pengalaman sensorik dan emosional yg tidak

menyenangkan akibat kerusakan jaringan baik
aktual maupun potensial atau yg digambarkan
dlm bentuk kerusakan tsb

(Meliala at al 2000).
 Visual Analogue
Visual Analogue Scale
Scale

0 5 10
Tidak Nyeri Paling Nyeri yg terbayangkan
Jenis Nyeri
Nyeri Nosiseptif
- stimulasi singkat, tdk timbul
kerusakan jaringan
Nyeri Inflamatorik
- stimulasi kuat,kerusakan/ lesi
jaringan atau proses inflamasi
- Dapat bersifat spontan atau
dibangunkan
- Berguna utk proses penyembuhan
Jenis Nyeri
Nyeri Neuropatik
-adanya lesi sistem saraf perifer atau
sentral

Nyeri Fungsional
-nyeri akibat abnormalitas sistem saraf
pusat berupa peningkatan sensitivitas thd berbagai stimuli
-dahulu dikenal dgn nyeri psikogenik

Meliala,2004
The quality of the pain

The quality of the pain often suggests its

pathophysiology.
Somatic nociceptive pains are usually well localized
and described as sharp, aching, throbbing, or
pressurelike.
Visceral nociceptive pains are generally diffuse and
may be gnawing or crampy when due to obstruction of a
hollow viscus, or aching, sharp, or throbbing when due to
involvement of organ capsules or mesentery.
Neuropathic pains may be described as burning,
tingling, or shocklike (lancinating).
JALUR NYERI
PERSEPSI

NYERI

MODULASI

TRANSMISI

TRANSDUKSI
 NOSISEPSI
Stimulus Noksius perifer

Panas

Dingin
Otak

Mekanikal

Saraf penghantar
Kimiawi

Panas

Sumsum tulang belakang

Dingin
 NYERI INFLAMASI
Inflamasi

Otak

Saraf penghantar

rusakan jaringan

Sumsum tulang belakang

EXAMPLE OF CHRONIC NOCICEPTIVE
PAIN: OSTEOARTHRITIS OF THE KNEE
Perceived pain

Ascending Descending
input modulation

Tissue
damage Spinal cord Peripheral
nerve

Activation of
local nociceptors
 MECHANISTIC APPROACH TO TREATMENT

Beydoun, 2002 BRAIN

TCAs
SSRIs
Descending
Inhibitors SNRIs
NE/5HT Tramadol
Opiate receptors Opiates
Peripheral
Central Sensitization
Sensitization
PNS Ca++ : Pregabalin,
GBP,OXC,LTG,LVT
Na+
NMDA : Ketamine, TPM
CBZ
Dextromethorphan
OXC
PHT SPINAL CORD Methadone
Others
TCA
Capsaicin
TPM
NSAIDs
LTG
Cox inhibitors
Mexiletine
Levodopa
Lidocaine

Modified by MELIALA 2006

KARAKTERISTIK KLINIK
NYERI NEUROPATIK
Umumnya menunjukkan gejala:
Continuous burning pain
Paroxysmal (electric shock-like) pain
Allodynia
Radiating dysesthesias
Paresthesias

Tanda-tanda umumnya:
Sensory loss
Weakness
Autonomic changes
 Freezing, like the feet are on ice,
Burning, feeling like the feet are on fire although they feel warm to touch

Stabbing, like sharp knives Modified by Meliala 2006 Lancinating, like electric shocks
 NYERI FUNGSIONAL

NOSISEPTOR

Otak

NOSISEPTOR

Saraf penghantar

NOSISEPTOR
Proses sentral abnormal
Mekanisme Inflamasi
Hiperalgesia
Respon yang berlebihan terhadap
stimulus yang secara normal
menimbulkan nyeri

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

PEMERIKSAAN NYERI KHUSUS PADA
HIPERALGESIA
Jenis Hiperalgesia Cara Periksa Respon

Mekanisme Tusukan dengan Rasa nyeri tajam

tusukan jarum superfisial
Termal dingin Kontak dengan Rasa nyeri
pendingin (aseton, terbakar
alkohol)

Termal panas Kontak dengan Rasa nyeri

tabung air hangat terbakar
40oC
Alodinia
Nyeri yang disebabkan oleh stimulus yang
secara normal tidak menimbulkan nyeri

