Tata Laksana nyeri kronik fokus pada LBP DR

Tata Laksana nyeri kronik fokus pada LBP DR

Tata Laksana nyeri kronik fokus pada LBP DR L.LAKSMIASANTI SP S(K) Tata Laksana nyeri Merupakan spesialisasi baru Di USA merupakan spesialisasi ke 34 Nyeri telah ada sejak

Firman Tuhan pada EvaSusah payahmu wkt mengandung akan banyak dengan kesakitan engkau akan melahirkan anakmu 16) ".(kejadian 3, Nyeri selalu ingin dihilangkan pain relief against gods

wish Obat2an herbal China 2000 thn lalu Tata Laksana nyeri What is new? Pengetahuan baru tentang pathophysiology

nyeri Konsep2 baru tentang terapi dengan analgetik Obat2 baru untuk tata laksana nyeri Interventional Pain Management untuk diagnose & pengobatan nyeri Nyeri Apakah itu ?

Nyeri Definitions: Nyeri adalah pengalaman sensorik dan emosi yang tidak menyenangkan dimana berhubungan dengan kerusakan jaringan atau potensial terjadi kerusakan jaringan. nyeri tidaklah selalu berhubungan dengan derajat kerusakan jaringan yang dijumpai. nyeri bersifat individual yang dipengaruhi oleh genetik, latar belakang kultural, umur dan jenis kelamin

Nyeri sering tidak mendapat pengobatan Tipe nyeri 1. Acute 2. keganasan 3. Kronik non-malignant Major Categories of Pain Klasifikasi berdasar pathophysiology: Nyeri Nociceptive (stimuli dari somatic dan organ dalam)

2. Nyeri neuropathic (stimuli abnormal di proses di sistema saraf) 1. Anatomi dan fisiologi dari nyeri Nociceptiv 4 proses terjadinya nyeri 1 Transductionujung saraf nociceptors yang dpt membedakan stimuli bahaya dan

tidak jika terkena stimuli baik mekanik, suhu, atau kimia dr jaringan yang rusak akan mengeluarkan substansi. Substansi ini memfasilitasi impuls nyeri ke medula spinalis. karenanya Non-steroidal anti-inflammatories, seperti ibuprofen, effectif mengurangi nyeri karena mengurangi efek substansi yang keluar

terutama prostaglandin. Corticosteroids, seperti dexamethasone dipakai untuk nyeri karena kanker juga mempunyai sifat yang sama thd produksi prostaglansin. Substansi kimia yg keluar substansi yang keluar karena kerusakan jaringan adalah: prostaglandins

bradykinin serotonin substance P histamine Transduksi Stimulasi ini menyebabkan membran sel dari neuron menjadi permeabel thd ion sodium/Na, hingga ion2 ini masuk ke sel neuron dan menyebabkan ion2 positif

meningkat dan kalium kembali ke luar sel hingga kembali ke charge negatip . Dengnn peristiwa depolarisasi dan repolarisasi ini stimulasi nyeri diubah menjadi impuls Impuls ini muncul hanya dlm wakt bbrp milisekond. Bbrp analgetik mengurangi nyeri dg jalan menurunkan pergerakan ion Na dan K didalam neuron hingga memperlambat atau

meniadakan transmisi nyeri. Contohlocal anesthetics, anticonvulsants digunakan untuk nyeri neuropathic Process #2Transmission Impulse spinal cord brain stem thalamus central structures of brainrasa nyeri di proses. Neurotransmitters dibutuhkan meneruskan impuls nyeri dari medulla spinalis ke otak

opioids (narcotics) effective karena mencegah/menblok keluarnya neurotransmitters Process #3Perception nyeri Terakir dari aktivitas nyeri adalah transmission Diketahui bahwa rasa nyeri disadari di korteks otakdisini behavior terapi bisa dipakai nuntuk mengurangi rasa nyeri.

