BMS2-K5 Pain & Neuralgia

7/21/2019 BMS2-K5 Pain & Neuralgia

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PAINPAIN

YUNELDI ANWAR YUNELDI ANWAR

Bagian Neurologi FK-USU/Bagian Neurologi FK-USU/RSUP H. Adam ali! edanRSUP H. Adam ali! edan



DEFINISI NYERIDEFINISI NYERI

Pengalaman sensorik dan emosional yangPengalaman sensorik dan emosional yang

tidak menyenangkan akibat kerusakan jaringan,tidak menyenangkan akibat kerusakan jaringan,

baik aktual maupun potensial, atau yang digambarkan dalambaik aktual maupun potensial, atau yang digambarkan dalam

bentuk kerusakan tersebut.bentuk kerusakan tersebut. International Association forInternational Association for

the Study of Painthe Study of Pain!!



Lemniskus Medialis

Traktus

spinotalamikus

lateralis

Korteks Sensori

Talamus

Kornu posterior

Radiks dorsalis

Nervus spinalis

Ganglion dorsalis

Reseptor

nyeri

(Nosiseptor )Nyeri nosiseptik

Nyeri neuropatik

Jaras penyaluran rasa nyeri



Classification

of

Peripheral

nerve

4



Serabut – serabut aferen nyeri perifer Serabut – serabut aferen nyeri perifer Sera"u# $Sera"u# $

halus, tidak bermielinhalus, tidak bermielin

diameter 0,4 – 1,1 umdiameter 0,4 – 1,1 um

kecepatan hantaran 0,5 – 2 m /seckecepatan hantaran 0,5 – 2 m /sec

resporesponnsiblesible stimulus polimodal( termal,stimulus polimodal( termal,

mekanikal, chemikal)mekanikal, chemikal)

sensasi agak lambat dan tumpul dan diffusesensasi agak lambat dan tumpul dan diffuse Sera"u#Sera"u# A % del#aA % del#a

tipis, bermielintipis, bermielin diameter 1,0 – 5 umdiameter 1,0 – 5 um

kecepatan hantaran 5 – 30 m / seckecepatan hantaran 5 – 30 m / sec

sensasi angsensasi ang cepat dancepat dan ta!amta!am dan terlokalisirdan terlokalisir

"espons to mekanikal and thermal stimuli"espons to mekanikal and thermal stimuli



D"N

PAININN#$%#%S SENSA&I#N

N#'I#%S

S&I(%)%SINN#$%#%S

S&I(%)%S

D"N

Touch

Tactile

Pressure

Physiological Pain

Aδ C fiber Aβ

First Pain

Second Pain



Stimulus yg membangkitkan nyeriStimulus yg membangkitkan nyeri

Kuli#Kuli# in&ur' &aringan o! #u(u!an)in&ur' &aringan o! #u(u!an)(a'a#an) *ana( dan dingin(a'a#an) *ana( dan dingin

Lam"ung/u(u(Lam"ung/u(u( in+lama(i mu!o(a)in+lama(i mu!o(a)

(*a(ma o#o# *olo() *erleng!e#an(*a(ma o#o# *olo() *erleng!e#an

,#o#-o#o# luri!,#o#-o#o# luri! i(!emi!i(!emi! ,#o# (!le#al,#o# (!le#al !on#ra!(i #eru( meneru(!on#ra!(i #eru( meneru(

,#o# &an#ung,#o# &an#ung i(!emi!i(!emi!

SendiSendi in+lama(i) (aline i*er#oni!in+lama(i) (aline i*er#oni!

Ar#eriAr#eri di(#en(i) *ul(a(i "erle"iandi(#en(i) *ul(a(i "erle"ian

Peregangan ar#eri dan mening (a!i#Peregangan ar#eri dan mening (a!i#

!e*ala!e*ala



Distribusi dermatom serabut*Distribusi dermatom serabut*

serabut nyeriserabut nyeri

Wa&a 0 "g de*an !e*ala -----Wa&a 0 "g de*an !e*ala ----- N 1N 1 Bela!ang !e*ala ----------------- $ 2Bela!ang !e*ala ----------------- $ 2

