CASE REPORT

ISCHIALGIA et causa Susp.

HERNIATED NUCLEUS PULPOSUS

By:
Dwi Ulfa Annisa

Supervisor
dr. RIKI SUKIANDRA, SpS

DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2016
 I. PATIENT’S IDENTITY
Name Mrs. N
Age 58 years old
Gender Female
Address Marpoyan Damai - Pekanbaru
Religion Islam
Marital Status Widow
Occupation Trader
Date of
August, 27th 2016
Admission
Medical
9327XX
Record
 II. ANAMNESIS
Chief Complain
 
 Continue
Past Illness
 III. PHYSICAL EXAMINATION

General status
 Blood Pressure : 140/80 mmHg / 140/80
mmHg
 Heart Rate : 84 bpm / 84 bpm (regullar)
 Respiratory Rate : 22 x/I thoracoabdominal
 Temperature : 36.8°C
Neurological status
 Consciousness : composmentis GCS : 15
 Cognitive Function : Normal
 Neck Stiffness : Negative
 Cranial Nerves : Normal
1. Cranial nerve I (Olfactory)
  Right Left Interpretation

Sense of Smell Normal Normal Normal

2. Cranial nerve II (Optic)

  Right Left Interpretation
Visual Acuity
Visual Fields
Normal Normal Normal
Colour Recognition

3. Cranial nerve III (Oculomotor)

Interpretatio
Right Left
n
Ptosis (-) (-)
Pupil    
Shape Round Round
Size Φ3 mm Φ3 mm
Extraokuler movement Normal Normal Normal
        
Pupillary reactions to    
light
Direct (+) (+)
Indirect (+) (+)
4. Cranial nerve IV (Trochlear)
  Right Left Interpretation
Extraokuler + +
Normal
movement

5. Cranial nerve V (Trigeminal)

  Right Left Interpretation
Motoric (+) (+)
Normal
Sensory Normal Normal
Corneal reflex (+) (+)

6. Cranial nerve VI (Abducens)

  Right Left Interpretation
Extraocular
(+) (+)
movement
(-) (-) Normal
Strabismus
(-) (-)
Deviation
 7. Cranial nerve VII (Facial)
Interpretatio
Right Left
n
Tic Motor (-) (-)
•Frowning Normal Normal
•Raised eye brow Normal Normal
•Close eyes  Normal  Normal
•Corners of the Normal Normal Normal
mouth  Normal  Normal
•Nasolabial fold    
  Normal Normal
Sense of Taste

8. Cranial nerve VIII (Acoustic)

  Right Left Interpretation

Hearing sign (+) (+) Normal

9. Cranial nerve IX (Glossopharyngeal)
  Right Left Interpretation

Arcus farings Normal Normal

Flavour sense Normal Normal Normal
Gag Reflex (+) (+)

10. Cranial nerve X (Vagus)

  Right Left Interpretation
Arcus farings Normal Normal
Normal
Dysphonia - -

11. Cranial nerve XI (Accessory)

  Right Left Interpretation
Motoric Normal Normal
Trophy eutrof eutrof Normal

12. Cranial nerve XII (Hypoglossal)

  Right Left Interpretation
Motoric Normal Deviation  
Trophy Eutrophy Eutrophy Normal 
Tremor - -
Dysarthria - -
 Interpretatio
Right Left
n
Upper Extremity
Strength IV. MOTOR SYSTEM
Distal 5 5
Proximal 5 5
Tone Normal Normal Normal
Trophy Eutrophy Eutrophy
Involuntary (-) (-)
movements (-) (-)
Clonus
Lower Extremity
Strength
Distal 5 5
Proximal 5 5
Normal, but
Tone Normal Normal
Patient feels
Trophy Eutrophy Eutrophy
pain
Involuntary (-) (-)
movements (-) (-)
Clonus
 V. SENSORY SYSTEM
Interpretatio
Right Left
n
Touch Decrease Normal
Pain Decrease Normal
Temperature No test No test
Proprioceptiv
Decrease of
e
 Position touch and
 Two point pain
Normal Normal
discriminati sensation in
Normal Normal
on right leg
 Stereognosi Normal Normal
(L4-L5)
s Normal Normal
 Graphestesi Normal Normal
a
 Vibration
 Right Left Interpretation

Physiologic
Biceps (+) VI. REFLEX
(+)
Triceps (+) (+) Physiologic reflex (+)
Knee (+) (+)
Ankle (+) (+)

Pathologic
Babinsky
(-) (-)
Chaddock Pathologic reflex (-)
(-) (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer
(-) (-)
Primitive Reflex
(-) (-)
Palmomental No Primitive Reflex
(-) (-)
Snout
 VII. COORDINATION