Process #4Modulasi nyeri Nyeri dihambat atau diubah di traktus desendens (otakmedula spinalis) Serabut ini mengeluarkan substansi juga spt norepinephrine dan serotonin (dikenal sbg endogenous opioids atau endorphins) yg mempunyai kemampuanmenghambat trnasmisi stimuli nyeri.Krn proses inilah rasa nyeri dialami secara berbeda pd bbrp

orang. Nyeri krn keganasan dpt mengurang dgn antidepressants karena mempengaruhi reuptake serotonin and norepinephrine Nyeri Neuropathi Proses Abnormal impuls nyeri terjadi di susunan saraf tepi atau pusat Bisa disebabkan karena trauma (amputation and subsequent phantom limb

pain), jaringan parut karena operasi (back surgery high risk), nerve entrapment (carpal tunnel), atau kerusakan saraf (diabetic neuropathy) Where Can We Intervene? We have the science, but are we making any progress ???

Pain is a more terrible lord of mankind than death itself. Albert Schweitzer Always increase by a percentage of the present dose based upon patients pain rating and current assessment Opioid Dose Escalation 50-100% increase

25-50% increase Moderate pain 25% increase 4-6/10 Mild pain 1-3/10 Severe pain 7-10/10 Tata laksana nyeri Recovery

Operation Strong opioids Weak opioids +/nonNon- opioids opioids World of Misery Non-pharmacological methods Interventional Pain Management

merupakan prosedur invasif yg minimal yang dpt memberikan kesembuhan yang permanent atau jangka panjang. Mengisi kekosongan antara terapi obat2an dan tindakan operatif/invasif berat. Problem 2 di punggung bg bawah/ problems in low back pain

Back Pain Penyebab ke 2 untuk mengunjungi dokter 60-80% penduduk mengalami LBP dlam hidupnya Penyebab disbilitas utk usia < 45 th Beaya sp: $20-50 billion/thn Pusat2 Back Pain

Ligaments Tendons Bones Facet joints Muscles Discs (the outer rim of the disc, the annulus, can be a source of significant back pain due to its rich nerve supply and tendency towards injury) - Anatomy

Lesson #1 The Intervertebral Disc Berupa jelly berbenyuk donat berguna sebagai bantalan thd trauma Terdiri 2 bg:bg luar (annulus fibrosus)dan bg lunak (nucleus pulposus)

Sewkt lahir, 80% drf the disc berupa cairan Dg bertambah umur disc dehydration micromotion instability inflammatory proteins of nucleus pulposus leak out of the disc space inflammation of structures next Facet join arthropati

Terjadi degenerasi menjadi tak stabil daerah banyak gerakan nyeri waktu flexi 50% muncul dipanggul, dan 50% muncul di daerah lumbal Gerakan flexi terbagi diantara ryas2 lumbal namun proporsi terbanyak di daerah L3-4 dan L45

Akibatnya facet joint arthropati terbanyak di daerah tersebut The Nerve Roots In the cervical spine, the nerve root is named for the lower segment that it runs between (e.g. C6 at C5-C6 segment)

In the lumbar spine, the nerve is named for the upper segment that it runs between (e.g. L4 at L4-L5 segment) The nerve passing to the next level runs over a weak spot in the disc space discs tend to herniate

(extrude) right under the nerve root leg pain or arm pain (radiculopathy) The Nerve Roots (contd) Suatu HNP menimbulkan nyeri daerah kaki dan tidak punggung maka sering dikira penyebab nyeri berasal dari kaki atau lengan Nyeri kaki dari hnp lumbal

umumnya dirasakan dibawah lutut sp bawah ankle, sering disertai dengan rasa tebal/numness N isciadicus Distribution: daerah lumbal pantat kaki bg belakang + foot / toes Description: nyeri bersifar burning/ tingling/ shooting menjalar

kebawah dengan memburuk dengan posisi duduk berdiri Associated symptoms: kelemahan, numbness kesulitan mengerakkan tungkai atau kaki Pathogenesis: -

herniated disc lumbar spinal stenosis degenerative disc disease spondylolisthesis Prognosis: baik Anterior Longitudinal Ligament

Ada di anterior corps vertebra dan div , menahan ekstensi Bisa terjadi rupture karena hyperekstensi berat mis trauma terutama cervical

Ligamentum Flavum Berada diantara lamina Sebelah lateral bergabung dg capsul dari facet joint

