paresis

PRESENTASI KASUS BANGSAL TETREPARESIS

Diajukan Kepada : Dr. Gama Sita Setya P., Sp.S

Disusun Oleh : Budi Nugraha 2007 031 0032

KEPANITERAAN KLINIK ILMU PENYAKIT SYARAF FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH YOGYAKARTA BPRSUD SALATIGA 2011

LEMBAR PENGESAHAN PRESENTASI KASUS BANGSAL TETRAPARESIS

Telah disetujui dan dipresentasikan Pada tanggal

Februari 2010

Menyetujui :

Dokter Pembimbing

(Dr. Gama Sita Setya P., Sp.S)

LEMBAR PENGESAHAN PRESENTASI KASUS BANGSAL TETRAPARESIS

Telah disetujui dan dipresentasikan Pada tanggal

Februari 2010

Menyetujui :

Dokter Pembimbing

(Dr. Gama Sita Setya P., Sp.S)

BAB I TINJAUAN PUSTAKA TETRAPARESIS

DEFINISI

Parese adalah kelemahan/ke kelemahan/kelumpuha lumpuhan n parsial parsial yang ringan/ti ringan/tidak dak lengkap lengkap atau suatu kondisi yang ditandai oleh hilangnya sebagian gerakan atau gerakan terganggu. Kelemahan adalah hilangnya sebagian fungsi otot untuk satu atau lebih kelompok otot yang dapat menyebabkan menyebabkan gangguan mobilitas bagian yang terkena. terkena. Parese pada anggota gerak dibagi mejadi 4 macam, yaitu: Monoparese adalah kelemahan pada pad a satu ekstremitas atas atau ekstremitas bawah. Paraparese adalah kelemahan pada kedua ekstremitas bawah. Hemiparese adalah kelemahan pada satu sisi tubuh yaitu satu ekstremitas atas dan satu ekstremitas bawah pada sisi yang sama. Tetraparese adalah kelemahan pada keempat ekstremitas. Tetraparese Tetraparese/Quadr /Quadripare iparese se adalah kelumpuhan/ke kelumpuhan/kelemaha lemahan n yang disebabkan disebabkan oleh  penyakit atau trauma pada manusia

yang menyebabkan hilangnya sebagian

fungsi

motorik motorik pada keempat anggota anggota gerak, dengan kelumpuhan/kelema kelumpuhan/kelemahan han lengan lebih atau sama hebatnya dibandingkan dengan tungkai. Hal ini diakibatkan oleh adanya kerusakan otak, kerusakan tulang belakang pada tingkat tertinggi (khususnya pada vertebra cervikalis), kerusakan sistem saraf perifer, kerusakan neuromuscular atau penyakit otot. kerusakan kerusakan diketahui karena adanya adanya lesi yang menyebabkan menyebabkan hilangnya fungsi motorik   pada keempat anggota gerak, yaitu lengan dan tungkai. Penyebab khas pada kerusakan ini

adalah trauma (seperti tabrakan mobil, jatuh atau  sport injury) injury) atau karena penyakit (seperti mielitis transversal, polio, atau spina bifida). Pada tetrapares tetraparesee kadang terjadi kerusakan atau kehilangan kehilangan kemampuan dalam mengontrol mengontrol sistem sistem pencernaan, pencernaan, fungsi seksual, seksual, pengosongan pengosongan saluran saluran kemih dan rektum, rektum, sistem pernafasan atau fungsi otonom. Selanjutnya, dapat terjadi penurunan/kehilangan fungsi sensorik. adapun manifestasinya seperti kekakuan, penurunan sensorik, dan nyeri neuropatik. Walaupun pada tetraparese itu terjadi kelumpuhan pada keempat anggota gerak tapi terkadang terkadang tungkai tungkai dan lengan masih masih dapat digunakan digunakan atau jari-jari jari-jari tangan tangan yang tidak dapat memegang kuat suatu benda tapi jari-jari tersebut masih bisa digerakkan, atau tidak bisa menggerakkan tangan tapi lengannya masih bisa digerakkan. Hal ini semua tergantung dari luas tidaknyanya kerusakan. EPIDEMIOLOGI

