LBP - Dr. Dessy Sp.s
LBP - Dr. Dessy Sp.s
LBP - Dr. Dessy Sp.s
Occupation
Lecturer of Neurology Department, Medical Faculty of Syiah Kuala
University/Dr Zainoel Abidin hospital (RSUZA), Banda Aceh
Consultant in Pain and Headache.
Chairman of Neurology Training Program of Syiah Kuala Medical Faculty
Chairman of The Integrated Pain Management Program in RSUZA
Organization
• Vice of Chief Indonesian Neurological Association Banda Aceh
• Vice of Chief Indonesian Medical Doctor Association, Aceh Region
• Chairman of Pain Study Group, Indonesian Neurological Association Banda Aceh
• Member of Pain Study Group, Indonesian Neurological Association Indonesia
• Member of International Association for study of pain (IASP)
Publication
• Emril D, Syafruddin, Samekto W, Lucas M, Rina S. Perbandingan Metode Crush Injury
dengan Metode Partial Sciatic Transection dalam Induksi Nyeri Neuropatik pada Hewan
Coba. Neurona Vol. 32 No. 1; 2014.
• Emril D, Basic and Advance Interventional Pain Management, ASNA Conference, Bali,
2011.
• Emril D, Interventional Pain Management in Neurology Case. INA Conference, Manado,
2011
• Emril D, Kok Yuen Ho. 2010. Treatment of trigeminal neuralgia: role of radiofrequency.
Journal of Pain Research :3 1-6
• Emril D. Management of Trigeminal Neuralgia. 2010. Neurona. April 2010
• Syahrul, Emril D, Penggunaan Skala Stroke Syiah Kuala Sebagai Metode Diagnosis yang
Cepat dan Akurat. 2010. Neurona; Vol 27 no 2: 59-65.
• Emril D. Interventional management of Trigeminal neuralgia. 2009. Jurnal Kedokteran
Syiah Kuala; 2: 83-9
• Emril D. Interventional management for chronic pain. 2009. Jurnal Kedokteran Syiah
Kuala; 3: 139-44
• Emril D, Puspitasari V, Mayza A. 2005. Elevated Blood Viscocity in People 60
Years Up. Neurona. 14: 21-23
• Emril D, JAnnis J. 2004. Diagnosis Etiologi Lesi Desak Ruang Intrakranial:
Infeksi atau Neoplasma?. Neurona. 2: 34-7
• Emril D, Jannis J, Kiemas L. 2003. Leukositosis Sebagai Salah Satu Indikator
Adanya Lesi Struktural Intrakranial Pada Penderita Cedera Kranioserebral dengan
SKG 13-15. Neurona. 21:13-9
• Emril D. Cytidine 5’-Dophosphocoline Administration Prevent Peripheral
Neuropathic Pain after Rat Sciatic Nerve Crush Injury. Journal of Pain Research
Vol. 9, p.1-5; 2015.
• Emril D. Pain Intervention with USG Guidence. Continuing Neurology Education;
2014.
• Emril D. How to diagnose low back pain properly, Nyeri Punggung Bawah. Badan
Penerbit Universitas Diponegoro; 2013; ISBN : 978-602-097-352-4.
• Emril D. Faktir Risiko Nyeri Pinggang Bawah Kronik pada Penderita Usia Dewasa
Muda di RSUD dr. Zainoel Abidin Banda Aceh. Neurona Vol. 27 No. 4 Juli; 2012.
• Emril D. The role of interventional technique in the management of chronic pain,
50-4. Prosiding 9th Biennial Convention of ASNA Bali; 2011; ISBN : 978-602-
042.
• Emril D. Interventional Pain Management in Neurology Case. Prosiding
Neurology Update Konas Perdossi VII; 2011; ISBN : 978-979-115-138-2.
• Emril D. Treatment of Trigeminal Neuralgia: Role of Radiofrequency Abalation.
Journal of Pain Research; 2011; 3; 1-6.
• Emril D. Management of Neuralgia Trigeminal. Neurona Vol. 27 No. 4 Juli; 2010.
• Emril D. Penggunaan Skala Stroke Syiah Kuala pada Penderita Stroke sebagai
Metode Diagnosis Cepat dan Akurat. Neurona Vol. 27 No. 2 Januari; 2010; ISSN :
0216-6402.
• Emril D. Interventional Management for Chronic Pain. Jurnal Kedokteran Syiah
Kuala Vol. 9 No. 3 Desember; 2009; ISSN : 1412-1026.
• Emril D. Interventional Management of TN. Jurnal Kedokteran Syiah Kuala Vol. 9
No. 2 Agustus; 2009.
• Emril D. Elevated Blood Viscocity in People 60 Years Up. Neurona, 14: 21-23;
2005.
• Emril D. Diagnosis Etiologi Lesi Desak Ruang Intrakranial : Infeksi atau
Neoplasma?. Neurona, 2: 34-7; 2004.
• Emril D. Leukositosis sebagai salah satu indikator adanya lesi struktural
intrakranial pada penderita cedera kranioserebral dengan SKG. 13-15. Neurona,
21:13-9; 2003.
• Emril D. Continuing Neurology Education. Pain Intervention with USG Guidence.
Malang; Agustus 2014.
• Emril D. Advance Interventional Pain Management. Cervical Facet Joint Block.
Malang; Oktober 2014.
• Emril D. Neurology Update 2016. Introduction of IPM, and Interventional Pain
Management Approach in Low Back Pain. Jakarta; 2016.