Menahan flexi Dpt menekuk ke dlm menekan medulla spinalis terutama pada kontusi

Muscle Strain Penyebab terutama pd LBP akut penyebab: mengangkat benda berat , gerakan mendadak atau jatuh Pathogenesis: muscle strain inflammation spasm nyeri hebat sulit gerak Prognosis: baik (dpt sembuh spontan)) Time course: bbrp jam bbrp minggu Jika nyeri > 2 weeks kelemahan

otot mengecil (disuse atrophy) otot tak mampu menahan tulang belakangnyeri bertambah Causes of Low Back Pain Lumbar strain or sprain 70% Degenerative changes 10% Herniated disk 4% Osteoporosis compression fractures 4% Spinal stenosis 3% Spondylolisthesis 2%

Penyebab Low Back Pain Spondylolysis, diskogenic low back pain or other instability 2% Traumatic fracture - <1% Congenital disease - <1% Cancer 0.7% Inflammatory arthritis 0.3% Infections 0.01%

Role of X-rays (Radiology) Kadang2 tak diperlukan Plain X-ray: umur>50 tahun Tak sembuh ssdh 6 mg Ada gejala2 lain

MRI: Jika sdh 6 minggu dengan gejala sciatika New England Journal of Medicine (February 2001) Why discourage routine imaging for non-specific low back pain? MRI studies have revealed lumbar disc

abnormalities in up to three-quarters of asymptomatic subjects, including those with no previous history of LBP, sciatica or neurogenic claudication. (Sheehan NJ. Postgrad Med J. 2010; 86: 374-8) Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. (Chou R et al. Lancet 2009; 373: 463-72)

Assessment of Back Pain Nyeri pd perkusi muncul pada metastase atau infeksi tdk muncul pd HNP Radiological test: foto polos dpt menunjukkan degenerasi diskus, spondilitis, kompressi, ggan metabolik tulang metastase dsbnya Oblique view drf lumbosacral level dipakai untuk visualize facet & sacroiliac joint Flexion-extension view dpt untuk melihat adanya

instabilitas spinal Straight leg raising test Pemeriksaan Straight leg raising test dpt utk memprediksi adanya iritasi radiks/HNP Juga menilai adanya perbaikan A +ve crossed SLR test has

the highest correlation w myelographic finding of a herniated disc Muscular Pain Nyeri lumbal sering krn strain otot atau ligamentts Nyeri bersifat lokal dan pd sentuhan

Pain not involved shooting pain nyrtivvOsteoporosisVvvVNyer Osteoporosis is painful due to mikro fraktur Berbaring lama , tak ada beban latihan membuat demineralization & fraktur Postmenopause & pt Rx dg

corticosteroid beresiko fraktur r/o w serum protein electrophoresis, sed rate, alkaline phosphatase, ca, xrays. Osteomyelitis Pd immunocompetent pasien, tak jarang muncul infeksiStaphylococcus aureus Inf mengenai vertebral bodies, endplates, &

disc spaces, spares post elements Kadang2 muncul actinomycosis or coccidiodomycosis Vertebral metastases Metastases Vertebral muncul dengan nyeri punggung, biasanya terlokalisir Jika saraf terkena nyeri muncul sesuai distribusi saraf Umumnya mengenai daerah thoracal

Epidural spinal cord compression merupakan medical emergency & karena dpt menyebabkan paraparesis, sensory loss, gangguan bab maupun bak Vertebral metastases Pd foto polos gejala awal adalah erosi pedikel lama2 vertebral body kehilangan kepadatannya

MRI menunjukkan perubahan signal intensitasnya Jika tumor bertumbuh mk akan sp ke ruang epidural dan menekan medulla spinalis Facet joint pain Corpus vertebral mempunyai 4 facet

joint, 1 pasang diatas & 1pasang dibawah Dalam Synovial joints ada cairan didlmnya arthritis pd facet joints umumnya midline & dan dpt menyebar ke punggung dan panggul Bertambah nyeri pd bending keblkg dan

Herniated Disc Intervertebral disc consists of an outer fibrous body called the annulus fibrosus & an inner gel like substance called the nucleus pulposus It acts as a shock absorber & spacer for the spine giving room for the intervertebral neural foramina which are portals for the exit of the spinal nerves The nucleus pulposus contains noxious

chemicals which can be irritating to nerves Herniated disc-contThe intervertebral discs lie between the vertebral bodies. In front is the ant. longitudinal ligament & behind the post. longitudinal ligament & behind that is spinal cord. Wear & tear can cause annulus fibrosus to weaken allowing bulges of nucleous pulposis These bulges may protrude out enough to touch the spinal cord causing irritation to nerves