Tetraparese salah satunya disebabkan karena adanya cedera pada medula spinalis. menurut Pusat Data Nasional Cedera Medula Spinalis (The (The National Spinal Cord Injury  Data Research Centre) Centre) memperkirakan ada 10.000 kasus baru cedera medula spinalis setiap tahunnya di Amerika Serikat. Angka insidensi paralisis komplet akibat kecelakaan diperkirakan 20 per 100.000 penduduk, dengan angka tetraparese 200.000 per tahunnya. Kecelakaan kendaraan bermotor merupakan penyebab utama cedera medula spinalis. Cedera medula spinalis dapat dibagi menjadi komplet dan tidak komplet  berdasarkan ada/tidaknya fungsi yang dipertahankan di bawah lesi. Pembagian ini  penting untuk meramalkan prognosis dan penanganan selanjutnya. Data di Amerika Serika Serikatt menunju menunjukkan kkan urutan urutan frekue frekuensi nsi disabi disabili litas tas neurolo neurologis gis karena karena cedera cedera medula medula spinal spinalis is trauma traumatik tikaa sbb : (1) tetrap tetrapare arese se inkomp inkomplet let (29,5% (29,5%), ), (2) parapa parapares resee komplet komplet

(27,3%), (3) paraparese inkomplet (21,3%), dan (4) tetraparese komplet (18,5%). ETIOLOGI

Tabel 1. Penyebab umun dari tetraparesis : Complete/incomplete transection of cord with fracture  Prolapsed disc Cord contusion-central cord syndrome, anterior cord syndrome Guillain-Barre Syndrome (post infective polyneuropathy) Transverse myelitis Acute myelitis  Anterior spinal artery occlusion Spinal cord compression  Haemorrhage into syringomyelic cavaty  Poliomyelitis

PATOFISIOLOGI

Tetraparese dapat disebabkan karena kerusakan Upper Motor Neuron (UMN) atau kerusakan Lower kerusakan  Lower Motor Neuron (LMN). Kelumpuhan/kelemahan yang terjadi pada kerusakan Upper Upper Motor Motor Neuron Neuron (UMN) (UMN) diseba disebabkan bkan karena karena adanya adanya lesi lesi di medula medula spinalis. Kerusakannya bisa dalam bentuk jaringan scar, atau kerusakan karena tekanan dari vertebra atau diskus intervetebralis. Hal ini berbeda dengan lesi pada LMN yang  berpengaruh pada serabut saraf yang berjalan dari kornu anterior medula spinalis sampai ke otot. Pada columna vertebralis terdapat nervus spinalis, yaitu nervus servikal, thorakal, lumbal, lumbal, dan sakral sakral.. Kelump Kelumpuhan uhan berpen berpengar garuh uh pada pada nervus nervus spinal spinalis is dari dari servik servikal al dan