Leer ------------------------------- $ 3Leer ------------------------------- $ 3 Punda! ----------------------------- $ 4Punda! ----------------------------- $ 4 Bau ------------------------------- $ 5Bau ------------------------------- $ 5 Lengan "a6a radial/i"u &ari --- $ 7Lengan "a6a radial/i"u &ari --- $ 7

8elun&u! 0 &ari #enga ----------- $ 98elun&u! 0 &ari #enga ----------- $ 9 Lengan "a6a ulnar/!eling!ing % $ : 0 8;Lengan "a6a ulnar/!eling!ing % $ : 0 8;



Distribusi dermatomDistribusi dermatom

Pu##ing (u(u ----------------------- 8 5Pu##ing (u(u ----------------------- 8 5 Pu(a# ------------------------------- 8 ;<Pu(a# ------------------------------- 8 ;< Sela *aa -------------------------- L ;Sela *aa -------------------------- L ;

Si(i medial lu#u# ------------------ L 3Si(i medial lu#u# ------------------ L 3 I"u &ari !a!i ----------------------- L 5I"u &ari !a!i ----------------------- L 5 =ari !a!i !e 5 ---------------------- S ;=ari !a!i !e 5 ---------------------- S ; Paa "ela!ang -------------------- S 2Paa "ela!ang -------------------- S 2

>eni#o anal ----------------------->eni#o anal ----------------------- S 2)3)4S 2)3)4 1i(?eral in#ra #ora!al ----------1i(?eral in#ra #ora!al ---------- 8 ; % 48 ; % 4 U**er a"dominal organ -------U**er a"dominal organ ------- 8 7 - :8 7 - :



&+e Proess o- Pain&+e Proess o- Pain

#he process of pain#he process of pain fourfour

phases $phases $ 1% #ransduction1% #ransduction

2% #ransmission2% #ransmission

3%3% &odulation&odulation 4%4% 'erception'erception



TransductionTransduction

onersion of chemical information atonersion of chemical information atcellular leelcellular leel electrical inpulses thatelectrical inpulses that

moe to*ard the spinal cordmoe to*ard the spinal cord

+egins *hen in!ured cells release+egins *hen in!ured cells release locallocal chemicals such aschemicals such as prostaglandin,prostaglandin,

ubstance ', bradkinin, histamin,ubstance ', bradkinin, histamin, -.,-.,

c#c# potasiumpotasium andand serotininserotinin

eciteecite no?i?e*#orno?i?e*#or in the skin, bone,in the skin, bone, !oints, muscles, and internal organs !oints, muscles, and internal organs



&RANS(ISSI#N&RANS(ISSI#N

#he process b *ich impulses are#he process b *ich impulses aresent to the dorsal horn of the spinalsent to the dorsal horn of the spinal

cord, and than along the sensorcord, and than along the sensor

tracts to the braintracts to the brain pinal neurons pro!ect aon to thepinal neurons pro!ect aon to the

contra lateral thalamuscontra lateral thalamus cortekcortek

somatosensor (sensor aspect ofsomatosensor (sensor aspect ofpain, such as intensit and 6ualit)pain, such as intensit and 6ualit)

andand frontal cortek, limbic sstemfrontal cortek, limbic sstem

a(*e?# emo#iional o+ *aina(*e?# emo#iional o+ *ain



Spinot+alamiSpinot+alamitrattrat

Perip+eralPerip+eral

nerenere

Dorsal "ornDorsal "orn

Dorsal rootDorsal root

ganglionganglion

PainPain

AsendingAsending

inputinput

DesendingDesending

modulationmodulation

Perip+eralPerip+eral

noieptorsnoieptors

&rauma&rauma

Adapted from Gottschalk A et al. Am Fam Physician. 200!"#$%&' and (ehlet ) et al. Anesth Analg . %%#!**$0+%.