These large disc bulges are called herniation Herniated Disc Dg adanya trauma mk diskus yg prolaps dpt menyebabkab ann fibrosus ruptur &dan nukl pulposus keluar Muncul nyeri yang menjalar sepanjang

distribusi saraf cairan nucleus pulposus menyebabkan udema dr saraf dan menyebabkan nyeri terus menerus spt Types of Herniate Disc Disc degeneration Disc prolapse Disc extrusion Disc seqestration

Radiographic herniated disc Spondylolisthesis Spondilolithesis Bergesernya corpus vertebrae satu dg yang lain Corpus vertebra umumnya segaris

hingga canalis spinalis berbentuk tabung Spondylolithesis Jika bergeser mk canalis spin menyempit/menekuk Jika terjadi stenosis medulla spinalis dpt

tertekan atau radiks Ini menyebabkan ischemia medulla spinalis dan nyeri kaki Grades of Spondylolisthesis Piriformis Syndrome PpiriripiPppppppppppp

Piriformis sindrom Sindrom LBP krn kontraktur kronis dr m piriformis yg menyebabkan iritasi n ischiadicus Nyeri dimulai dr pantat menjalar ke n ischiadicus Terjadi penjepitan saraf

diantara otot atau otot Piriformis Syndrome Dikenal sbg hip pocket neuropathy atauwallet neuritis Piriformis ms pipih, berbtk pyramidal berorigo di bg ant sacrum S2-S4 & sacrotuberous lig melintas notch dr n

ischiadicus dan berinsersi pd bgn superior trochanter mayor Buttock pain Nyeri pantat Penyebab umumnya Piriformis syndrome Ischial tuberosity .

Rupture of gluteal ms. Predominat leg pain Global without clear outline CRPSor sympatically mediated pain Dermatomal Pivd ,post herpetic pain

Nerve distribution Lat fem cut sciatica patchy Non dermatomal Non dermatomal Not along nerve

Mps, si Back pain Predominat back pain axial Aggravated on sitting : IDD, bil SIJ

#vertebra paramedian Relieved on sitting: Bilateral facet Canalis stenosis Aggravating

on sitting : Unilat sij MPS Relieved on sitting: Unilat facet TTherapyreThatment Terof Back Pain Terapi

Walking is best exercise Physical therapy for core stabilization Spinal manipulation & manual therapy Pharmacotherapy Application of heat or ice Acupuncture Intervensional injection operation Physical Treatment Options Exercise (stabilization training)

Neutral position Soft tissue mobilization Transcutaneous electrical nerve stimulation ( Electrothermal therapy Complementary measures (acupuncture; relaxation/hypnotic/biofeedback therapy) Spinal manipulative therapy Multidisciplinary treatment programs (back schools/education/counseling/pain

Pharmacotherapy Options* Antidepressants Anticonvulsants Muscle relaxants Opioid analgesics Corticosteroids NSAIDs Topical analgesics * Except for certain opioids, none of these agents are indicated for chronic LBP.

Interventional Treatment Options Neural blockade selective nerve root blocks facet joint blocks, medial branch blocks Si joint

caudoepidural Neurolytic techniques radiofrequency neurotomies pulse radio frequency Stimulatory techniques

spinal cord stimulation peripheral nerve stimulation Intrathecal medication pumps delivery into spinal cord and brain via CSF Intradiscal Electrothermal Therapy

IPM pd piriformis syndr caudoepidural Transforaminal epidural When to Refer for Surgical Consultation

Motor weakness of one or both legs New bowel and urinary incontinence MRI HNP compressing nerve root MRI of grade 3 spondylolisthesis MRI/CT evidence of severe spinal stenosis with correlative leg weakness and pain Standing flexion/extension films showing significant movement Summary

Pengobatan LBP difokuskan pd target oenyebab nyeri dp menghilangkan nyeri saja Biopsychosocial approach merupakan kuci sukses pengobatan chronic LBP Treatment/pengobatan untuk chronic LBP meliputi

new agents new uses of agents new combinations of agents Interventional pain management THANK YOU www.medschool.lsuhsc.edu/.../Low%20Back.. www.utswanesthesia.com/.../Back-Pain-and-

Treatment-Modalities www.painedu.org/Downloads/NIPC/Low_Back _Pain www.fresno.ucsf.edu/.../low_back_pain_3-4..

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