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2. Hernia Nucleus Puposus Cervicalis

HERNIA NUCLEUS PULPOSUS CERVICALIS

Oleh Dr H. Subagyo  SpB - SpOT

 

Herniated nucleus pulposus (HNP) secara umum digunakan untuk kelainan pada vertebra cervicalis, pergeseran (displacement) nucleus pulposus tidak selalu merupakan penyebab kelainan pada vertebra cervicalis. Herniasi vertebra cervicalis dapat dikategorikan menjadi tiga tipe: (1) herniasi tipe lunak (soft disc herniation) yang meliputi  herniasi nucleus pulposus melalui robekan pada annulus fibrosus, (2) herniasi tipe keras (hard disc protrusion) yang meliputi pembentukan bone spur, atau (3) kombinasi keduanya.5,28  Ketika materi lunak dari nucleus pulposus mengalami herniasi melalui robekan pada annulus fibrosus,maka disebut "soft disc herniation" karena material dari diskus yang mengalami herniasi mempunyai konsistensi yang lunak. Namun demikian, tanpa adanya robekan atau defek pada annulus fibrosus, gejala dari kelainan vertebra cervical tetap dapat terjadi akibat pembentukan bone spur (pertumbuhan yang berlebihan dari spikula tulang) pada tepi vertebra sehingga menekan saraf atau medula spinalis. Hal ini disebut "hard disc herniation" karena terbentuk dari bone spur. Kombinasi dari kedua jenis herniasi tersebut juga dapat terjadi.5,28

Manifestasi dari HNP dapat dibagi menjadi empat tipe yaitu29 :

                                                                                      

     

Gambar 29. Manifestasi HNP14,29

1. Disc Degeneration:

Terjadi perubahan kimiawi berhubungan proses penuaan, sehingga menyebabkan diskus menjadi lemah tetapi tanpa terjadinya herniasi

2. Disc Prolapse (bulge atau protrusion):

Perubahan bentuk atau posisi dari diskus intervertebralis dengan sedikit desakan (bulging atau protrusion) ke arah kanalis spinalis

3. Extrusion:

Bahan seperti gel (nucleus pulposus) menerobos keluar dari dinding annulus fibrosus tetapi masih tetap berada di dalam diskus intervertebralis

4. Sequestration or Sequestered Disc:

Nucleus pulposus menerobos keluar dari annulus fibrosus dan bahkan dapat bergerak keluar dari diskus intervertebralis sampai ke dalam kanalis spinalis

  • PATOFISIOLOGI

Diskus intervertebralis didesain untuk mengabsorbsi goncangan dan tekanan yang ditransmisikan melalui struktur rangka tubuh. Bagian tengah diskus intervertebralis tersusun dari bahan mirip gel yang disebut nucleus pulposus.17 Nucleus tersebut dikelilingi oleh jaringan ikat kolagen yang menyusun batas luar discus disebut annulus fibrosus. HNP (Herniated Nucleus Pulposus) terjadi akibat adanya beban tekanan terhadap tulang belakang yang terjadi secara tiba-tiba atau dalam jangka waktu lama. Ketika terjadi beban tekanan pada diskus intervertebralis, nucleus akan terdorong ke arah dinding annulus. Seiring dengan terjadinya peningkatan beban tekanan, maka mulai terjadi robekan pada serat annulus dan terjadi perubahan bentuk diskus intervertebralis.17,32 Diskus biasanya akan terdorong kearah postero-lateral (49 % kasus), posterocentral (8%), lateral/foraminal (<10%), intraosseous/vertical (14%): "Schmorl node" ,extraforaminal/anterior (29%). HNP sering ditemukan pada arah posterolateral karena bagian posterolateral merupakan bagian paling lemah dimana di daerah tersebut banyak terdapat persarafan di daerah leher, oleh karena itu herniasi sering menyebabkan penekanan terhadap saraf sehingga menimbulkan disfungsi saraf sensorik atau motorik.17,32