Pain TransmissionPain Transmission

Transduction

Transmission by

delta ! " #ibre

Subs P, glutamat

$erception



PereptionPereption

ccurs *hen theccurs *hen the *ain #re(old*ain #re(old (point(pointat *ich sufficient pain transmitting stimuliat *ich sufficient pain transmitting stimulireach the brain) is reached%reach the brain) is reached%

Pain #re(oldPain #re(old tend to be the sametend to be the sameamong health people, but each personamong health people, but each persontolerates the sensation of pain diffrentltolerates the sensation of pain diffrentl

Pain #oleran?ePain #oleran?e (amount of pain a person(amount of pain a person

endures) is influence b genetics,endures) is influence b genetics,behaiors (culture,gender,age) and otherbehaiors (culture,gender,age) and otherbiopschosociallbiopschosociall aniet leel, pastaniet leel, pastpain eperiences, and emotionalpain eperiences, and emotionaldispotitiondispotition



,-/AT1-,-/AT1-

7ate control theor (&el8ack and7ate control theor (&el8ack and9all, 1:;5)%9all, 1:;5)%

<escending modulation<escending modulation useuse

norepenephrine and serotinin asnorepenephrine and serotinin asneurotransmitterneurotransmitter

"elease of inhibitor transmitter"elease of inhibitor transmitter

7=+=, 7lsine7=+=, 7lsine "elease of endogeneous opiates"elease of endogeneous opiates

dnorphine, enkaphalinednorphine, enkaphaline



(lasifikasi yeri(lasifikasi yeri

Waktu Nyeri akut % kronik

Patofisiologi : Nyeri #isiologik Nyeri klinis

&' Nyeri nosisepti#

' Nyeri neuropatik $eri#er Sentral

*' Nyeri psikogenik + idiopatik

N Y E RI

Somatik

,isceral



yeri Akut 34 (ronikyeri Akut 34 (ronik

PenyebabPenyebab

DurasiDurasi

/iasanya/iasanya

diketa+uidiketa+ui

inyuriinyuri

DurasiDurasisingkatsingkat

0el patologi0el patologibaikbaik

nyeri +ilangnyeri +ilang

Seringkali tidakSeringkali tidak

diketa+uidiketa+ui inyuri daninyuri dan

penyakitpenyakit

/erlangsung minimal 1*/erlangsung minimal 1*2 bulan setela+ kelainan2 bulan setela+ kelainanpatologik asal sembu+.patologik asal sembu+.

/erlangsung melebi+i/erlangsung melebi+ibatas 3aktu 3ajarbatas 3aktu 3ajarpenyembu+an.penyembu+an.

0arakteristik0arakteristik Nyeri AkutNyeri Akut Nyeri 0ronikNyeri 0ronik



Nyeri Fisiologik

Nyeri yang timbul akibat berbagai stimuli yang tidak menimbulkan

kerusakan -aringan

Nyeri Nosiseptif Nyeri inflamasi

Nyeri yang timbul akibat berbagai stimuli yang menimbulkankerusakan -aringan

Nyeri Neuropatik

Nyeri yang dida.ului atau disebabkan ole. lesi atau dis#ungsi primer

pada sistem sara# Nyeri PsikogenikNyeri Fungsional

Nyeri di mana #aktor psikogenik dominan! tanpa kerusakan -aringan

dan sistem sara# sebagai penyebab

!"F#N#S# N$"%# &"%!'S'%('N ()'S#F#('S#



'ctivation of

local nociceptors

PeripheralnerveSpinal cor*

Tissue

*amage

'scen*ing

input

E4ample o- +roni noieptie pain5E4ample o- +roni noieptie pain5

osteoart+ritis o- t+e kneeosteoart+ritis o- t+e knee

Perceive* pain

!escen*ing

mo*ulation



Peripheral

nociceptors

'scen*ing

input

!escen*ing

mo*ulation

56ample of neuropathic pain$56ample of neuropathic pain$

ulnar ner7e lesion follo8in9 bone fractureulnar ner7e lesion follo8in9 bone fracture

Trauma

lea*ingto nerve

lesion

Perceive* pain

#mpulses generate*

+ithin ulnar nerve

Spinal cor*

)esion



yeri osiseptif 34 europatikyeri osiseptif 34 europatik

Tipe campuran Timbul akibatkombinasi traumaprimer atau efek

sekunder

Nyeri nosiseptif Disebabkan olehaktivitasi nociceptorakibat stimulus

yang potensialmerusak jaringan

Nyeri neuropatik Diawali/disebabkanoleh lesi primer/disfungsi susunansaraf

Nyeri pasca

operasi

Nyeri punggung

ba/a. mekanik

Sickle cell

crisis

rtritisNeuralgia post herpes

)&P ec NP

Cancer pain

%a*ikulopati menyertai

)o+ &ack Pain

$olineuropati distal (mis' 0M! 12,) Nyeri Kanker Neuropatik

Neuralgiatrigeminal

Sakit kepala

(.eadac.e)