lumbosakral dapat menyebabkan kelemahan/kelumpuhan pada keempat anggota gerak. Wilayah ini penting, jika terjadi kerusakan pada daerah ini maka akan berpengaruh pada otot, organ, dan sensorik yang dipersarafinya. Ada dua tipe lesi, yaitu lesi komplit dan inkomplit. Lesi komplit dapat menyebabkan kehilangan kontrol otot dan sensorik secara total dari bagian dibawah lesi, sedangkan lesi inkomplit mungkin hanya terjadi kelumpuhan otot ringan (parese) dan atau mungkin kerusakan sensorik. Lesi pada UMN dapat menyebabkan parese  spastic sedangkan lesi pada LMN menyebabkan parese flaccid. 010009000003a7f700000000237c000000001610000026060f002220574d464301000000000 001007cef00000000080000000020000094ca000094ea0000010000006c00000000000000000 00000bd0000006e0000000000000000000000341a0000480f000020454d460000010094ea00 000f000000010000000000000000000000000000000005000020030000c40100001a0100000 00000000000000000000000e3e306006e4e0400460000002c00000020000000454d462b0140 01001c000000100000000210c0db01000000600000006000000046000000e4380000d838000 0454d462b224004000c000000000000001e4009000c00000000000000244001000c00000000 0000003040020010000000040000000000803f214007000c000000000000000840000530380 000243800000210c0db01000000000000000000000000000000000000000100000089504e47 0d0a1a0a0000000d49484452000000be0000006f080600000052167a1700000006624b47440 0ff00ff00ffa0bda7930000000774494d4507d80b0600051ee77a93090000200049444154789c ed9d797853d5d6877f27739a26e994a6234de7b9a585b6cc8350442920888aa8f753e12a8823c e5ef43a5d5041b9a282332a2820a0280282cc50660a1d286de9dca4f33ca469a6f3fdb193369dd 3342de0cdfb3c7d7a7a867d76d275f6597badb5d7026cd8b061c3860d1b366cd8b061c3c64d0e 1d35b4e7dffa306e74076c58139a0dd023013c00d014d9a61d015a02d0fe00cd03e818c36f164

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563355f3563345f3563355f3563345f3563355f3563345f3563786bde7bbd77bd77bd77de7bbd 77bd77bd77de7bbd77bd77bd771042ff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7f  ff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7fff7 Gambar 3. Lesi pada  Lower motor neuron (LMN). Lesi di Mid- or upper cervical cord 

Tiap lesi di medula spinalis yang merusak daerah jaras kortikospinal lateral menimbulkan kelumpuhan Upper Motor Neuron (UMN) pada otot-otot bagian tubuh yang terletak di bawah tingkat lesi. Lesi transversal medula spinalis pada tingkat servikal, misalnya C5 mengakibatkan kelumpuhan Upper Motor Neuron (UMN) pada otot-otot tubuh yang berada dibawah C5, yaitu sebagian otot-otot kedua lengan yang berasal yang  berasal dari miotom C6 sampai miotom C8, lalu otot-otot thoraks dan abdomen serta segenap otot kedua tungkai yang mengakibatkan kelumpuhan parsial dan defisit neurologi yang tidak masif di seluruh tubuh. Lesi yang terletak di medula spinalis tersebut maka akan menyebabkan kelemahan/kelumpuhan keempat anggota gerak yang disebut tetraparese spastic. Lesi di Low cervical cord 

Lesi transversal yang merusak segmen C5 ke bawah itu tidak saja memutuskan  jaras kortikospinal lateral, melainkan ikut memotong segenap lintasan asendens dan desendens lain. Disamping itu kelompok motoneuron yang berada didalam segmen C5 kebawah ikut rusak. Ini berarti bahwa pada tingkat lesi kelumpuhan itu bersifat Lower   Motor Neuron (LMN) dan dibawah tingkat lesi bersifat Upper Motor Neuron (UMN). Dibawah ini kelumpuhan  Lower Motor Neuron (LMN) akan diuraikan menurut