HNP cervical sering ditemukan pada verterbra cervicalis bagian bawah (level vertebra C6-7). Didaerah ini terdapat persarafan yang menyusun pleksus brachialis. Saraf-saraf dari pleksus brachialis berjalan mempersarafi sepanjang ekstremitas atas, sehingga gejala-gejala akibat kompresi saraf dapat timbul pada seluruh atau sebagian ekstremitas atas. Pada beberapa kasus, herniasi terjadi akibat trauma akut akibat beban tekanan yang tiba-tiba pada vertebra cervicalis. Sebagai contoh, herniasi terjadi ketika individu yang terbentur kepalanya pada waktu menyelam di kolam renang yang dangkal.  HNP cervical akibat trauma akut merupakan penyebab utama dari central cord syndrome.17,31

Gejala utama pada HNP cervical adalah rasa nyeri, parestesia atau kelemahan pada daerah leher atau ekstremitas atas. Rasa nyeri atau parestesia dapat timbul pada seluruh atau sebagian ekstremitas atas. Penelitian lain menunjukkan bahwa nucleus pulposus mengandung bahan-bahan kimia (phospholipise A, bradykinin, stromeolysn, histamine, VIP, and substance P) yang dapat mengiritasi saraf sehingga menimbulkan pembengkakan dan timbul rasa nyeri akibat perasangan chemoreceptors.14,17 HNP akut sering menyebabkan nyeri radicular melalui radikulitis kimiawi akibat terjadi pelepasan proteoglikans dan fosfolipase yang dilepaskan dari nucleus pulposus sehingga menyebabkan inflamasi kimiawi dan atau kompresi saraf langsung.14,31

Mediator kimiawi interleukin 6 dan nitric oxide juga dilepaskan dari diskus intervertebralis dan ikut berperan dalam kaskade inflamasi.  Radikulitis kimiawi merupakan kunci pokok penyebab rasa nyeri pada HNP karena kompresi saraf saja tidak selalu menimbulkan rasa nyeri kecuali ganglion saraf dorsal juga terlibat. Terkadang fragmen dari annulus fibrosus yang pecah dapat terdesak sampai ke kanalis spinalis.14,31

Herniasi juga dapat menginduksi demielinisasi saraf yang mengakibatkan gejala-gejala neurologik. HNP akibat trauma yang jarang ditemukan pada vertebra cervical level C2-3 memiliki manifestasi berupa rasa nyeri pada daerah leher dan bahu yang non-spesifik, hipestesia perioral, gejala radikulopati lebih menonjol daripada mielopati, dan disfungsi motorik dan sensorik tungkai atas lebih sering ditemukan daripada tungkai bawah. Radikulopati cervical terjadi akibat kompresi saraf secara mekanis atau reaksi peradangan (misal radikulitis kimiawi).

Regio cervical merupakan tempat tersering terjadinya radikulopati (5 – 36 % kasus). HNP dari vertebra cervical merupakan penyebab radikulopati pada 20 – 25 % kasus. Insiden dari cervical radikulopati secara berurutan adalah sebagai berikut: C7 (70%), C6 (19-25%), C8 (4-10%), and C5 (2%).14 Kelemahan otot dapat ditemukan pada bagian otot ekstremitas atas yang dipersarafi oleh serat saraf yang terkena. Karena gejala dapat ditemukan pada berbagai regio di ekstremitas atas, maka HNP cervical sulit dibedakan dengan kelainan akibat kompresi saraf yang lain yang terjadi pada ekstremitas atas,seperti thoracic outlet atau carpal tunnel syndromes.14,17

Gambar 32. Klasifikasi herniasi diskus intervertebralis.31

A: Gambaran anatomi diskus intervertebralis normal menunjukkan adanya

      nucleus pulposus (NP) dan annular margin (AM).

B: Gambaran Disc protrusion dengan penetrasi NP yang asimetris melalui serat

     annular tetapi masih belum melewati AM.

C: Gambaran Disc extrusion dengan NP melewati AM.

D: Disc sequestration dengan fragmen nuclear yang terpisah dari herniasi

     diskus.

