Herniasi Nukleus Pulposus (HNP): Patofisiologi dan

Gejala Klinis
Diskus intervetebralis adalah lempengan kartilago yang herbentuk sebuah bantalan di antara
dua tulang belakang. Material yang keras dari fibrosa digahungkan dalam satu kapsul.
Bantalan seperti bola di bagian tengah diskus dinamakan Nukleus Pulposus. Pada herniasi
diskus intervetebralis (ruptur diskus), nukleus pada diskus menonjol ke dalam anulus (cincin
fibrosa sekitar diskus) dengan akibat kompresi sarat.

Protrusi atau ruptur nukleus biasanya didahului dengan perubahan degeneratif yang terjadi
pada proses penuaan. Kehilangan protein dalam polisakarida dalam diskus menurunkan
kandungan air pada nukleus pulposus. Perkembangan pecahan yang menyebar di anulus
melemahkan pertahanan pada herniasi nukleus. Herniasi nukleus pulposus (HNP) terjadi
kebanyakan oleh karena adanya suatu trauma derajat sedang yang berulang mengenai diskus
intervetebralis sehingga menimbulkan sobeknya anulus fibrosus.

Pada kebanyakan klien gejala trauma bersilat singkat. Gejala ini disebabkan oleh cedera pada
diskus yang tidak terlihat selama beherapa bulan atau tahun. Kemudian pada generasi diskus,
kapsulnya terdorong ke arah medula spinalis, atau mungkin ruptur dan memungkinkan
nukleus pulposus terdorong terhadap sakus dural atau terhadap saraf spinal saat muncul dan
kolumna spinal.

HNP adalah keadaan nukleus pulposus keluar menonjol untuk kemudian menekan ke arah
kanalis spinalis melalui anulus fibrosis yang sobek. HNP merupakan suatu nyeri yang
disebabkan oleh proses patologis di kolumna vertebralis pada diskus
intervertebralis/diskogenik.

Patofisiologi
Pada tahap pertama sobeknya anulus fibrosus itu bersifat sirkumferensial. Karena adanya
gaya traurnatik yang berulang, sobekan itu menjadi lebih besar dan timbul sobekan radial.
Apabila hal ini telah terjadi, maka risiko HNP hanya menunggu waktu dan trauma berikutnya
saja. Gaya presipitasi itu dapat diasumsikan seperti gaya traumatik ketika hendak
menegakkan badan waktu terpeleset, mengangkat benda berat, dan sebagainya.
Menjebolnya (herniasi) nukleus pulposus dapat mencapai ke korpus tulang belakang di atas
atau di bawahnya. Bisa juga menjebol langsung ke kanalis vertebralis. Menjebolnya sebagian
nukleus pulposus ke dalam korpus vertebra dapat dilihat pada foto rontgen polos dan dikenal
sebagai nodus Schmorl. Sobekan sirkumferensial dan radial pada anulus fibrosus diskus
intervertebralis berikut dengan terbentuknya nodus Schmorl/ merupakan kelainan yang
mendasari low back pain subkronis atau kronis yang kemudian disusul oleh nyeri sepanjang
tungkai yang dikenal sebagai iskhialgia atau siatika. Menjebolnya nukleus pulposus ke
kanalis vertebralis berarti bahwa nukleus pulposus menekan radiks yang bersama-sama
dengan arteria radikularis yang berada dalam lapisan dura. Hal itu terjadi jika penjebolan
berada di sisi lateral. Tidak akan ada radiks yang terkena jika tempat herniasinya berada di
tengah. Pada tingkat L2, dan terus ke bawah tidak terdapat medula spinalis lagi, maka
herniasi yang berada di garis tengah tidak akan menimbulkan kompresi pada kolumna
anterior. Setelah terjadi HNP, sisa diskus intervertebral ini mengalami lisis, sehingga dua
korpora vertebra bertumpang tindih tanpa ganjalan.
Pada percobaan Les Laseque atau tes mengangkat tungkai yang lurus (straight leg raising),
yaitu mengangkat tungkai secara lurus dengan fleksi pada sendi panggul, akan dirasakan
nyeri di sepanjang bagian belakang (tanda Laseque positif).

Gejala yang sering muncul adalah:

1. Nyeri pinggang bawah yang intermiten (dalam beberapa minggu sampai beberapa tahun).
Nyeri menyebar sesuai dengan distribusi saraf skiatik.
2. Sifat nyeri khan dari posisi berbaring ke duduk,nyeri mulai dari pantat dan terus menjalar
ke bagian belakang lalu kemudian ke tungkai bawah.
3. Nyeri bertambah hebat karena pencetus seperti gerakan-gerakan pinggang saat batuk atau
mengedan, berdiri, atau duduk untuk jangka waktu yang lama dan nyeri berkurang klien
beristiraho berbaring.
4. Penderita sering mengeluh kesemutan (parostesia) atau baal bahkan kekuatan otot menurun
sesuai dengan distribusi persarafan yang terlibat.
5. Nyeri bertambah bila daerah L5—S1 (garis antara dua krista iliaka) ditekan.

Definition

A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs
when all or part of the soft center of a spinal disk is forced through a weakened part of the
disk.

Alternative Names

Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed

intervertebral disk; Slipped disk; Ruptured disk

Causes, incidence, and risk factors

The bones (vertebrae) of the spinal column run down the back, connecting the skull to the
pelvis. These bones protect nerves that come out of the brain and travel down the back and to
the entire body. The spinal vertebrae are separated by disks filled with a soft, gelatinous
substance, which provide cushioning to the spinal column. These disks may herniate (move
out of place) or rupture from trauma or strain.

