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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
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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!!
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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
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Classification
of
Peripheral
nerve
4
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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
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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
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Stimulus yg membangkitkan nyeriStimulus yg membangkitkan nyeri
Kuli#Kuli# in&ur' åan o! #u(u!an)in&ur' åan 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
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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;
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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 - :
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&+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
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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
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&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
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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
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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
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,-/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
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(lasifikasi yeri(lasifikasi yeri
Waktu Nyeri akut % kronik
Patofisiologi : Nyeri #isiologik Nyeri klinis
&' Nyeri nosisepti#
' Nyeri neuropatik $eri#er Sentral
*' Nyeri psikogenik + idiopatik
N Y E RI
Somatik
,isceral
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yeri Akut 34 (ronikyeri Akut 34 (ronik
PenyebabPenyebab
DurasiDurasi
/iasanya/iasanya
diketa+uidiketa+ui
inyuriinyuri
DurasiDurasisingkatsingkat
0el patologi0el patologibaikbaik
nyeri +ilangnyeri +ilang
Seringkali tidakSeringkali tidak
diketa+uidiketa+ui inyuri daninyuri dan
penyakitpenyakit
/erlangsung minimal 1*/erlangsung minimal 1*2 bulan setela+ kelainan2 bulan setela+ kelainanpatologik asal sembu+.patologik asal sembu+.
/erlangsung melebi+i/erlangsung melebi+ibatas 3aktu 3ajarbatas 3aktu 3ajarpenyembu+an.penyembu+an.
0arakteristik0arakteristik Nyeri AkutNyeri Akut Nyeri 0ronikNyeri 0ronik
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Nyeri Fisiologik
Nyeri yang timbul akibat berbagai stimuli yang tidak menimbulkan
kerusakan -aringan
Nyeri Nosiseptif Nyeri inflamasi
Nyeri yang timbul akibat berbagai stimuli yang menimbulkankerusakan -aringan
Nyeri Neuropatik
Nyeri yang dida.ului atau disebabkan ole. lesi atau dis#ungsi primer
pada sistem sara# Nyeri PsikogenikNyeri Fungsional
Nyeri di mana #aktor psikogenik dominan! tanpa kerusakan -aringan
dan sistem sara# sebagai penyebab
!"F#N#S# N$"%# &"%!'S'%('N ()'S#F#('S#
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'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
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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
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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
$olineuropati distal (mis' 0M! 12,) Nyeri Kanker Neuropatik
Neuralgiatrigeminal
Sakit kepala
(.eadac.e)
Trauma ola.raga
-isceral pain
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:>+/=<>+/=<
: Para(e#amolPara(e#amol
: =spirin=spirin
: ./? =d!uant./? =d!uant
@adder 1@adder 1
on?opiodon?opiod
@adder 2@adder 2
9eak?opiod9eak?opiod
: 8ramadol8ramadol
: 8ramadol/A8ramadol/APAPPAP
: odeinodein: ??