Trauma ola.raga

-isceral pain



:>+/=<>+/=<

: Para(e#amolPara(e#amol

: =spirin=spirin

: ./? =d!uant./? =d!uant

@adder 1@adder 1

on?opiodon?opiod

@adder 2@adder 2

9eak?opiod9eak?opiod

: 8ramadol8ramadol

: 8ramadol/A8ramadol/APAPPAP

: odeinodein: ??

@adder 3@adder 3

trong?opiodtrong?opiod

A or+inor+in

A Fen#an'lFen#an'l

A Su+en#aSu+en#a

A @/- Ad&uan#@/- Ad&uan#



(lasifikasi yeri europatik(lasifikasi yeri europatik

I. /erdasarkan intensitas nyeriI. /erdasarkan intensitas nyeri

II. /erdasarkan penyebabII. /erdasarkan penyebab

III. /erdasarkan lokasiIII. /erdasarkan lokasi

I6. /erdasarkan mekanismeI6. /erdasarkan mekanisme



1. ;erdasarkan intensitas nyeri1. ;erdasarkan intensitas nyeri

. umeric Pain 1ntensity Scale <P1S=. umeric Pain 1ntensity Scale <P1S=

– # – # yeri rin9anyeri rin9an+ – "+ – " yeri sedan9yeri sedan9

* – 0* – 0 yeri beratyeri berat

2. >isual Analo9 Scale2. >isual Analo9 Scale

#. Faces Pain ?atin9 Scale <untuk anak=#. Faces Pain ?atin9 Scale <untuk anak=

Pengukuran menggunakan skala nyeri



Visual Analog Scale (,S)

Faces Pain Rating Scale (untuk anak)

Numeric Pain Rating Scale (N$RS)



11. ;erdasarkan Penyebab11. ;erdasarkan Penyebab

(ttal N!et al 333)

Trauma

eda.Sindrom -ebakan sara#

"R$S -enis 22

mputasi

(nyeri #antom+nyeri tungkul)

"edera medula spinalis

"edera KLL

Toksin

5bat kemoterapi5bat

rsen! tima.! emas! air raksa

6at organik

Meng.irup lem (Glue sniffing)

2n#eksi

1erpes 7oster 2n#eksi mononukleosis

HIV

Tabes

0i#teri

Lepra

0e#isiensi nutrisi+neuropati alko.olik Niasin! tiamin! piridoksin

Nyeri

Neuropatik

* CRPS Com!le" Regional Pain S#ndrome




(ttal N!et al 333)

KeganasanKompresi# 2n#iltrati#

$araneoplastik

2atrogenik

Metastatik

Kompresi + tekananStenosis Spinal

Sindrom Tero/ongan Karpal

Radikulopati

Gangguan Metabolik

0iabetes melitus8remia

$or#iria

1ipotiroidisme

miloidosis

5toimunMultipel sklerosis

Nyeri

Neuropatik




(ttal N!et al 333)

Genetik $enyakit 9abry

Neuropati sensori

.erediter

Kelainan vaskuler +

iskemiaSL:

R

$oliarteritis nodosaStroke

Lain;lainGS

SiringomieliaLS

$olineuropati kronik

progresi#+rekuren

NyeriNeuropatik



111. ;erdasarkan lokasi111. ;erdasarkan lokasi

&' Nyeri neuropatik sentral

' Nyeri neuropatik peri#er



1>. ;erdasarkan ,ekanisme1>. ;erdasarkan ,ekanisme

<Ge@ala dan Tanda=<Ge@ala dan Tanda=

Stimulus-independent

pain .nyeri spontan/

Stimulus-evoked pain

Kontinu

(terus;

menerus)

$aroksismal

(serangan)

Stimulus non;

noksius

Stimulus

noksius

lodinia

mekanikal

lodinia

termal

1iperalgesia

mekanikal

1iperalgesia

termal

Dinamik Statik Dinamik Statik

Nyeri Neuropatik



Ge@ala dan Tanda yeri europatikGe@ala dan Tanda yeri europatik

Rasa terbakar kontinyuRasa terbakar kontinyu burning sign! burning sign!

