Neuropati perifer non diabetik
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Neuropati Perifer
Non Diabetik
dr. Herlyani Khosama, Sp.S(K)Divisi Neurofisiologi Klinik dan Saraf Perifer
FK UNSRAT/RS Prof RD Kandou
Manado
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PENDAHULUAN
Neuropati perifer terminology umum gangguan sarafperifer sensorik, motorik dan autonom
Gangguan sensorik termasuk neuropati perifer 5 besaralasan rujukan ke neurolog
Prevalensi neuropati perifer 2,4%, usia > 55 thn 8%
Bagaimana mendiagnosis, kasus apa yang perlu dirujukdan bagaimana penanganan simptomatik neuropatiperifer tantangan untuk dokter umum
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Pendahuluan
Kompetensi dokter umum:
Diagnosis Kompetensi
Carpal Tunnel Syndrome 3A
Tarsal Tunnel Syndrome 3A
Neuropati 3A
Peroneal Palsy 3A
Guillain Barre Syndrome 3B
Bells Palsy 4A
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KLASIFIKASI
NEUROPATI PERIFER
Anatomi:
Mononeuropati
Mononeuropati multipleks
Polineuropati
Onset:
Akut
Kronik
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Klasifikasi berdasar Etiologi
Acquired
Vasculitis (SLE)
Infection (HIV, CMV, EBV, Lepra)
Trauma
Autoimun
Metabolik (DM, def.vit B12,hipotiroid, renal, hepatik, porfiria)
Infiltratif (sarkoidosis, amilodosis)
Neoplasma, paraneoplastik
Demyelinating (GBS)
Toksisitas : Pb, Alkohol
Hereditary: Charcot-Marie-Tooth, HNPP
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Klasifikasi berdasar Patologi
Axonal
Demyelinating
Pemeriksaan neurofisiologi:
KHS dan EMG jarum
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Diagnosis Neuropati Perifer
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang
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Anamnesis
Keluhan pasien
Gejala sensorik: Kesemutan, kram,
hilang rasa
Gejala motorik: kelemahan
Gejala autonom: hipotensi
ortostatik, gangguan berkeringat
Gejala nyeri neuropatik: nyeri
terbakar, kesetrum, nyeri seperti
ditikam
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Anamnesis
Onset: akut atau kronis progresif
Lokalisasi keluhan: length dependent, length independent, multifocal
Modalitas yang terkena: 1 ataukombinasi
Riwayat Penyakit Dahulu, keluarga, kebiasaan, pekerjaan, obat
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Pemeriksaan Fisik
Sensori:
Kurang rasa
Hiperesthesia atau disesthesia
Stocking-Glove distribution
Propioseptif dan rasa getar
berkurang
Sensory ataxia: dismetri telunjuk
hidung (tutup mata)
Rasa Suhu berkurang sampai
hilang
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Pemeriksaan Fisik
Motorik:
Kekuatan otot menurun
Distal >proximal
< sensorik
Tanda-tanda LMN :
- Hiporefleks-arefleks achiless
- Atrofi
- Hipotoni
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Pemeriksaan Fisik
Otonom:
Gangguan berkeringat
Hipotensi Ortostatik
Lain-lain:
PES CAVUS
MEES LINE
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PEMERIKSAAN PENUNJANG
Neurofisiologi : EMG dan NCS
LP: Protein, glukosa, WBC
Lab Mencari penyebab
Autoimun, endokrin, infeksi,
inflamasi, metabolic,
neoplasma
Biopsi Saraf
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PENDEKATAN DIAGNOSIS NP
DI IGD
SIMETRIS ASIMETRIS
PROX/DISTAL DISTAL PROX/DISTAL DISTAL
MIXED MIXED MIXED PUREMIXED
MONONEUROPATHYMONONEUROPATHY
MULTIPLEX
GBS
DSPN
PRIMARY
AXONOPATHY
PLEXOPATI
/RADIKU-
LOPATI
MONO
NEURO
NOPATI
SENSORY
NEURON
OPATHY
AKUT KRONIK
CIDP
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Management
Polineuropati perifer
Obati Underlying disease
Terapi simptomatik:
Neuropatik pain
Rehabilitasi
KIE
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Recommendation for first- and second-line treatment (EFNS Guideline)
Kondisi
Nyeri
Lini pertama Level
Evidence
Lini kedua Level
evidence
Nyeri
Neuropati
Perifer
Pregabalin
Gabapentin
TCA
Opioid
A
A
A
A
Lamotrigin
SNRI
Tramadol
B
A
A
Post
Neuralgia
Herpetika
Pregabalin
Gabapentin
TCA
Lidocain
topical
A
A
A
B
Capsaicin
Tamadol
Opioid
Valproat
B
B
A
B
Tigeminal
neuralgia
Oxcarbazepin
Carbamazepin
B
A
Surgery
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Terapi Nyeri Neuropatik
pada Neuropati perifer
Pregabalin 150-600 mg/hari
Gabapentin 900-3600 mg/hari
Amitritilin 25-100 mg/hari
Duloxetine 60-120 mg/hari
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Bell’s Palsy Kelumpuhan N. VII Perifer
Akut, unilateral
Nyeri retroauricular sampai leher dan occiput
Gangguan pengecapan ipsilateral
Hiperakusis
Gangguan lakrimasi
Etiologi
- Edema N. VII perifer disebabkan Herpes Virus
(HSV-1 dan VZV)
- Iskemi, autoimun inflammatory disorders.