@adder 3@adder 3
trong?opiodtrong?opiod
A or+inor+in
A Fen#an'lFen#an'l
A Su+en#aSu+en#a
A @/- Ad&uan#@/- Ad&uan#
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(lasifikasi yeri europatik(lasifikasi yeri europatik
I. /erdasarkan intensitas nyeriI. /erdasarkan intensitas nyeri
II. /erdasarkan penyebabII. /erdasarkan penyebab
III. /erdasarkan lokasiIII. /erdasarkan lokasi
I6. /erdasarkan mekanismeI6. /erdasarkan mekanisme
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1. ;erdasarkan intensitas nyeri1. ;erdasarkan intensitas nyeri
. umeric Pain 1ntensity Scale <P1S=. umeric Pain 1ntensity Scale <P1S=
– # – # yeri rin9anyeri rin9an+ – "+ – " yeri sedan9yeri sedan9
* – 0* – 0 yeri beratyeri berat
2. >isual Analo9 Scale2. >isual Analo9 Scale
#. Faces Pain ?atin9 Scale <untuk anak=#. Faces Pain ?atin9 Scale <untuk anak=
Pengukuran menggunakan skala nyeri
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Visual Analog Scale (,S)
Faces Pain Rating Scale (untuk anak)
Numeric Pain Rating Scale (N$RS)
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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
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11. ;erdasarkan Penyebab11. ;erdasarkan Penyebab
(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
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11. ;erdasarkan Penyebab11. ;erdasarkan Penyebab
(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
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111. ;erdasarkan lokasi111. ;erdasarkan lokasi
&' Nyeri neuropatik sentral
' Nyeri neuropatik peri#er
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1>. ;erdasarkan ,ekanisme1>. ;erdasarkan ,ekanisme
<Ge@ala dan Tanda=<Ge@ala dan Tanda=
Stimulus-independent
pain .nyeri spontan/
Stimulus-evoked pain
Kontinu
(terus;
menerus)
$aroksismal
(serangan)
Stimulus non;
noksius
Stimulus
noksius
lodinia
mekanikal
lodinia
termal
1iperalgesia
mekanikal
1iperalgesia
termal
Dinamik Statik Dinamik Statik
Nyeri Neuropatik
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Ge@ala dan Tanda yeri europatikGe@ala dan Tanda yeri europatik
Rasa terbakar kontinyuRasa terbakar kontinyu burning sign! burning sign!
Nyeri seperti ditusuk, menyentakNyeri seperti ditusuk, menyentak
intermitenintermiten
Nyeri seperti tersetrumNyeri seperti tersetrum
ParestesiaParestesia
DisestesiaDisestesia /aron, 78889 :ool-, ;<<<.
((=ejala nyeri diutarakan ole+ pasien=ejala nyeri diutarakan ole+ pasien)) seperti5seperti5
Stimulus Independent PainStimulus Independent Pain
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/urning, -eeling like t+e -eet are on -ire
Stabbing, like s+arp knies )aninating, like eletri s+oks
Free>ing, like t+e -eet are on ie,
alt+oug+ t+ey -eel 3arm to tou+
,odified by ,eliala 200"
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=ejala dan &anda Nyeri Neuropatik=ejala dan &anda Nyeri Neuropatik
Nyeri dibangkitkan pada pemeriksaan!Nyeri dibangkitkan pada pemeriksaan! seperti5seperti5
Stimulus Evoked PainStimulus Evoked Pain
Alodinia
Nyeri yang disebabkan ole+ stimulus yang
seara normal tidak menimbulkan nyeri"iperalgesia
Respon yang berlebi+an ter+adap stimulus
yang seara normal menimbulkan nyeri
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I. (ekanisme Peri-er
;. Aktiasi ektopik
7. Sensitisasi nosiseptor
1. Interaksi abnormal antar serabut sara- ?. Sensitisasi ter+adap katekolamin
II. (ekanisme Sentral
;. Sensitisasi sentral7. Disin+ibisi
1. Reorganisasi struktural
(E0ANIS(E NYERI NE%R#PA&I0
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;. Anamnesis
7. Pemeriksaan -isik
* %mum * Neurologik
* )okal
1. Pemeriksaan Psikologik
?. Pemeriksaan Penunjang
DIA=N#SIS
Pemeriksaan yeri (husus$Pemeriksaan yeri (husus$
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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
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ResponRespon
Rasa nyeri tajamRasa nyeri tajam
super-isialsuper-isial
Rasa nyeri terbakar Rasa nyeri terbakar
Rasa nyeri terbakar Rasa nyeri terbakar
$ara periksa$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
Pemeriksaan yeri (husus$Pemeriksaan yeri (husus$
Pada )iperal9esiaPada )iperal9esia
;aron' 2000.
ResponRespon$ara periksa$ara periksa@enis "iperalgesia@enis "iperalgesia
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&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
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&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
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&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
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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
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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%
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(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=+=)%
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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
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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
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;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
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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
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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;/
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)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
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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
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<anita lebi. seringRi/ayat -atu. terduduk Nyeri .ebat % menetap
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'*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@
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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
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#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