Right Left Interpretation

Point to point
(+) (+)
movements
Not Tested Not Tested
Walk heel to toe
Not Tested Not Tested
Gait Normal
Not Tested Not Tested
Tandem
Not Tested Not Tested
Romberg
 VIII. AUTONOMY SYSTEM
• Urination : Urine catheterized
• Defecation : Normal

IX. Others Examination

• Laseque : Limited mobility due to pain />70 0
• Kernig : Limited mobility due to pain/ > 135 0

• Patrick : Limited mobility due to pain /-

• Contrapatrick : Limited mobility due to pain /-
• Valsava test : +
• Naffziger : +
• CVA : -/-
 X. THE SUMMARY OF
EXAMINATION
 General Status :
 Blood Pressure :140/80 mmHg / 140/80 mmHg
 Heart Rate : 84 bpm / 84 bpm
 Respiratory Rate: 22 times per minute
 Temperature : 36,8°C

 Cognitive Function : Normal

 Neck Stiffness : Negative
 Cranial Nerves : Normal
 Motoric : Normal
 Sensory : Normal
 Coordination : Normal
 Autonomy : Normal
 Reflex : Normal
• Other Examination:
• Laseque : Positive/>70 0
• Kernig : Positive > 130 0
• Patrick : Positive /-
• Contrapatrick : Positive /-
• Valsava test : Positive
• Naffziger : Positive
 XI. WORKING DIAGNOSIS

 CLINICAL DIAGNOSIS:
Lumbal Radiculopathy
 TOPICAL DIAGNOSIS:
 Ischiadica Nervus Radix
 ETIOLOGICAL DIAGNOSIS:
 susp. Herniated Nukleus Pulposus
regio Lumbal
 DIFFERENTIAL DIAGNOSIS :
 Radiks Trauma
 XII. SUGGESTION EXAMINATION
 Blood routine
 Blood chemistry
 Electrolyte
 Lumbosacral AP lateral X-Ray
 Lumbal MRI
 XIII. MANAGEMENT

1. Bed Rest
2. Analgetic
 Tramadol drip 1 amp in NaCL 0,9% /
12 hours iv
 Ketorolac 3 x 30mg iv
 Amitriptilin 1 x ½ (25mg)(night)
 Ranitidin 2 x 1 amp (50mg)
 Mecobalamin 3 x 500 mg
3. Physiotheraphy
 XIV. LABORATORY AND
RADIOLOGY FINDINGS
 Blood Routine (August, 27th 2016)
• Hemoglobin : 12 g/dL
• Hematocrit : 34,6 %
• Leukocyte : 8.000/mm3
• Thrombocyte : 450.000/mm3

 Interpretation: Normal
Thoracic spine X-ray (August, 27 th
2016)

 Interpretation : Narrowing of L5-S1 disc

 Advise : Lumbal MRI
 FOLLOW UP
Tuesday , August, 30st 2016
S : Lower back pain radiating to the right leg
O :Composmentis, GCS: E4V5M6
Blood Pressure :140/90 mmHg
Heart Rate : 88 bpm
Respiratory Rate : 20 x/i
Temperature : 37,2 °C
Visual analog scale : 6
Motoric :
5 5
5 5
Sensory : Decrease of Right leg

Autonomy : urinate with urine catheterized

Reflex : Pathologic (-), Physiology (+)
 Continue ..

A : Ischialigia dextra et causa suspect HNP

P :
•Tramadol drip 1 amp in NaCL 0,9% /12
•Ketorolac 3 x 30mg iv
•Amitriptilin 1 x ½ tab 25mg (night)
•Ranitidin 2 x 1 amp (50 mg)
•Mecobalamin 3 x 500 mg
•Pro Lumbal Magnetic Resonance Imaging (MRI)
 FOLLOW UP

Wednesday , August, 31st 2016

S : Lower back pain radiating to the right leg
O :Composmentis, GCS: E4V5M6
Blood Pressure :140/90 mmHg
Heart Rate : 82 bpm
Respiratory Rate : 20 x/i
Temperature : 36,7 °C
Visual analog scale : 4
Motoric :
5 5
5 5
Sensory : Decrease of Right leg

Autonomy : urinate with urine catheterized

Reflex : Pathologic (-), Physiology (+)
 Lumbal MRI (August,31th 2016)

Interpretation :
•Disc Protrutio L4-5 type broad based with spinalis canalis stenosis.
•Foramen neural stenosis dextra and sinistra with iritation of Spinalis
nerve radix L5 bilateral.
•L5-S1 Disc Bulging.
 Continue ..