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

PEMERIKSAAN NYERI KHUSUS PADA ALODINIA

Jenis Alodinia Cara Periksa Respon

Mekanis statis Tekanan ringan Rasa nyeri tumpul

(serabut C) dengan bendaumpul (dull pain)
Mekanis pungtat Beberapa tusukan Rasa nyeri tajam
ringan dengan jarum superfisial
Mekanisme dinamis Usapan ringan Rasa nyeri tajam
(A ) dengan kapas terbakar, superfisial
Mekanisme somatik Tekanan ringan pada Rasa nyeri yang
dalam sendi dalam
Termal panas Tabung air hangat Rasa seperti terbakar
40oC
Termal dingin Tabung air dingin 20oC Rasa nyeri terbakar
Hiperestesia
Meningkatnya sensitivitas terhadap
stimulasi, tidak termasuk di dalamnya
sensasi khusus (indera lain)

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Analgesia
Tidak adanya respon nyeri terhadap
stimulasi yang dalam keadaan normal
menimbulkan nyeri

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Hipoestesia
Menurunnya sensitivitas terhadap
stimulasi, kecuali sensasi khusus (indera
lain)

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Anestesia Dolorosa
Nyeri pada area atau regio yang
semestinya bersifat anestetik

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Kausalgia
Sindroma yang timbul pada lesi saraf
pasca trauma yang ditandai nyeri seperti
terbakar, alodinia, hiperpatia yang
menetap, seringkali bercampur dengan
disfungsi vasomotor, serta sudomotor, dan
kemudian diikuti gangguan trofik

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Nyeri sentral
Nyeri yang didahului atau disebabkan oleh
lesi atau disfungsi primer pada sistem
saraf pusat

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Nosiseptor
Reseptor yang sensitif terhadap stimulus
noksious (yang merusak) atau terhadap
stimulus yang merusak apabila
berkepanjangan

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Stimulus noksious
Stimulus yang menimbulkan kerusakan
terhadap jaringan tubuh normal

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Nilai ambang nyeri
Pengalaman nyeri terkecil yang dapat
dikenali subyek

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Tingkat toleransi nyeri
Tingkat nyeri terbesar yang mampu
ditoleransi subyek

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Titik picu (trigger point)
Titik dalam satu area tertentu pada otot
atau fasianya yang menimbulkan nyeri
menjalar yang khas, dapat berupa
kesemutan atau tebal (baal) sebagai
reaksi terhadap tekanan yang agak lama

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

Titik nyeri (tender point)
Nyeri lokal yang timbul pada otot,
ligamentum, tendo, atau jaringan
periosteal pada penekanan yang agak
lama

Meliala, et.al, 2002, Pokdi Nyeri Perdossi

 PENGERTIAN MODEL NYERI

Terapi kognitif PERILAKU NYERI

Restorasi fungsional (PAIN BEHAVIOUR)
Antidepresan
PENDERITAAN Psikotropika
(SUFFERING)
Relaksasi
Opioid NYERI Spiritual
(PAIN)
Tramadol
Oxcarbazepine Indo.farnesil
Gabapentin Etodolac
Eperisone HCL NOSISEPSI Dexketoprofen
(NOCICEPTION)
Paracetamo Celecoxib
OAINS Diklofenak
Modalitas fisik
BIOPSIKOSOSIAL
(BIOPSYCHOSOCIAL)
BYERS AND BONICA, 2001
MODIFIKASI PENULIS
METHYCOBAL

An active form of cobalamin

Participates in transmethylation

Improves synthesis of proteins, nucleic

acids and phospholipids which are needed in the
repair of damaged nerves.
 METHYCOBAL IN NUCLEIC ACID AND PROTEIN
SYNTHESIS
DNA

5 methyltetra- Methycobal
hydrofolic acid Tetrahydrofolic acid
CH3

Homocysteine Methionine

S-adenosylhomocysteine S-adenosylmethionine

Modified MELIALA, 2006

 BENEFITS ALL TYPES OF
Muscle
PERIPHERAL NEUROPATHIES
SEGMENTAL DEMYELINATION
Myelin sheath Axon
e.g :
Diabetic neuropathy
Alcoholic neuropathy
Uremic neuropathy
Guillain-Barre syndrome Nerve cell

WALLERIAN DEGENERATION
e.g : Direction of degeneration
Spondylosis deformans
Hernia of intervartebral disc
Carpal tunnel syndrome
Facial palsy
Glaucomatous optic atrophy

AXONAL DEGENERATION
e.g :
Drug-induced neuropathies Direction of degeneration
[Vincristine, isonicotinic
acid hydrazide (INH), etc]
Herpes zoster