komponen-komponen Lower Motor Neuron (LMN). Motoneuron-motoneuron berkelompok di kornu anterius dan dapat mengalami gangguan secara selektif atau terlibat dalam satu lesi bersama dengan bangunan disekitarnya, sehingga di dalam klinik dikenal sindrom lesi di kornu anterius, sindrom lesi yang selektif merusak motoneuron dan jaras kortikospinal, sindrom lesi yang merusak motoneuron dan funikulus anterolateralis dan sindrom lesi di substantia grisea sentralis . Lesi ini biasanya disebabkan karena adanya infeksi, misalnya poliomielitis. Pada umumnya motoneuron-motoneuron yang rusak didaerah intumesensia servikal dan lumbalis sehingga kelumpuhan LMN adalah anggota gerak. Kerusakan pada radiks ventralis (dan dorsalis) yang reversibel dan menyeluruh dapat terjadi. Kerusakan itu merupakan perwujudan reaksi imunopatologik. walaupun segenap radiks (ventralis/dorsalis) terkena, namun yang berada di intumesensia servikalis dan lumbosakralis paling berat mengalami kerusakan. Karena daerah ini yang mengurus anggota gerak atas dan bawah. Pada umumnya bermula dibagian distal tungkai kemudian  bergerak ke bagian proksimalnya. Kelumpuhannya meluas ke bagian tubuh atas, terutama otot-otot kedua lengan. Kelainan fungsional sistem saraf tepi dapat disebabkan kelainan  pada saraf di sumsum tulang belakang atau kelainan sepanjang saraf tepi sendiri. Salah satu penyakit dengan lesi utama pada neuron saraf perifer adalah polineuropati. Lesi di otot dapat berupa kerusakan struktural pada serabut otot atau selnya yang disebabkan infeksi, intoksikasi eksogen/endogen, dan degenerasi herediter. Karena serabut otot rusak, kontraktilitasnya hilang dan otot tidak dapat melakukan tugasnya. Penyakit di otot bisa berupa miopati dan distrofi, dapat menyebabkan kelemahan di

keempat anggota gerak biasanya bagian proksimal lebih lemah dibanding distalnya. Pada  penderita distrofia musculorum enzim kreatinin fosfokinase dalam jumlah yang besar, sebelum terdapat manifestasi dini kadar enzim ini di dalam serum sudah jelas meningkat. akan tetapi mengapa enzim ini dapat beredar didalam darah tepi masih belum diketahui. KLASIFIKASI

Pembagian tetraparese berdasarkan kerusakan topisnya: Tetraparese spastik  Tetraparese spastik terjadi karena kerusakan yang mengenai upper motor neuron (UMN), sehingga menyebabkan peningkatan tonus otot atau hipertoni.

Tetraparese flaksid Tetraparese flaksid terjadi karena kerusakan yang mengenai lower motor neuron (LMN), sehingga menyebabkan penurunan tonus atot atau hipotoni. DIAGNOSIS BANDING

a. Penyakit infeksi -

Mielitis transversa Dapat menyebabkan satu sampai dua segmen medula spinalis rusak sekaligus, infeksi dapat langsung terjadi melalui emboli septik, luka terbuka ditulang belakang,  penjalaran osteomielitis atau perluasan proses meningitis piogenik. Istilah mielitis tidak  hanya digunakan jika medula spinalis mengalami peradangan, namun juga jika lesinya

mengalami peradangan dan disebabkan oleh proses patologik yang mempunyai hubungan dengan infeksi. Adakalanya reaksi imunologik timbul di medula spinalis setelah beberapa minggu sembuh dari penyakit viral. Pada saat itu sarang-sarang reaksi imunopatologik  yang berukuran kecil tersebar secara difus sepanjang medula spinalis. Serabut-serabut asenden dan desenden panjang dapat terputus oleh salah satu lesi yang tersebar luas, sehingga dapat menimbulkan kelumpuhan parsial dan defisit sensorik yang tidak masif di seluruh tubuh atau yang dikenal dengan istilah tetraparese. Poliomielitis Poliomielitis adalah peradangan pada daerah medula spinalis yang mengenai substantia grisea. Jika lesi mengenai medula spinalis setinggi servikal atas maka dapat menyebabkan kelemahan pada anggota gerak atas dan bawah . Pada umumnya kelompok  motoneuron di segmen-segmen intumesensia servikal dan lumbalis merupakan substrat tujuan viral. Tahap kelumpuhan bermula pada akhir tahap nyeri muskular. Anggota gerak  yang dilanda kelumpuhan LMN adalah ekstremitas.  b. Polineuropati Polineuropati adalah kelainan fungsi yang berkesinambungan pada beberapa  saraf perifer di seluruh tubuh. Penyebab karena infeksi bisa menyebabkan polineuropati, kadang karena racun yang dihasilkan oleh beberapa bakteri (misalnya pada difteri) atau karena reaksi autoimun, bahan racun bisa melukai saraf perifer dan menyebabkan  polineuropati atau mononeuropati (lebih jarang), kanker bisa menyebabkan polineuropati dengan menyusup langsung ke dalam saraf atau menekan saraf atau melepaskan bahan racun, kekurangn gizi dan kelainan metabolik juga bisa menyebabkan polineuropati. Kekurangan vitamin B bisa mengenai saraf perifer di seluruh tubuh, penyakit yang bisa