  • GEJALA KLINIK

Tidak semua HNP menimbulkan gejala, bahkan pada beberapa individu ,HNP ditemukan secara tidak sengaja pada waktu dilakukan pemeriksaan X-ray untuk indikasi yang berbeda. Gejala yang timbul dapat dikategorikan menjadi tiga kelompok5:

1. Kelompok pertama (Axial Joint Pain) meliputi: rasa nyeri di

daerah leher, nyeri menjalar sampai di daerah  skapula (scapular pain) dinding dada, atau daerah bahu,  nyeri pada bagian belakang kepala, kesulitan dalam pergerakan kepala, dan dizziness ,khususnya jika leher digerakkan ke belakang atau dimiringkan. Tidak ditemukan adanya tanda-tanda defisit neurologik. Gejala ini timbul akibat kompresi lokal dari ligamen dan struktur anatomi sekitar.5,35

2. Kelompok kedua (Cervical Radiculopathy) meliputi : rasa nyeri di sepanjang bahu, lengan atas dan tangan, rasa baal di tangan

dan jari-jari, dan kelemahan pada lengan atas. Gejala-gejala pada kelompok kedua ini diakibatkan oleh kombinasi kompresi saraf

yang melewati daerah herniasi (pada level vertebra C5-6 atau C6- 7) inflamasi pada saraf spinal. Jika yang terkena adalah pada level

vertebra C5-6, gejala yang dapat timbul meliputi penurunan reflex brachialis radialis, kelemahan pada otot bisep dan rasa nyeri /

parestesia yang menjalar ke ibu jari dan jari telunjuk. Jika yang terkena adalah pada level vertebra C6-7, maka gejala yang dapat

timbul adalah kehilangan reflex trisep, kelemahan otot trisep, dan rasa nyeri atau parestesia yang menjalar ke jari tengah. Gejala lain

yang dapat ditemukan (sensitifitas 50 %) adalah:

  • Spurling sign (rasa nyeri timbul akibat ekstensi,  fleksi lateral dan axial load pada area yang terkena.
  • Rasa nyeri hilang dengan traksi pada leher
  • Rasa nyeri berkurang jika pasien meletakkan lengan atas di atas kepalanya5,35

3. Kelompok ketiga (Cervical Myelopathy) merupakan gejala

yang memerlukan perhatian khusus karena adanya potensi menyebabkan kerusakan pada keempat ekstremitas, kelemahan pada keempat ekstremitas dengan disertai hilangnya rangsang sensorik (rasa baal) , reflex fisiologis meningkat, timbulnya reflex patologis (Hoffmans dan atau Babinski signs), keseimbangan terganggu, gangguan dalam cara berjalan (gait  disorder), clumsy spastic  legs, gangguan dalam fine motor movements dan kesulitan dalam kontrol buang air besar dan buang air kecil (akibat peningkatan tonus otot pada dinding kandung kemih sehingga menimbulkan frekuensi dan nokturia). Pada kelompok ketiga ini gejala timbul akibat kompresi dari  medula spinalis baik akut maupun kronik. Deteksi dini merupakan hal yang penting, karena jika telah ditemukan gejala defisit neurologik yang berat, maka sulit untuk sembuh secara spontan, bahkan dengan terapi bedah sekalipun, fungsi yang hilang tidak dapat kembali.5,35

Secara umum gejala yang dapat ditemukan pada HNP cervical meliputi27,29:

  • Nyeri di daerah leher khususnya pada bagian belakang dan samping
  • Rasa nyeri yang dalam di dekat atau sekitar bahu pada bagian yang terkena
  • Rasa nyeri yang menjalar ke bahu, lengan atas dan bawah, dan yang jarang pada tangan, jari-jari atau dada (Referred pain)
  • Rasa nyeri memburuk dengan batuk, peregangan atau tertawa
  • Peningkatan rasa nyeri ketika fleksi leher atau menengokkan kepala
  • Spasme dari otot-otot leher
  • Kelemahan otot-otot lengan
  • Rasa baal atau  tingling (a "pins-and-needles" sensation) di daerah bahu atau lengan
  • Posisi atau pergerakan leher tertentu dapat menimbulkan rasa nyeri hebat

Gejala kompresi medula spinalis meliputi awkward or stumbling gait, kesulitan dalam gerakan motorik terampil pada tangan dan lengan, dan rasa kesemutan yang menjalar sampai ke kaki. Gejala ini dapat bervariasi tingkat keparahannya dan tidak seluruhnya ditemukan pada pasien.2,29