Modified MELIALA, 2006

Methycobal 500 g injeksi
pada berbagai kasus Lumbago

Spondilosis lumbar
Nyeri pinggang 500g1 ampul/waktu setiap
Nyeri pinggang myofascial 349 2 hari atau 2 x seminggu, i.m.
Sciatic neuralgia kasus
Injeksi lokal
Herniated nucleus pulposus Area Kanagawa
Bermakna 23 institusi
0 50 100 %
Spondilosis lumbar Sedang Ringan
n=105 14.3 41.0 39.0 5.7 Tidak berubah
Nyeri pinggang
n=67 13.4 37.3 41.8 5.7
Nyeri pinggang myofascial
n=76 22.4 39.5 29.0 9.2
Sciatic neuralgia
n=10 10.0 30.0 50.0 10.0
Herniated nucleus pulposus
n=46 8.7 41.3 37.0 13.0

Total
n=349 14.6 38.7 37.5 9.2
Modified MELIALA, 2006
Yamamoto R. et al. Prog. Med. 1984; 4(3):769
Methycobal 500 g injeksi
menunjukkan angka perbaikan yang tinggi terhadap gejala subyektif
pada pengobatan neuropati diabetika
n=8 pasien neuropati diabetika
Angka perbaikan tinggi pada gejala gejala subyektif
Methycobal 500g injeksi, 3 kali
seminggu i.v. selama 4 minggu

Nyeri spontan pada lengan bawah 85.7%

Nyeri spontan pada lengan atas 80.0% Methycobal injeksi menunjukkan efikasi terbesar
pada gejala-gejala subyektif, khususnya nyeri spontan,
Numbness 75.0% numbness dan hipestesia.

Berkurangnya
kepekaan sensorik 71.4% Perbaikan menyeluruh yang tinggi

Sedang Ringan Tidak ada

4 minggu 37.5 50.0 perubahan
12.5

Angka perbaikan meningkat

sejalan dengan lamanya pengobatan; Bermakna Tidak ada
Sedang Ringan
angka perbaikan sebesar 87.5% teramati 8 minggu 25.0 37.5 25.0
perubahan
12.5
setelah 4 minggu
pengobatan

Bermakna Sedang Ringan

12 minggu 25.0 37.5 37.5

Yasuda et al. Medical Consultant & New Remedies 1988,

25(11), 2375
 Improvement of the symptoms caused by
autonomic nerve disturbances
Diabetic Neuropathy

Objective To investigate the efficacy of Methycobal for diabetic autonomic neuropathies

in comparison with general vitamins other than vitamin B 12
i
Method sa Methycobal group: CH3B12 1500g/day 12 weeks
48 Ei
cases General vitamin group: General vitamins 3g/day 12 weeks
Each case alternated
Recovery Rates
Methycobal Group 23 cases General Vitamin Group 25 cases
% 50 0 0 50 100 %
100
Orthostatic
90 dizziness 50

50 Hyperhidrosis 14

36 Dry mouth 25

Spontaneous
66 44
pain
Pain during
55 50
motion

44 Paresthesia 12

31 Hiroshi Taniguchi et al : 7th Asia Oceania Congress of Neurological Bulletin, Sept. 1987.
Kesimpulan
Metilkobalamin adalah bentuk aktif Vit B12, siap
digunakan tubuh dalam reaksi metilasi homosistein
membentuk metionin
Reaksi metilasi berperan pada pembentukan DNA,
protein yang penting untuk saraf, pembentukan mielin
dan transpor aksonal
Metilkobalamin berperan pada regenerasi saraf yang
mengalami kerusakan, misalnya pada, nyeri neuropatik,
neuralgia nervus kranialis, peripheral nerve injury, vertigo
dan tinitus dengan mengurangi ectopic discharge
Kesimpulan
Metilkobalamin berperan pada penurunan kadar
homosistein mengurangi kerusakan saraf akibat
terbentuknya reactive oxygen species
Berperan pada proteksi neuron SSP akibat
glutamate-induced neurotoxicity proteksi
neuron pada stroke, cedera serebral, Alzheimer,
Parkinson, Hipoglikemia dan Status epileptikus
Secara umum sediaan oral maupun injeksi cukup
aman dengan kejadian efek samping yang kecil
Sindroma Medula Spinalis
1.Sindrom Ganglion Spinalis

Pada dermatome yang terkait

- Parestesi / nyeri pada dermatome yang terkena

Duus, 1996
Sindroma Medula Spinalis
2. Sindrom Radiks Posterior

- Gangguan somatosensork
- Gangguan sensorik (Nyeri)

