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

(kalo tjd luka tembak pada L3, tdk ada MS yg rusak)

o Segmen Thoracalis → level V.T1-10

(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 MSo Suatu kumpulan “Badan Sel” Neurono 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 MSo 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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FisiologyOtak Medula Spinalis

Divisi Aferen

SSP

Somatik Otonom

Motorik Simpatis Parasimpatis

Otot Rangka

Otot Jantung, Kelenjar

Stimulation Sensorik

Divisi Eferen SST

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:1. high Tonus muscle or hipertonia

2. Hipereflexia

3. Klonus

4. Patologik Reflex

5. There no atrofi at palsied muscle.

6. Refleks automatisme spinal

“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 CordTumor Spinalis CordInfection, good infection by bactery although

virus on Spinal CordDefitient from nutrition

Patomekanisme paraparesis

Lesion in medulla spinalis Effected to nerve

Nerve bindNerve havn’t O2 from vassel

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 nervesnear it

inhibit passingthe impuls

Nerves becomedamage

Effect the moving

Paraparesis at both of feet

Widespread tofeet

Pain on lumbal To abdomen

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

MEDIAL

LATERAL

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 sufferer’s cough, sneeze, sputum (droplet) or

speak that released to air. Mycrobacterium get into human’s 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 diagnosismielitis Trauma medula spinalis

D

E

F

E

N

I

s

I

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

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

E

P

I

D

E

M

I

O

L

O

G

I

•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

Gambaran 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

examination

• Lumbal pungsi• 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.

Continue.....

And......

www.dokterfoto.com

www.medicastore.com

www.dinkessleman.go.id

www.indomedia.com

www.infeksi.com

www.kalbe.co.id

www.sriwijayapos.com

Wassalam....

Thanks

For

Attention