menyebabkan polineuropati kronik  (menahun) adalah diabetes, gagal ginjal dan kekurangan gizi (malnutrisi) yang berat. Polineuropati kronik cenderung berkembang secara lambat (sampai beberapa bulan atau tahun) dan biasanya dimulai di kaki (kadang di tangan). Kelainan pada saraf perifer dijumpai sebagai berikut : tiga sampai empat hari  pertama pembengkakan dan menjadi irreguler dari selubung myelin. Hari ke lima terjadi desintegrasi myelin dan pembengkakan aksis silinder. Pada hari ke sembilan timbul limfosit, hari ke sebelas timbul fagosit dan pada hari ketiga belas proliferasi Schwan sel. Kesemutan, mati rasa, nyeri terbakar dan ketidakmampuan untuk merasakan getaran atau  posisi lengan, tungkai dan sendi merupakan gejala utama dari polineuropati kronik.  Nyeri seringkali bertambah buruk di malam hari dan bisa timbul jika menyentuh daerah yang peka atau karena perubahan suhu. Ketidakmampuan untuk merasakan posisi sendi menyebabkan ketidakstabilan ketika berdiri dan berjalan. Pada akhirnya akan terjadi kelemahan otot dan atrofi (penyusutan otot). Kelumpuhan biasanya timbul sesudah tidak  ada panas, kelumpuhan otot biasanya bilateral dan simetris dengan tipe "lower motor  neuron dengan penyebaran kelumpuhan yang bersifat ascending yaitu mulai dari ekstrimitas bawah yang menjalar ke ekstrimitas atas, tetapi bisa pula descending yaitu mulai dari ekstrimitas atas yang turun ke ekstrimitas bawah. Sindrom Guillain Barre (SGB) Sindroma Guillain Barre (SGB) adalah suatu kelainan sistem saraf akut dan difus yang mengenai radiks spinalis dan saraf perifer, dan kadang-kadang juga saraf kranialis, yang biasanya timbul setelah suatu infeksi. Manifestasi klinis utama dari SGB adalah suatu kelumpuhan yang simetris tipe lower motor neuron dari otot-otot ekstremitas,

 badan dan kadang-kadang juga muka.

Sindrom Guillain Barr

Akibat suatu infeksi atau keadaan tertentu yang mendahului SGB akan timbul autoantibodi atau imunitas seluler terhadap jaringan sistim saraf-saraf perifer. Infeksiinfeksi meningokokus, infeksi virus, sifilis ataupun trauma pada medula spinalis, dapat menimbulkan

perlekatan-perlekatan

selaput

araknoid.

Di

negara-negara

tropik 

 penyebabnya adalah infeksi tuberkulosis. Pada tempat-tempat tertentu perlekatan pasca infeksi itu dapat menjirat radiks ventralis (sekaligus radiks dorsalis). Karena tidak  segenap radiks ventralis terkena jiratan, namun kebanyakan pada yang berkelompokan saja, maka radiks-radiks yang diinstrumensia servikalis dan lumbosakralis saja yang  paling umum dilanda proses perlekatan pasca infeksi. Oleh karena itu kelumpuhan LMN  paling sering dijumpai pada otot-otot anggota gerak, kelompok otot-otot di sekitar   persendian bahu dan pinggul. Kelumpuhan tersebut bergandengan dengan adanya defisit sensorik pada kedua tungkai atau otot-otot anggota gerak. Secara patologis ditemukan degenerasi mielin dengan edema yang dapat atau tanpa disertai infiltrasi sel. Infiltrasi terdiri atas sel mononuklear. Sel-sel infiltrat terutama terdiri dari sel limfosit berukuran kecil, sedang dan tampak pula, makrofag, serta sel