Level       

C4-C5    

C5-C6    

C6-C7    

C7-T1

Kelemahan

Shoulder

Forearm flexion

Wrist extension

Grip

Rasa baal

Shoulder

Upper arm, thumb

Middlefinger,allfingertips

Ring and little fingers

 Tabel 2. Level vertebra yang terkena sesuai letak persarafannya2

 

DIAGNOSA

Anamnesa

  • Meliputi:
    • onset 
    • Mekanisme trauma
    • Gejala sistemik yang menyertai (misal, demam merupakan pertanda infeksi, penurunan berat badan dapat merupakan pertanda keganasan).
  • Discogenic pain tanpa keterlibatan saraf biasanya bersifat samar-samar, difus, dan distribusi secara axial. 
    • Aktivitas yang dapat meningkatkan tekanan intra-diskus (misal, mengangkat, manuver Valsalva) dapat memperburuk gejala. Sebaliknya, berbaring terlentang dapat memperbaiki gejala dengan menurunkan tekanan intra-diskus.31
  • Beban getaran (Vibrational stress) akibat mengemudi dapat memperburuk discogenic pain.
  • Bergantung pada adanya keterlibatan sensorik atau motorik, nyeri radicular dapat bersifat dalam, tumpul, atau tajam, rasa terbakar, dan rasa seperti tersetrum (electric).
    • Nyeri radicular tersebut biasanya mengikuti pola persarafan dermatom atau myotomal pada tungkai atas.
    • Nyeri radicular cervical sering ditemukan menjalar ke region interskapular meskipun nyeri juga dapat dirujuk ke regio occipital, bahu, atau lengan.
    • Nyeri di daerah leher tidak selalu menyertai radikulopati dan sering tidak ditemukan bersamaan.
    • Selain itu, pasien juga dapat mengeluh rasa baal pada tungkai bagian distal dan  kelemahan di bagian proximal. Atrofi juga dapat ditemukan.
    • Penelitian menunjukkan bahwa HNP cervical dapat menginduksi perubahan suhu dengan distribusi spesifik pada ekstremitas atas.31

Pemeriksaan fisik

  • Pasien dengan gejala nyeri radicular juga memiliki manifestasi berupa penurunan  ruang gerak (range of motion (ROM)) cervical.
    • Rasa nyeri radicular dapat ditimbulkan dengan ekstensi leher dan rotasi atau dengan manuver Spurling (leher pasien diekstensikan, dimiringkan ke lateral, dan ditahan ke bawah)??
    • Gejala rasa nyeri dapat dikurangi dengan fleksi leher atau abduksi tungkai atas yang bergejala ke atas kepala (abduction sign).
    • Penurunan sensasi terhadap rasa nyeri, rasa raba ringan, atau rasa getar dapat timbul pada tungkai atas bagian distal. Kelemahan pada tungkai bagian proksimal dapat bermanifestasi jika terdapat kompresi saraf motorik yang signifikan
    • Hilangnya atau menurunnya reflex yang berhubungan dengan level saraf yang terkena dapat juga ditemukan.
    • Peningkatan reflex tungkai atas dan bawah atau tanda-tanda UMN lainnya merupakan pertanda mielopati dan merupakan indikasi dilakukan evaluasi diagnostik yang agresif.
  • Pasien dengan nyeri diskogenik tanpa keterlibatan saraf menunjukkan manifestasi penurunan ruang gerak cervical, pemeriksaan neurologik normal, dan peningkatan rasa nyeri dengan kompresi axial dan pengurangan rasa nyeri dengan distraksi.
  • Pada palpasi dapat ditemukan nyeri tekan miofasial atau trigger points, yang dapat bersifat primer maupun sekunder akibat proses patologik lainnya.31

 

Pemeriksaan khusus25:

  1. Distraction test: Pemeriksaan ini bertujuan untuk mengetahui apakah traksi leher dapat membantu mengatasi rasa nyeri yang timbul. Tes ini dapat mengurangi rasa nyeri jika: (1) rasa nyeri diakibatkan oleh penyempitan foramen, (2) timbul iritasi pada facet joint. Pemeriksaan ini dapat meningkatkan rasa nyeri yang timbul di daerah ligamen. 
  2. Compression test: Dengan menekan vertebra cervicalis sampai berdekatan akan menimbulkan rasa nyeri jika terjadi penyempitan foramen atau iritasi facet joint.
  3. Valsalva test: Pemeriksaan ini dilakukan dengan menahan napas sekuatnya sehingga menyebabkan peningkatan tekanan intratekal yang mengindikasikan adanya space occupying lesion.
  4. Swallowing test: Kesulitan menelan dapat disebabkan oleh kelainan pada vertebra cervicalis. Peningkatan rasa nyeri atau kesulitan menelan (disfagia) selain dapat disebabkan oleh kelainan vertebra cervical anterior, juga dapat disebabkan oleh vertebral subluxations, osteophytes protrusion, soft tissue swelling dan atau tumor.  
  5. Adson's test: Pemeriksaan ini bertujuan untuk mengetahui keadaan arteri subclavia. Adanya kekakuan otot-otot di daerah leher atau kelainan patologis lainnya dapat menyebabkan penekanan pada arteri tersebut. Raba denyut nadi radialis pasien, kemudian lakukan abduksi, ekstensi dan rotasikan lengan kearah lateral. Pasien disuruh mengambil napas dalam dan kepala dirotasikan kearah yang terdapat kelainan. Hasil tes positif jika terdapat pengurangan pengisian denyut nadi (pada Thoracic outlet syndrome, hasil tes positif pada kurang lebih 20 % kasus).
  6. Vertebral Artery Test: Pemeriksaan ini bertujuan untuk menilai aliran dari arteri vertebralis. Pasien diposisikan dalam posisi terlentang. Kemudian tangan pemeriksa memegang bagian kepala pasien, kepala pasien kemudian diekstensikan, rotasi, dan fleksi kearah lateral secara perlahan. Pada pasien diamati terhadap terjadinya dizziness, bicara ngawur (slurred speech) dan hilang kesadaran. Jika terjadi salah satu atau seluruh gejala diatas maka hasil pemeriksaan positif terhadap terjadinya oklusi total atau parsial dari arteri vertebralis.
  7. Spurling's Sign: Hiperekstensi dengan disertai rotasi eksternal. Rasa nyeri yang timbul pada arah rotasi menunjukkan adanya stenosis foramen dan iritasi radix saraf

Test Position: Dengan posisi pasien dalam keadaan duduk, pemeriksa melakukan kompresi pada kepala pasien. Tekanan diarahkan tegak lurus kebawah dan kemudian diulangi dengan fleksi lateral ke setiap sisi. Hasil tes positif jika ditemukan adanya rasa nyeri atau kesemutan pada ekstremitas atas di bagian yang sesuai dengan arah fleksi kepala. Rasa nyeri timbul akibat adanya tekanan pada radix saraf dan berkorelasi dengan persarafan dermatom. Hati-hati melakukan pemeriksaan pada pasien dengan osteoarthritis, osteoporosis,dan congenital cervical stenosis

 

Gambar 34. Spurling test37

H. Foraminal Distraction Test

Dilakukan dengan posisi yang sama dengan Spurling’s Test. Tangan pemeriksa diletakkan pada bagian belakang kepala dan dagu sambil memberikan tekanan (distraction force). Jika keluhan rasa nyeri dan atau gejala parestesia berkurang atau menghilang berarti hasil tes positif. Tes ini tidak dilakukan jika terdapat kecurigaan adanya vertebra cervicalis yang tidak stabil.2

Pemeriksaan laboratorium

  • Pemeriksaan laboratorium reumatologi dapat dipertimbangkan untuk dilakukan untuk mengevaluasi kemungkinan penyebab berupa rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, dan polymyalgia rheumatica. Tes ini meliputi:
    • Rheumatoid factor (meningkat pada rheumatoid arthritis)
    • HLA-B27 (positif pada ankylosing spondylitis)
    • Laju endap darah (meningkat pada polymyalgia rheumatica)
  • Pertimbangkan untuk melakukan pemeriksaan laboratorium terhadap kemungkinan penyebab berupa infeksi discitis, abses epidural , dan osteomielitis vertebra. Tes ini meliputi:
    • Hitung leukosit dan hitung jenis leukosit (peningkatan pergeseran ke kiri (shift to the left) pada infeksi bakteri))
    • Kultur darah
    • Laju endap darah (meningkat pada infeksi tetapi tidak spesifik)31