The spinal column is divided into several segments -- the cervical spine (the neck), the
thoracic spine (the part of the back behind the chest), the lumbar spine (lower back), and
sacral spine (the part connected to the pelvis that does not move).

Radiculopathy refers to any disease affecting the spinal nerve roots. A herniated disk is one
cause of radiculopathy (sciatica).

Most herniation takes place in the lower back (lumbar area) of the spine. Lumbar disk
herniation occurs 15 times more often than cervical (neck) disk herniation, and it is one of the
most common causes of lower back pain. The cervical disks are affected 8% of the time and
the upper-to-mid-back (thoracic) disks only 1 - 2% of the time.

Nerve roots (large nerves that branch out from the spinal cord) may become compressed
resulting in neurological symptoms, such as sensory or motor changes.

Disk herniation occurs more frequently in middle aged and older men, especially those
involved in strenuous physical activity. Other risk factors include any congenital conditions
that affect the size of the lumbar spinal canal.

Symptoms

SYMPTOMS OF HERNIATED LUMBAR DISK

 Muscle spasm
 Muscle weakness or atrophy in later stages
 Pain radiating to the buttocks, legs, and feet
 Pain made worse with coughing, straining, or laughing
 Severe low back pain
 Tingling or numbness in legs or feet

SYMPTOMS OF HERNIATED CERVICAL DISK

 Arm muscle weakness

 Deep pain near or over the shoulder blades on the affected side
 Neck pain, especially in the back and sides
 Increased pain when bending the neck or turning head to the side
 Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest
 Pain made worse with coughing, straining, or laughing
 Spasm of the neck muscles

Signs and tests

A physical examination and history of pain may be all that is needed to diagnose a herniated
disk. A neurological examination will evaluate muscle reflexes, sensation, and muscle
strength. Often, examination of the spine will reveal a decrease in the spinal curvature in the
affected area.

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually
suggests a herniated lumbar disk.

A foraminal compression test of Spurling is done to diagnose cervical radiculopathy. For this
test, you will bend your head forward and to the sides while the health care provider provides
slight downward pressure to the top of the head. Increased pain or numbness during this test
is usually indicative of cervical radiculopathy.

DIAGNOSTIC TESTS

 EMG may be done to determine the exact nerve root(s) that is (are) involved.
 Nerve conduction velocity test may also be done.
  Myelogram may be done to determine the size and location of disk herniation.
 Spine MRI or spine CT will show spinal canal compression by the herniated disk.
 Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not
possible to diagnosis herniated disk by spinal x-ray alone.

Treatment

The main treatment for a herniated disk is a short period of rest with pain and anti-
inflammatory medications, followed by physical therapy. Most people who follow these
treatments will recover and return to their normal activities. A small number of people need
to have further treatment, which may include steroid injections or surgery.

MEDICATIONS

Nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic pain killers will be given
to people with a sudden herniated disk caused by some sort of injury (such as a car accident
or lifting a very heavy object) that is immediately followed by severe pain in the back and
leg.

If the patient has back spasms, muscle relaxants are usually given. On rare occasions, steroids
may be given either by pill or directly into the blood through an IV.

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not
respond to anti-inflammatory drugs.

LIFESTYLE CHANGES

Any extra weight being carried by an individual, especially up front in the stomach area, will
make back pain worse. Diet and exercise are crucial to improving back pain in overweight
patients.

Physical therapy is important for nearly everyone with disk disease. Therapists will tell you
how to properly lift, dress, walk, and perform other activities. They will also work on
strengthening the muscles of the abdomen and lower back to help support the spine.
Flexibility of the spine and legs is taught in many therapy programs.

Some health care providers recommend the use of back braces to help support the spine.
However, overuse of these devices can weaken the abdominal and back muscles leading to a
worsening of the problem. Weight belts can be helpful in preventing injuries in those whose
work requires lifting of heavy objects.

INJECTIONS

Steroid injections into the back in the area of the herniated disk can help control pain for
several months. Such injections reduce swelling around the disk and relieve many symptoms.
Spinal injections are usually done on an outpatient basis using x-ray or fluoroscopy to
identify the area where the injection is needed.

SURGERY
Surgery may be an option for the few patients whose symptoms persist despite other
treatments.

Diskectomy removes a protruding disk. This procedure requires general anesthesia (asleep
and no pain) and 2-3 day hospital stay. You will be encouraged to walk the first day after
surgery to reduce the risk of blood clots.

Complete recovery takes several weeks. If more than one disk needs to be taken out or if
there are other problems in the back besides a herniated disk, more extensive surgery may be
needed. This may require a much longer recovery period.

Other surgical options include microdiskectomy, a procedure removing fragments of

nucleated disk through a very small opening.

Chemonucleolysis involves the injection of an enzyme (called chymopapain) into the

herniated disk to dissolve the protruding gelatinous substance. This procedure may be an
alternative to diskectomy in certain situations.

Expectations (prognosis)

Most people will improve with conservative treatment. A small percentage may continue to
have chronic back pain even after treatment.

It may take several months to a year or more to resume all activities without pain or strain to
the back. People with certain occupations that involve heavy lifting or back strain may need
to change job activities to avoid recurrent back injury.

Complications

 Long-term back pain

 Loss of movement or sensation in the legs or feet
 Loss of bowel and bladder function
 Permanent spinal cord injury (very rare)

Calling your health care provider

Call your health care provider if persistent, severe back pain develops, especially if you have
any numbness, loss of movement, weakness, or bowel or bladder changes.

Prevention

Safe work and play practices, proper lifting techniques, and weight control may help to
prevent back injury in some people.