 polimorfonuklear pada permulaan penyakit. Setelah itu muncul sel plasma dan sel mast. Serabut saraf mengalami degenerasi segmental dan aksonal. Lesi ini bisa terbatas pada segmen proksimal dan radiks spinalis atau tersebar sepanjang saraf perifer. Predileksi  pada radiks spinalis diduga karena kurang efektifnya permeabilitas antara darah dan saraf   pada daerah tersebut. Manifestasi klinis utama adalah kelumpuhan otot-otot ekstremitas tipe lower  motor neuron. Pada sebagian besar penderita kelumpuhan dimulai dari kedua ekstremitas  bawah kemudian menyebar secara asenden ke badan, anggota gerak atas dan saraf  kranialis. Kadang-kadang juga bisa keempat anggota gerak dikenai secara serentak, kemudian menyebar ke badan dan saraf kranialis. Kelumpuhan otot-otot ini simetris dan diikuti oleh hiporefleksia atau arefleksia. Biasanya derajat kelumpuhan otot-otot bagian  proksimal lebih berat dari bagian distal, tapi dapat juga sama beratnya, atau bagian distal lebih berat dari bagian proksimal. d. Miastenia Grafis Miastenia grafis adalah penyakit neuromuskular yang menyebabkan otot skelet menjadi lemah dan lekas lelah. Kelelahan/kelemahan ini disebabkan karena sirkulasi antibodi yang memblok  acetylcholine receptors pada post sinaptik  neuromuscular   junction , stimulasi penghambatan ini berpengaruh pada neurotransmiter asetilkolin. Manifestasi klinisnya dapat berupa kelemahan pada otot yang mengatur pergerakan mata, kelemahan otot pada lengan dan tungkai, perubahan ekspresi wajah, disfagia, dan disartria.

Miastenia Gravis

e. Amyotrophic Lateral Sclerosis (ALS) Penyakit  Amyotrophic Lateral Sclerosis (ALS) adalah suatu kelainan yang  progresif dari sistem saraf yang banyak terjadi pada orang dewasa dengan penyakit motoneuron. Kondisi tersebut menyebabkan degenerasi saraf motorik bagian atas (brain) dan saraf motorik bagian bawah ( spinal cord ) dengan kombinasi tanda upper motor  neuron (UMN) dan lower motor neuron (LMN). Penurunan kualitas saraf ini, menyebabkan Kelemahan pada otot dan dapat berakhir pada kematian.

Amyotrophic Lateral Sclerosis

Proses degenerasi hanya menyerang pada neuron motorik, yaitu sel-sel saraf yang mengatur pergerakkan otot. Akibat kelemahan itu, kemampuan tubuh untuk mengatur  gerakan otot yang disadari akan hilang secara perlahan-lahan. Misalnya, memegang, menjentik, menggaruk, dan sebagainya. Namun penyakit ini tidak mempengaruhi saraf  sensoris (perasa) dan fungsi mental. Meskipun penyebab pasti ALS belum diketahui, teori yang dikenal saat ini menyatakan neurotransmiter glutamat  (suatu zat kimia yang menghantarkan impuls atau sinyal ke sel-sel saraf) kemungkinan memegang peranan sebagai penyebab matinya sel-sel saraf motorik. Zat-zat kimia lainnya, seperti molekul radikal bebas dan kalsium kemungkinan juga ikut terlibat. Penyakit ALS mengakibatkan sistem neuromuscular tidak berfungsi karena kedua saraf motorik penderita ALS telah rusak.