Duus, 1996
Sindroma Medula Spinalis
3. Sindroma Traktus Posterior

- Gangguan rasa posisi, getaran, diskriminasi

- Ataxia ( Dengan mata tertutup )
- Kadang ada hipersensitivitas nyeri
- Ex: Tabes Dorsalis Duus, 1996
Sindroma Medula Spinalis
4. Sindrom Kornu Posterior

- Def sensorik segmental

- Ipsilateral: def nyeri, suhu (Ggn Disosiasi sensorik)

Duus, 1996
Sindroma Medula Spinalis
5. Sindrom Substansia Grisea

- Melibatkan semua jaras menyilang

- Ggn Disosiasi sensorik bilateral
- Bila kornu Anterior terlibat paralisis flaksid
- Bila Traktus pirramidalis terkena paralisis spastik
- Ex: Siringomielia, tumor intramedular
- Jika kornu lateral ggn trofi Duus, 1996
Syringomyelia

Fluid filled cavitation in the center of the cord

Cervical cord most common site
Loss of pain and temperature related to the crossing
fibers occurs early
cape like sensory loss

Weakness of muscles in arms with atrophy and

hyporeflexia (AHC)
Later - CST involvement with brisk reflexes in the
legs, spasticity, and weakness
May occur as a late sequelae to trauma
Can see in association with Arnold Chiari malformation

Duus, 1996
Sindroma Medula Spinalis
6. Sindr Gabungan traktus posterior n jaras kortikospinal

- Def rasa posisi extremitas bawah, ataksia

- Tr piramidalis paraparese spastik

Duus, 1996
Sindroma Medula Spinalis
7. Sindrom Kornu Anterior

- Paralisis flaksid, atrofi otot

- Ex: Amyotropk Lateral Sklerosis

Duus, 1996
Sindroma Medula Spinalis
8. Sindrom gabungan kornu anterior n tr piramidalis

- Kornu anterior Paresis flaksid, atrofi otot

- Tr Piramidalis Paresis spasstik
- Ex: ALS

Duus, 1996
Sindroma Medula Spinalis
9. Sindroma Traktus kortikospinal

- Paraperese spastik

Duus, 1996
Sindroma Medula Spinalis
10. Sindoma hemiseksi MS ( Brown-Sequard )

- Ipsilateral: Paresis flasid, paresis spastik, Def sensorik

( posisi, getar, diskriminasi), Ataxia (tertutup oleh
paresis)
- Kontralateral: Ggn Nyeri dan suhu
Duus, 1996
Brown Sequard Syndrome
Cord hemisection
Trauma or tumor
Dissociated sensory loss
loss of pain and temperature contralateral to lesion,
one or 2 levels below
crossing of spinothalamic tracts 1-2 segments

above where they enter

loss of vibration/proprioception ipsilateral to the lesion
these pathways cross at the level of the brainstem

Weakness and UMN findings ipsilateral to lesion

Duus, 1996
Bladder

Duus, 1996
Rectum

Duus, 1996
Ereksi

Duus, 1996
Duus, 1996
Duus, 1996
Duus, 1996
Duus, 1996
Duus, 1996
 Sindrom Epikonus,
Konus & Cauda Equina
Sindrom Epikonus, Konus & Cauda
1. Sindr Epikonus
Equina
- L4 - S2
- eksorotasi (L4S1) dan
dorsofleksi pinggul (L4-5)
dan fleksi ekstensi jari
kaki dan sendi kaki
berkurang atau (-)
- Ggn sensorik L4 S5
- Inkontinensia alvi et uri
overflow
- priapismus +
- Ref Akiles (-), Ref patella
(+)
Duus, 1996
Sindrom Epikonus, Konus & Cauda
Equina
2. Sindrom Konus
- S3 - Conus
- Paralisis flaksid VU
berhubungan dengan
inkontinentia ( Urine
menetes terus )
- Inkontinensia alvi
- Impotensi
- Saddle Anestesi ( S3-S5 )
- Refleks anal (-)
- Paralisis ext bawah (-),
reflek akiles (+)
Duus, 1996
Sindrom Epikonus, Konus & Cauda
Equina
3. Sindr Kauda Equina

- ependimoma & lipoma

- pada radiks saraf ( Cauda Equina )
- Nyeri radikuler
- Nyeri hebat pada VU ( batuk bersin )
- Ggn sensorik meluas ke bawah
- Bila melibatka daerah rostral inkontinensia
alvi, urin, potensi
- Gejala lambat dan tak teratur toleransi
pergeseran radiks