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Bell’s Palsy
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Prednisolon 50-60 mg 10 hari
Aciclovir 2000mg (HZ)
4000mg (VZ)
Lindungi kornea :
Eye ointment +proteksi
Fisioterapi
Penatalaksanaan Bells Palsy
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Prognosis Bells Palsy
2/3 sembuh total dalam 4 bulan
Kecepatan terapi steroid:
Pemberian steroid >9 hari onset
menurunkan kemungkinan sembuh
total.
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Bendera Merah Bells Palsy
Bilateral
Berulang
Berhubungan dengan rash
Disertai defisit neurologislain
RUJUK
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Guillain Barre Syndrome
Polineuropati akut akibat mediasi imun, sering
terjadi setelah suatu infeksi
Berdasarkan klinis dan temuan elektrofisiologi
dibagi:
- AIDP = Acute Inflamatory Demyelinating
Polineuropathy
- AMSAN= Acute Motor Sensory Axonal
Neuropathy
- AMAN= Acute Motor Axonal Neuropathy
- MFS= Miller Fisher Syndrome
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Guillan-Barré Syndrome
Antecedent infection : ISPA, infeksi GI
beberapa hari-beberapa minggu
Akut, simetris, arefleks
Extremitas bawah>atas (pola
ascending)
Otot-otot gerak mata jarang terkena
kecuali pada MFS
Berisiko terdapat keterlibatan otot-ototnapas1/3 butuh ventilator.
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Carpal Tunnel Sindrome
(Sindrom Terowongan Karpal)
Kompresi pada N. Medianus padacarpal tunnel
Faktor risiko:
Obesitas Artritis inflamasi
Hipotiroid Akromegali
DM Genetik
Kehamilan Usia
Gangguan ginjal Merokok
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Diagnosis CTS
Nocturnal Paresthesia
Awakening from sleep
Relief upon shaking the hand
Pain/Paresthesia with driving,
holding a phone or newspaper
Sensory disturbance in digit 1, 2, 3
Weekness/wasting of thenar
eminence
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Tarsal Tunnel Syndrome
Kompresi pada N. Tibialis posterior pada ankle
Gerakan repetitive dorsofleksi dan plantar fleksi
Biasanya berhubungan dengan factor intrinsic:
tendinitis, ganglioma, lipoma, trauma, edema,
dll
Nyeri pada tumit dan medial pergelangan kaki,
bisa terlokalisir pada postero-inferior malleolus
medial
Kesemutan pada posteroinferior malleolus
medial tumit menjalar ke plantar pedis
Nyeri bertambah saat berdiri, jalan dan lari
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Diagnosis TTS
Tinnel Sign
Dorsoflexion-aversion test
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Peroneal Neuropathy
Disfungsi pada N. Common Peroneal yang
menyebabkan gangguan motorik dan atau
sensorik pada kaki
Penyebab tersering:
Trauma/cedera lutut
Fraktur fibula
Penggunaan plester yang terlalu ketat pada paha
Penggunaan sepatu berhak tinggi
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Neuropati N. Peroneal
Berkurangnya sensasi pada lateral
tungkai atas dan bawah, punggung kaki
Kelemahan pada ankle dan kaki sulit
mengangkat kaki dan jari dan membuat
gerakan jari keluar
Drop foot
Slapping/steppage gait
Atrofi pada otot kaki
Pemeriksaan penunjang: Edx dan MRI
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Kesimpulan
Neuropati perifer dapat mengenai saraf
sensorik, motorik, otonom atau
kombinasi.
Anamnesis yang detail dan benar,
pemeriksaan fisik neurologi dan
pengetahuan anatomi yang baik dapat
membantu menentukan diagnosis
neuropati perifer dan membedakan
kasus gawat darurat dan tidak.
Pada kasus akut, diagnosis yang akurat
dan penanganan awal biasanya
mempengaruhi prognosis.
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