Seiring berjalannya waktu, penyakit ALS

menyebabkan saraf–saraf motorik yang berada di otak dan batang tubuh mengecil, dan  pada akhirnya menghilang. Akibatnya, otot – otot tubuh tidak lagi mendapat sinyal untuk   bergerak. Karena otot yang berada dalam tubuh kehilangan pemasok nutrisinya, sehingga otot–otot yang menjadi lebih kecil dan melemah. Saraf-saraf di dalam sistem

neuromuscular  yang memberi nutrisi ke otot-otot tersebut terlokalisir, sehingga menyebabkan tumbuhnya jaringan yang rusak mengantikan saraf–saraf yang normal. f. Spondilosis servikalis

merupakan suatu penyakit yang menyerang usia pertengahan dan usia lanjut, dimana diskus

dan tulang belakang di leher mengalami kemunduran (degenerasi).

Spondilosis Servikalis

Spondilosis servikalis menyebabkan menyempitnya kanal spinalis (tempat lewatnya medula spinalis) di leher dan menekan medula spinalis atau akar saraf spinalis, sehingga menyebabkan kelainan fungsi. Gejalanya bisa menggambarkan suatu penekanan medula spinalis maupun kerusakan akar sarafnya. Jika terjadi penekanan medula spinalis, maka

 pertanda awalnya biasanya adalah perubahan pada cara berjalan. Gerakan kaki menjadi kaku dan penderita berjalan dengan goyah. Leher terasa nyeri, teutama jika akar sarafnya terkena. Kelemahan dan penciutan otot pada salah satu atau kedua lengan bisa terjadi sebelum

maupun

sesudah

timbulnya

gejala

penekanan

medula

spinalis.

g. Spondilitis Tuberkulosa

Tuberkulosis tulang belakang atau dikenal juga dengan spondilitis tuberkulosa merupakan peradangan granulomatosa yang bersifat kronik destruktif yang disebabkan oleh mikobakterium tuberkulosa. Spondilitis tuberkulosa dikenal juga sebagai penyakit Pott, paraplegi Pott. Spondilitis ini paling sering ditemukan pada vertebra T8-L3 dan  paling jarang pada vertebra C1-2.(1,2,3,4). Spondilitis tuberkulosa merupakan 50% dari seluruh tuberkulosis tulang dan sendi. Tuberkulosis tulang belakang merupakan infeksi sekunder dari tuberkulosis di tempat lain di tubuh, 90-95% disebabkan oleh mikobakterium tuberkulosis tipik (2/3 dari tipe human dan 1/3 dari tipe bovin) dan 5-10% oleh mikobakterium tuberkulosa atipik. Kuman ini berbentuk batang, mempunyai sifat khusus yaitu tahan terhadap asam pada pewarnaan. Oleh karena itu disebut pula sebagai Basil Tahan Asam (BTA). Kuman TB cepat mati dengan sinar matahari langsung, tetapi dapat bertahan hidup beberapa jam di tempat yang gelap dan lembab. Dalam jaringan tubuh kuman ini dapat dorman, tertidur lama selama beberapa tahun. Basil TB masuk ke dalam tubuh sebagian besar melalui traktus respiratorius. Pada saat terjadi infeksi primer, karena keadaan umum yang buruk maka dapat terjadi basilemia. Penyebaran terjadi secara hematogen. Basil TB dapat tersangkut di paru, hati limpa, ginjal dan tulang. 6 hingga 8 minggu kemudian, respons imunologik timbul dan fokus tadi dapat mengalami reaksi selular yang kemudian menjadi tidak aktif atau mungkin

sembuh sempurna. Vertebra merupakan tempat yang sering terjangkit tuberkulosis tulang. Penyakit ini paling sering menyerang korpus vertebra. Penyakit ini pada umumnya mengenai lebih dari satu vertebra. Infeksi berawal dari bagian sentral, bagian depan, atau daerah epifisial korpus vertebra. Kemudian terjadi hiperemi dan eksudasi yang menyebabkan osteoporosis dan perlunakan korpus. Selanjutnya terjadi kerusakan  pada korteks epifise, discus intervertebralis dan vertebra sekitarnya. Kerusakan pada  bagian depan korpus ini akan menyebabkan terjadinya kifosis yang dikenal sebagai gibbus. Berbeda dengan infeksi lain yang cenderung menetap pada vertebra yang  bersangkutan,

tuberkulosis

akan

terus

menghancurkan

vertebra

di

dekatnya.