Nyeri seperti ditusuk, menyentakNyeri seperti ditusuk, menyentak

intermitenintermiten

Nyeri seperti tersetrumNyeri seperti tersetrum

ParestesiaParestesia

DisestesiaDisestesia /aron, 78889 :ool-, ;<<<.

((=ejala nyeri diutarakan ole+ pasien=ejala nyeri diutarakan ole+ pasien)) seperti5seperti5

Stimulus Independent PainStimulus Independent Pain



/urning, -eeling like t+e -eet are on -ire

Stabbing, like s+arp knies )aninating, like eletri s+oks

Free>ing, like t+e -eet are on ie,

alt+oug+ t+ey -eel 3arm to tou+

,odified by ,eliala 200"



=ejala dan &anda Nyeri Neuropatik=ejala dan &anda Nyeri Neuropatik

Nyeri dibangkitkan pada pemeriksaan!Nyeri dibangkitkan pada pemeriksaan! seperti5seperti5

Stimulus Evoked PainStimulus Evoked Pain

Alodinia

Nyeri yang disebabkan ole+ stimulus yang

seara normal tidak menimbulkan nyeri"iperalgesia

Respon yang berlebi+an ter+adap stimulus

yang seara normal menimbulkan nyeri



I. (ekanisme Peri-er

;. Aktiasi ektopik

7. Sensitisasi nosiseptor

1. Interaksi abnormal antar serabut sara- ?. Sensitisasi ter+adap katekolamin

II. (ekanisme Sentral

;. Sensitisasi sentral7. Disin+ibisi

1. Reorganisasi struktural

(E0ANIS(E NYERI NE%R#PA&I0



;. Anamnesis

7. Pemeriksaan -isik

* %mum * Neurologik

* )okal

1. Pemeriksaan Psikologik

?. Pemeriksaan Penunjang

DIA=N#SIS

Pemeriksaan yeri (husus$Pemeriksaan yeri (husus$




Pada AlodiniaPada Alodinia

ResponRespon$ara periksa$ara periksa@enis Alodinia@enis Alodinia

;aron' 2000.

Rasa nyeri tumpulRasa nyeri tumpuldull pain!dull pain!

Rasa nyeri tajamRasa nyeri tajam

super-isialsuper-isial

Rasa nyeri tajamRasa nyeri tajamterbakar, super-isialterbakar, super-isial

Rasa nyeri terbakarRasa nyeri terbakar

Rasa nyeri terbakar Rasa nyeri terbakar

&ekanan ringan dengan&ekanan ringan denganbenda tumpulbenda tumpul

/eberapa tusukan ringan/eberapa tusukan ringan

dengan jarumdengan jarum

%sapan ringan dengan%sapan ringan dengankapas, jari tangankapas, jari tangan

&abung air +angat ?8&abung air +angat ?888 $!$!

&abung air dingin 78&abung air dingin 7888 $!,$!,/atang re-le4 +ammer/atang re-le4 +ammer

(ekanis statis(ekanis statisserabut $!serabut $!

(ekanis(ekanis

pungtatpungtat

(ekanis dinamis(ekanis dinamisserabut Abeta!serabut Abeta!

&ermal panas&ermal panas

&ermal dingin&ermal dingin

Rasa nyeri dalamRasa nyeri dalam&ekanan ringan pada&ekanan ringan pada

sendisendi

(ekanis somatik(ekanis somatik

dalamdalam



ResponRespon

Rasa nyeri tajamRasa nyeri tajam

super-isialsuper-isial



$ara periksa$ara periksa

&usukan dengan jarum&usukan dengan jarum

0ontak dengan pendingin0ontak dengan pendinginaseton, alko+ol!aseton, alko+ol!

0ontak dengan tabung0ontak dengan tabungair +angat ?8$!air +angat ?8$!

(ekanis(ekanis

tusukantusukan

&ermal dingin&ermal dingin

&ermal panas&ermal panas


Pada )iperal9esiaPada )iperal9esia

;aron' 2000.