Pemeriksaan radiologi

  • Pemeriksaan radiologi lebih mengarah pada evaluasi struktur anatomi dibandingkan fungsi dan dapat menyebabkan hasil false positive dan negative.
  • Pemeriksaan foto polos (Plain radiographs)
    • Pemeriksaan foto polos cervical dapat mengevaluasi perubahan degeneratif kronik, penyakit metastasis, infeksi, deformitas dan stabilitas  tulang belakang.
    • Foto vertebra cervicalis akibat trauma (Cervical spine trauma films ) menggunakan 7 posisi, meliputi anteroposterior (AP), lateral, bilateral oblique, open-mouth, fleksi, dan ekstensi.
      • Posisi fleksi-ekstensi dapat mengidentifikasi subluksasi atau vertebra cervicalis yang tidak stabil.
      • Posisi Open-mouth dapat mengevaluasi prosesus odontoid  dan stabilitas C1-C2.
      • Posisi AP dapat mengidentifikasi  tumor, osteofit, dan fraktur.
      • Posisi Lateral dapat menilai stabilitas dan spondilosis
      • Posisi Oblique dapat mengidentifikasi penyakit degeneratif yang mengenai diskus intervertebralis atau z-joint osteophytes.
  • Computed tomography
    • CT scan dapat mengidentifikasi fraktur vertebra cervicalis dan sering digunakan pada kasus trauma.
    • Helical atau spiral CT scan dapat memberikan gambaran mengenai fraktur yang lebih detil dibandingkan CT scan konvensional.31
  • CT-mielografi
    • Pemeriksaan mielogram diikuti oleh CT scan dapat dilakukan sebelum dilakukannya operasi dekompresi medula spinalis cervical atau  radix.
    • Pemeriksaan mielogram dengan foto X-ray setelah diinjeksi zat kontras (iophendylate / pantopaque) kedalam ruang cairan serebrospinal; dapat menunjukkan adanya penekanan pada medula spinalis atau saraf akibat HNP, bone spurs atau tumor
    • CT-mielography, masih menjadi pemeriksaan standar, lebih efektif dibandingkan MRI dalam mendeteksi penyempitan ke arah foramen dan lateral  meskipun dengan total biaya dan angka morbiditas yang lebih tinggi. Sebaliknya, CT-mielography bukan merupakan pemeriksaan awal dalam mengevaluasi vertebra cervicalis dan biasanya dipergunakan pada kasus-kasus yang rumit.14,28,31
  • MRI tetap merupakan alat pemeriksaan terpilih untuk mengevaluasi HNP cervical karena angka morbiditasnya rendah.
    • Keuntungan pemeriksaan radiologi ini meliputi dapat mengevaluasi jaringan lunak (misal diskus intervertebralis, medula spinalis), cairan serebrospinal, noninvasif, dan tidak memiliki resiko terekspos terhadap radiasi.
    • Semakin baru rangkaian gelombang dan semakin tinggi medan magnet maka semakin cepat dan detail gambar yang dihasilkan.
    • Sayangnya pada beberapa rangkaian gelombang (misal spin echo), gambaran patologi yang didapat digambarkan lebih besar daripada ukuran aslinya dan menyamarkan kelainan lainnya. Kerugian lainnya meliputi biaya yang mahal, pasien yang menderita klaustrofobia mengalami kesulitan dalam penggunaan metode ini, hasil yang didapatkan bergantung pada kerjasama pasien sehingga artifak dapat diminimalkan, nilai positif semu tinggi, dan sensitivitasnya rendah bila dibandingkan CT scan dalam mengevaluasi struktur tulang
    • Lebih jauh lagi, pada pemeriksaan MRI juga sulit untuk membedakan prolaps diskus cervicalis (misal soft cervical disc) dengan  dengan spondylitic osteophytic compression (misal hard cervical disc).
    • Kontraindikasi MRI berupa pada pasien yang ditanam benda-benda logam didalam tubuhnya seperti pacemakers, surgical clips, spinal cord stimulators, atau katup jantung buatan yang dapat tertarik oleh magnet MRI.31

                           