A : Herniated Nucleus Pulposus L5-S1

P :
•Tramadol drip 1 amp in NaCL 0,9% /12
•Ketorolac 3 x 30mg iv
•Amitriptilin 1 x ½ tab 25mg (night)
•Ranitidin 2 x 1 amp (50 mg)
•Mecobalamin 3 x 500 mg
•Pro Lumbal Magnetic Resonance Imaging (MRI)
DISCUSSION
 Mechanism of pain
Transduction
Pathofisiology and Classification
BASED ON TIME

Acute pain  Chronic pain 

Which usually occurs

in response to tissue
injury, results from Related to ongoing
activation of peripheral tissue injury is
pain receptors and presumably caused by
their specific A delta persistent activation of
and C sensory nerve these fibers
fibers (nociceptors)
 BASED ON
MECHANISM
Inflammatory
Nociceptive Pain
Pain
1. Nociceptive Pain
• Transient pain in response to noxious stimulus
• Arises from a stimulus outside of the nervous system
• Pain proportionate to the stimulation of nociceptors
• Serves as a protective function
2. Inflammatory Pain
•Initiated by tissue damage and/or inflammation
•Arises from a stimulus that is outside of the nervous system
•Spontaneous pain and hypersensitivity to noxious stimulus
•Disproportionate to the stimulation of nociceptors
•Serves no protective function
 BASED ON
MECHANISM

Neuropathic Pain Functional Pain

3. Neuropathic Pain
•Initiated or caused by a primary lesion or dysfunction in the nervous
system
•No nociceptive stimulation
•Disproportionate to the stimulation of receptors
•Other evidence of nerve damage (eg, postherpetic neuralgia)
4. Functional Pain
•Hypersensitivity to pain resulting from abnormal central processing of
normal input
•No nociceptive stimulation or nervous system lesion
Consequences of Peripheral and
Central Sensitization
Paresthesias
 Pain
Visual Analog Scale
(VAS)

Numerical Rating Scale

(NRS)

Verbal Rating Scale

(VRS)

Faces Pain Rating

Scale
 ANALGETIC MANAGEMENT

 Acetaminophen
 Nonselective nonsteroidal anti-inflammatory
drugs
 Cyclooxygenase (COX)-2 selective drugs
 Tramadol
 Opioids
 Tricyclic antidepressants
 Serotonin-norepinephrine reuptake inhibitors
 Local anesthetics
 Gabapentinoids (gabapentin and pregabalin)
 Capsaicin
 Ethiology
 •Irritation of the roots of the lower lumbar
and lumbosacral spine
 •Lumbar spinal stenosis (narrowing of the
spinal canal)
 •Degenerative disc disease (breakdown of
discs, which act as cushions between the
vertebrae)
 •Spondylolisthesis (a condition in which
one vertebra slips forward over another
one)
 •Piriformis Syndrome
 •More rarely, the nerve can be compressed
by a tumor or damaged by a disease such
 Diagnosis and Treatment

Physical Examination : Lasègue's sign

Radiologic: Vertebrae X-Ray

GOLD STANDAR : MRI

•Medications: Anti-inflammatory, Muscle

relaxants.
•Steroid injections: Corticosteroids help
reduce pain by suppressing inflammation
around the irritated nerve.
•Surgery
•Physical therapy
Anatom
y
DERMATOME
 RISK FACTOR OF HNP
Risk factors Risk factors
that can not that can be
be changed changed

1. Age: increasingly 1. Employment and

higher risk age activities
2. Gender: male more 2. Sports irregular
than female 3. Smoking
3. History of back 4. Excessive body
injury or trauma weight
Patophysiology HNP
 Lower Back Pain on HNP
L
LBP caused by a serious spinal disease (red
flags)
Abnormality Red Flags
Cancer or infection  Age> 50 or <20 years
 History of cancer
 Weight loss for no apparent reason
 immunosuppressant therapy
 UTI, IV drug abuse, fever, chills
 Back pain does not better with rest

Vertebral Fractures  History of significant trauma

 Long-term use of steroids
 Age> 70 years

Cauda equina  Acute urinary retention or overflow

syndrome or severe incontinence
neurologic deficits  Alvi incontinence or anal sphincter atony
 Saddle anesthesia
 Progressive paraparesis or paraplegia
 Diagnosis
Anamnesis
 Physical examination
General
 Supporting Examination

Laboratory
Radiologic: Vetebrae X-Ray

GOLD STANDAR : MRI

Management
Management
 THE BASIC OF
DIAGNOSE
C
E
THANK YOU