ResponRespon$ara periksa$ara periksa@enis "iperalgesia@enis "iperalgesia



&ERAPI NYERI NE%R#PA&I0&ERAPI NYERI NE%R#PA&I0(#DA)I&AS &ERAPI(#DA)I&AS &ERAPI

I. &erapi Farmakologik

Analgetik, adjuan, topikal

II. /lok Sara- dan Neurolitik

III. Neuromodulasi

&ENS, stimulasi medula spinalis, lemniskus medialis

I6. /eda+

R+i>otomy, simpatektomi, DREB, kordotomi,+ipo-sektomi, miroasular deompression

6. Re+abilitasi

&erapi -isikal, psikologik

&erapi Adjuan Nyeri Neuropatik



&erapi Adjuan Nyeri Neuropatik

/erdasar (ekanisme

#tak#tak

(edulla

Spinalis

(edulla

Spinalis

In+ibisi

Asending pat+3ay

opioid

Sensitisasi peri-erC ion Na

)esi

=A/APEN&IN0arbama>epin#kskarba>epin

FENI&#IN(eksiletin)idokain, dll

Th

Th

&$A&ramadol

#pioid

dll

Sensitisasi

sentral

N(DA,

$alium!

Th

=A/APEN&IN#kskarba>epin)amotrigin0etaminDe4trome*t+orp+an

/eydoun, 78879 modi-ikasi penulis

0o*ulation *escen*ing

path+ay



&ransmission&ransmission

9hen pain impulses reach the9hen pain impulses reach thethalamusthalamus t*o responses occurst*o responses occurs

Fir(#Fir(# inpuls from spinothalamicinpuls from spinothalamic

tracttract thalamusthalamus transmits thetransmits themessage to the cortemessage to the corte somatosensoriksomatosensorik,,*here the location and seerit*here the location and seerit,,

durationduration

of the in!ur are identifiedof the in!ur are identified

Se?ondSe?ond inpuls from spinoreticularinpuls from spinoreticulartracttract #halamus and hpothal#halamus and hpothal inoled in emotional aspect of paininoled in emotional aspect of pain%%

h f



Dorsal Horn

Dorsal root

ganglion

Peripheral sensory

Nerve fibers

A

A

C

Largefibers

Small

fibers

There are Two Sensory AferentNeurons

1. Large myelinated Aβ bers! very fast conduction velocity."espond to innocuous stimuli

#. $mall myelinated Aδ % & unmyelinated bers! have slowconduction velocity. "espond to no'ious stimuli Pain



TransmissionTransmission

#he phase during *ich stimuli moe from#he phase during *ich stimuli moe from

the peripheral nerous sstemthe peripheral nerous sstem brainbrain

ccurs *hen peripheral nociceptor formccurs *hen peripheral nociceptor form

snapses *ith neurons *ithin the spinalsnapses *ith neurons *ithin the spinalcord that carr pain inpulses ia fast andcord that carr pain inpulses ia fast and

slo* nere fibers ( = delta and fiber )%slo* nere fibers ( = delta and fiber )%

9ith the help of substance ',9ith the help of substance ', glutamatglutamat

pain impulses moepain impulses moe higher leel in thehigher leel in thebrainbrain "=, thalamus, cerebral corte"=, thalamus, cerebral corte

and limbic sstem%and limbic sstem%



(odulation(odulation

#he last phase of pain impulse#he last phase of pain impulse

transmission during *ich the braintransmission during *ich the brain

interacts *ith the spinal neres in ainteracts *ith the spinal neres in adon*ard fashion to subse6uentl alterdon*ard fashion to subse6uentl alter

the pain eperience%the pain eperience%

=t this point, the release of pain?=t this point, the release of pain?

inhibiting neurochemicals reduces theinhibiting neurochemicals reduces thepainful sensation ( endogenous opioids,painful sensation ( endogenous opioids,

7=+=)%7=+=)%



Terapi Farmakolo9ik ePTerapi Farmakolo9ik eP

A. AnalgetikA. Analgetik

:eak:eak*#pioid*#pioid 5 &ramadol 5 &ramadol

/. Analgetik Adjuan Yang Paling sering di =unakan/. Analgetik Adjuan Yang Paling sering di =unakan

;. Antidepresan 5 Amitriptilin, Nortriptilin, dll;. Antidepresan 5 Amitriptilin, Nortriptilin, dll