Duus, 1996
 Conus Medullaris vs. Cauda Equina
Lesion

Finding Conus CE

Motor Symmetric Asymmetric

Sensory loss Saddle Saddle
Pain Uncommon Common
Reflexes Increased Decreased
Bowel/bladder Common Uncommon
Cervical Spodylosis Lindsay, 2004
Myelopathy Lindsay, 2004
Sympathetic Nervous System
Mobilization of bodily resources
Flight or fight reactions
Pre-ganglionic neuron
spinal cord
ACh as transmitter
Post-ganglionic neuron
paravertebral
chain=widespread action
Thoracic and lumbar regions
of the cord=Thoracolumbar
division of ANS
NE as neurotransmitter
(except sweat glands = ACh)
also peptides
Parasympathetic System
Generally associated with
restorative functions, e.g.,
stimulation of peristaltic and
secretory activities of the GI tract
Pre-ganglionic
Brainstem and sacral cord
Craniosacral division of ANS
ACh as neurotransmitter
Post-ganglionic
Located either in the wall of
the organs they innervate or in
close proximity to target=more
localized action
ACh as neurotransmitter (also
peptides)
Timetable of Wallgren
Spondylodiscitis Penularan

Hematogen
- Venous theory retrograd flow
- arteriolar theory Batson`s end
arteri

Percontinuatum
Limfogen

Kumar, 2004
Spondylodiscitis Predileksi

Thoracal / cervical >>

Korpus vertebra >> menyebar ke
diskus vertebra didekatnya

Kumar, 2004
Spondylodiscitis Predisposisi

Diabetes
RA
Umur tua
KS jangka panjang
Imunocompromise
Kemotx
HIV/AIDS

Kumar, 2004
Spondylodiscitis Komplikasi

Abses
Fr patologis
Vertebra & diskus collapse
Instabilitas vertebra
Defisit neurologi
Meningitis

Kumar, 2004
Spondylodiscitis Penatalaksanaan

Kultur kuman
Nutrisi
Cegah progresivitas
Cegah kecacatan
Stabilisasi vertebra
Antibiotik iv
Operasi

Kumar, 2004
Kasus TB
Kasus Baru
Belum pernah mendapat OAT / OAT < 1 Bln

Kasus Relaps
Tb (+) OAT sembuh BTA (+)

Kasus drop out

OAT > 1bln tidak melanjutkan OAT > 2bln
berturut turut / lebih

Pedoman Diagnosis dan Penatalaksanaan tuberkulosis, 2006

Kasus TB
Kasus gagal
BTA masih (+) / kembali (+) pada akhir bln
ke 5
/ akhir pengobatan

Kasus kronis
BTA (+) stlh pengobatan ulang dgn
kategori 2

Pedoman Diagnosis dan Penatalaksanaan tuberkulosis, 2006

TH10

Tn S / 40th
MRI T1
 TH10

Tn S / 40 th
MRI T2
Evaluating the usefulness of the ICT tuberculosis test
kit for the diagnosis of tuberculosis

Chulhun Ludgerus Chang1, Eun Yup Lee1, Han Chul Son1, Soon Kew Park2

ResultsThe diagnostic sensitivities of ICT were 73% in patient

group 1 and 87.1% in patient group 2. In two patients with
extrapulmonary tuberculosis, both tested positive using ICT. The
specificities of ICT were 88%, 94%, and 94% in healthy adults,
hospital workers, and non-tuberculous patients, respectively.

Conclusions ICT is a useful tool for the diagnosis of tuberculosis.

MRI
Vertebra metastase
MRI
Vertebra metastase
 Spondilodiscitis Steroids
Potts paraplegia Problem terapi TB
M. Tb Operasi
Epidemiologi Prognosis
Epid Spin piogenik Abses
Dx TB Efusi Pleura
Dx spondilitis tb Xtra pulmo TB
Laboratorium Anatomi Spine
Rontgen Jaringan Peka Nyeri :
CT Scan Medula spinalis
MRI Tempo MS Disease
Patofisiologi DD Pasien
Neurologic injury intra n extra tumor
Fx predisposisi
prevalensi tumor
Tipe Spondilitis TB
CORTICOSTEROID
Komplikasi
Ranitidin
Manajemen umum
Sp Metastasis
OAT
Definisi Nyeri
Pedoman nasional
Nyeri et al
Karakteristik OAT
Jenis nyeri
ESO
Sindroma Medula Spinalis
 Bladder
Rectum
Dermatome
Sensorik
Motorik
epi. conus, cauda equina
Sympathetic
Parasympathetic
Timetable of Wallgren
Sp penularan
Sp Predileksi
Sp Predisposisi
Sp Komplikasi
Sp Penatalaksanaan
Kasus TB