Kemudian eksudat (yang terdiri atas serum, leukosit, kaseosa, tulang yang fibrosis serta  basil tuberkulosa) menyebar ke depan, di bawah ligamentum longitudinal anterior dan mendesak aliran darah vertebra di dekatnya. Eksudat ini dapat menembus ligamentum dan berekspansi ke berbagai arah di sepanjang garis ligament yang lemah. Pada daerah servikal, eksudat terkumpul di belakang fasia paravertebralis dan menyebar  ke lateral di belakang muskulus sternokleidomastoideus. Eksudat dapat mengalami  protrusi ke depan dan menonjol ke dalam faring yang dikenal sebagai abses faringeal. Abses dapat berjalan ke mediastinum mengisi tempat trakea, esophagus, atau kavum  pleura. Abses pada vertebra torakalis biasanya tetap tinggal pada daerah toraks setempat menempati daerah paravertebral, berbentuk massa yang menonjol dan fusiform. Abses  pada daerah ini dapat menekan medulla spinalis sehingga timbul paraplegia. Abses pada daerah lumbal dapat menyebar masuk mengikuti muskulus psoas dan muncul di bawah ligamentum inguinal pada bagian medial paha. Eksudat juga dapat menyebar ke daerah krista iliaka dan mungkin dapat mengikuti pembuluh darah femoralis pada trigonum

skarpei atau region glutea. DIAGNOSIS

Diagnosis ditegakkan berdasarkan : Anamnesis (Riwayat penyakit sekarang, riwayat penyakit dahulu dan riwayat penyakit keluarga). Pemeriksaan penunjang : Foto vertebrae servikal/lumbal→untuk mengetahui adanya trauma, penyempitan maupun pergeseran susunan tulang belakang. Fungsi lumbal→untuk menyingkirkan beberapa penyakit pembanding seperti sindrom guillain barr→adanya peningkatan protein sito albumin yang disertai  peningkatan jumlah selnya. Elektromiografi→menunjukan adanya fibrilasi, fasikulasi, atrofi dan denervasi (pada  penyakit ALS) MRI PENATALAKSANAAN

Penatalaksanaan dilakukan berdasarkan penyebabnya. Namun dapat dilakukan terapi umum sebagai berikut: Medikamentosa Kortikosteroid→ untuk mengurangi nyeri, juga dipercaya dapat menghasilkan

 perbaikan neurologis. Antidiabetika→ pada kasus-kasus yang diperburuk oleh penyakit diabetes mellitus. Terapi konservatif  a.Tirah baring (bed rest)  b. Memberi korset yang mencegah gerakan vertebra /membatasi gerak vertebra c. Memperbaiki keadaan umum penderita 3. Fisioterapi : Program : Infra Red, ROM (range of motion) dan meningkatkan kekuatan otot ekstremitas atas dan bawah. Terapi Okupasi 

Problem : agak kesulitan melakukan pekerjaan yang biasanya dilakukan sendiri karena terlalu lama berbaring. Assesment: Pasien mengalami deconditioning syndrome. Program : Melatih pasien untuk latihan bekerja, seperti apa yang biasanya dilakukan sendiri, melatih kekuatan duduk, berdiri dan berjalan. Melakukan kegiatan sehari-hari sendiri, dan tanpa bantuan orang lain, misalnya  berpakaian, makan, dan rawat diri. AKS/ADL secara luas berkaitan dengan aspek psikologis, komunikasi, sosial.

I. PROGNOSIS Prognosis penderita dipengaruhi oleh pengobatan terhadap penyebab tetraparesis

itu sendiri. Diagnosis sedini mungkin dan dengan pengobatan yang tepat, prognosisnya  baik meskipun tanpa tindakan operatif. Penyakit dapat kambuh jika pengobatan tidak  teratur atau tidak dilanjutkan setelah beberapa saat.