7. Antikonulsan 5 =abapentin, Fenitoin, 0arbamasepin7. Antikonulsan 5 =abapentin, Fenitoin, 0arbamasepin

&4



Suatu sin*roma *engan karakteristik a*anya perasaan nyeri

*i sepan1ang *istribusi saraf tanpa a*anya tan*a2tan*a ob1ektif gangguan fungsi *ari saraf tersebut, bersifat rekuren *an

paroksismal3

T#!'( !#J40P'#:

5 gangguan motorik

5 perubahan refleks

5 kelainan patologis serabut saraf

!apat mengenai:5 saraf perifer

5 saraf kranial

#ritasi toksis

infeksi



;Perasaan nyeri pa*a belakang kepala

; melibatkan -erte6 *an bilateral

; 7777 bergerak, batuk 8 bersin

; kulit kepala: hiperestesia

; nyeri tekan pa*a protuberansia oksipital

"tiologi:

93 Spon*ilitis T&C

3 Tumor 0e*ula spinalis;3 <steoarthritis



Nyeri sepan1ang lengan, bahu *an leher

"tiologi:5 Trauma

5 Neoplasma

5 #nfeksi

5 NP5 'rthritis servikalais

5 'neurisma arteri brachialis

5 (ompresi cervical rib



Perasaan nyeri sepan1ang *istribusi saraf intercostal

Penyebab:

5 Tumor 0e*ula spinalis

5 Spon*ilitis T&C

5 0etastasis tumor ke -ertebra

Perasaan nyeri sepan1ang cabang Pleksus )umbalis .T9,)92=/

*an Pleksus sakralis .)>2=, S92;/



)S2Neuralgia:93 Crural Neuralgia? nyeri sepan1ang bagian *epan paha

3 <bturator neuralgia? nyeri sepan1ang bagian *alam paha

N$"%# !#S"(#T'%:

5 Perineum5 Scrotum

5 Penis

5 Testis



N'eri e"a# di(e!i#ar #e(#i( di(er#aiN'eri e"a# di(e!i#ar #e(#i( di(er#ai

?olla*(?olla*(

N'eri #e!an *ada #e(#i(N'eri #e!an *ada #e(#i(

='"=@ B"=@7=='"=@ B"=@7=

neri di sekitar anusneri di sekitar anus sering pada *anitasering pada *anita



<anita lebi. seringRi/ayat -atu. terduduk Nyeri .ebat % menetap



'*alah nyeri pa*a *istribusi sensorik N #@, @

"tiologi:

5 Penekananpenarikan

5 #nfeksi akut pharyn6

(linis:

5 Nyeri spasm pa*a pharyn622222 men1alar ke telinga

5 !apat *icetuskan oleh menelan, batuk, mengunyah, bersin

bicara, memutar kepala3

5 serangan ka*ang2ka*ang *isertai *engan bra*ikar*i, aritmia hipertensi, syncope .-agal stimulation/

Pengobatan:

5 karbamaAepin

5 (asus intraktable 22222 #ntrakranial section N3@



P-ST )5?P5T1C 5/?AG1AP-ST )5?P5T1C 5/?AG1A

= common cause of seere= common cause of seereneuropathic pain, especiall in theneuropathic pain, especiall in the

elderlelderl

ften intractable to conentionalften intractable to conentionalanalgetics and is rarel totallanalgetics and is rarel totall

relieed%relieed%

ncidence of '- $ :?15Cncidence of '- $ :?15C 35?55 still haing pain 3 months35?55 still haing pain 3 months

later, and 30C haing seer painlater, and 30C haing seer pain

persisting for 1 earpersisting for 1 ear



#he pain has been described as both#he pain has been described as both

stead and parosmal, *ith dsesthesia,stead and parosmal, *ith dsesthesia,hperesthesia and allodnia%hperesthesia and allodnia%

#he dermatomal fre6uencies in '- $#he dermatomal fre6uencies in '- $

#horacic dermatomes#horacic dermatomes 55C55C#rigeminal distribution#rigeminal distribution 20C20C

erical dermatomeserical dermatomes 10C10C

@umbar dermatomes@umbar dermatomes 10C10C

acral dermatomesacral dermatomes 5C 5C

BMS2-K5 Pain & Neuralgia

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