Accurate Diagnosis as
Fundamental of Appropriate
Technique and Treatment in
Low Back Pain
Dr. dr. Dessy R. Emril, SpS (K)
Pain and Headache Divison, Neurology Department
Faculty of Medicine, Syiah Kuala University.
Banda Aceh
• The most recent guidelines for LBP patients:
o The clinician should go through a careful diagnosis of the mechanisms that sustain acute
and/or chronic pain. Treatment has to be addressed specifically to these mechanisms.
o avoid the common mistake of making the diagnosis of “simply low back pain”, resulting
in improper treatment of a definition and not a complex disease.
o As chronic LBP could have simultaneous multiple pain generators, a multidisciplinary
diagnosis and multimodal treatment is necessary.
How to classified etiology and
source of Pain in LBP
I. Mechanisms-based classifications
II. Etiology-based classifications
Mechanisms-based
classifications
Mechanisms-based
classifications
• Nociceptive pain (NP)
• Peripheral neuropathic pain
• Central sensitisation (CSP)
• Mixed pain
Symptoms and signs of nociceptive pain
in patients with low back (leg) pain
• A cluster of seven clinical criteria predictive of Nociceptive
Pain , including:
o Pain localised to the area of injury/dysfunction
o Clear, proportionate mechanical/anatomical nature to aggravating and
easing factors
o Usually intermittent and sharp with movement/mechanical provocation
o May be a more constant dull ache or throb at rest
o The absence of ‘Pain in association with other dysesthesias
• Night pain/disturbed sleep
• Antalgic postures/movement patterns
• Pain variously described as burning, shooting, sharp or electric-shock-like
9. Iatrogenic etiologies
a. Instrumentation
b. Lumbar surgery
Neurogenic etiologies of low back Pain
1. Spinal stenosis
a. Central and foraminal spinal stenosis (degenerative)
o Degenerative disc disease
o Facet hypertrophy and arthropathy
o Ligamentum flavum hypertrophy
o Vertebral fractures
o Neoplastic
o Abscess formation
o Hematoma formation
o Iatrogenic because of leaked vetebro or kyphoplasty residue
b. Congenital and developmental
o Incomplete vertebral arch closure
o Segmentation failure
o Achondroplasia
o Shortened pedicles
o Spina bifida
o Thoracolumbar kyphosis
o Apical vertebral wedging
o Osseous exostosis
Extraspinal etiologies of low back
pain
1. Rheumatologic conditions
2. Gastrointestinal
3. Pelvic and gynecological
4. Vascular
5. Infection
6. Neoplasms
7. Psychological
Structural and neurogenic etiology
• In LBP patients with degenerative signs of the spine, several
etiologies of structural and neurologic nature appear to work
in unison to cause the pain experienced by the patient.
• An extensive understanding of the various neurologic
etiologies, in addition to the structural derangements, is
paramount to developing expertise in LBP.
DIAGNOSTIC
PROCEDURES OF LBP
ANAMNESIS
Spesicic
Phatologogic Radicular pain or
spinal stenosis
condition
o Spine injury
o Fracture
o Tear ligamentum
o Disc problem
• Wilde et al.
o Positive Injection diagnostic test
o Back pain unilateral and could be located,,
o Pain in palpation of facet joint or trasvrese procc
o Pain is not radiating, Decrese by flexion
o berkurang dengan gerakan fleksi, dan jika ada nyeri alih terasa di atas dari lutut.
o Refered pain above the knee
Research
• Screen Shot 2017-03-23 at 4.56.23 AM
Scaroiliaca joint pain
Prosedure diagnostic SIJ
pain
distraction test,
Uji provokasi
compression test
• Akurasi
terbatas
thigh thrust test • Kombinasi
beberapa uji
provokasi
Patrick’s sign lebih
bermanfaat
Gaenslen’s test
Special diagnostic tools
SI join Spesifisitas dan
Moderat
validitas
Block
2. Non-narcotic analgesics
/NSAID – Acts on peripheral
nerve endings at the injury site
& decrease inflammatory
mediators
3. Adjuvant analgesic
- Developed other than for
analgesia but found to decrease
certain types of chronic pain
NSAIDs for LBP
• The most commonly prescribed medications include nonsteroidal
anti-inflammatory drugs (NSAIDs) and muscle relaxants.
• Although NSAIDs are a chemically diverse class, their
similarities, efficacy, tolerability, and adverse effect profile have
more similarities than differences.
• The most common side effects of NSAIDs are gastrointestinal.
• Agents with cyclo-oxygenase 2 selectivity are associated with
reduced gastrointestinal bleeding, but problematic increases in
adverse cardiovascular outcomes continue to spark concern.
• Fortunately, short-term use of NSAIDs for LBP is generally both
safe and effective.
Summary
• LBP must always be addressed as a complex disease in which
it is mandatory that an accurate diagnosis of pain generators is
determined before starting any treatment.
• All the guidelines currently avalaible stress the importance of
a multimodal and multidisciplinary approach in order to
determine a strategy to solve the problem and not simply
alleviate symptomatic pain.
• A careful follow up is important to adapt our therapeuthic
strategies to dynamic clinical manifestations of CLBP.
• Short-term use of NSAIDs for LBP is generally both safe
and effective.
PAIN MANAGEMENT IN
RSUD Dr. Zaionel Abidin
Banda Aceh
DIVISI NYERI DAN NYERI KEPALA
BAGIAN/SMF NEUROLOGI
FK UNSYIAH/RSUDZA
IPM Activity @ RSUD Dr. Zaionel Abidin Banda Aceh
Pain Management Team
PAIN MANAGEMENT
TRAINING
AT RSUZA TRAINING
CENTER
Manequin Hands On
IPM Patient Hands on
Thank You