Gambar 36. Foto MRI menunjukkan adanya HNP cervical pada level C5 dan C66

  • Provocative cervical discography
    • Pemeriksaan ini masih bersifat kontroversial dengan cara meletakkan jarum spinal ke dalam diskus intervertebralis cervicalis. Sebelum dilakukan, pasien terlebih dahulu diberikan anestesi lokal
    • Terdapat 2 teknik yang berbeda yaitu :
      • Teknik paravertebral menggunakan palpasi digital untuk menarik struktur jaringan lunak vital (misal, trakea, arteri karotis, esofagus).
      • Teknik oblique tidak memerlukan palpasi digital. Setelah jarum spinal dimasukkan ke dalam bagian tengah nucleus pulposus (dengan bantuan fIuoroscopy), kontras kemudian diinjeksikan untuk menentukan  struktur internal diskus intervertebralis dan berbagai rasa nyeri yang ditimbulkan.
    • Provocative discography merupakan satu-satunya prosedur yang dapat menentukan apakah rasa nyeri yang timbul dihasilkan dari diskus intervertebralis.
    • Kerugian dari prosedur ini adalah adanya rasa tidak nyaman dan bersifat invasif dibandingkan cervical MRI, yang dapat memberikan informasi anatomi lebih baik dibandingkan pemeriksaan provocative discography.
    • Provocative cervical discography dapat mengidentifikasi diskus intervertebralis yang terkena, sehingga dapat membantu dalam mengevaluasi pasien dengan pemeriksaan diagnostik yang belum pasti dan presurgical fusion planning.
    • Kontraindikasi pemeriksaan provocative discography meliputi herniasi diskus intervertebralis yang berukuran besar dan ukuran diameter kanalis spinalis potongan sagital kurang dari 12 mm.
    • Komplikasi meliputi discitis, abses epidural, kuadriplegia, stroke, pneumothorax, kerusakan saraf dan medula spinalis. Angka kejadian cervical discitis yang dilaporkan sebesar 0.37%.
    • Discography dilakukan pada semua level vertebra cervicalis yang dapat diakses, sehingga hal ini menyebabkan insiden kerusakan multilevel dari vertebra cervicalis.14,31

    Pemeriksaan lain

  • Pemeriksaan elektrodiagnostik masih menjadi standar dalam mengevaluasi fungsi neurologik dari vertebra cervicalis.
    • Keuntungan pemeriksaan ini meliputi biayanya lebih murah dan angka morbiditasnya lebih rendah.
    • Nerve conduction studies (NCSs) dan elektromiografi (EMG) dapat menilai fisiologi dari radix saraf cervical dan fungsi saraf perifer.
      • Pemeriksaan EMG dapat mendeteksi nyeri radicular akut, subakut dan kronik jika terdapat kelainan saraf motorik. Pemeriksaan EMG digunakan untuk menentukan apakah gejala yang timbul (misal kelemahan, nyeri radicular dll) disebabkan oleh kelainan otot atau saraf. Pemeriksaan EMG menilai respon otot terhadap stimulasi saraf dan mengevaluasi aktivitas listrik pada serat saraf tertentu.
      • Pemeriksaan dilakukan dengan pasien berada dalam posisi duduk atau berbaring, kemudian satu atau lebih jarum elektroda dimasukkan melalui kulit ke kelompok otot tertentu, kemudian pasien diperintahkan untuk melakukan kontraksi otot tersebut. Kontraksi otot akan menimbulkan gelombang yang dapat dideteksi oleh oscilloscope
      • Diagnosis radikulopati ditegakkan jika pada pemeriksaan EMG menunjukkan adanya gelombang potensial abnormal secara spontan dan atau perubahan tertentu pada potensial aksi unit motorik pada 2 atau lebih otot yang dipersarafi oleh radix saraf yang sama tetapi saraf perifer yang berbeda. Idealnya, kelainan pada EMG seharusnya juga ditemukan pada otot paraspinal untuk memastikan diagnosis radikulopati.
      • Pada pemeriksaan NCS, elektrode mirip EKG diletakkan di sepanjang jalur saraf yang akan diperiksa. Saraf tersebut kemudian distimulasi dengan menggunakan arus listrik kecil pada suatu titik tertentu, saraf tersebut kemudian akan menghantarkan impuls listrik sepanjang perjalanan saraf tersebut, yang akan ditangkap oleh elektroda yang telah diletakkan sebelumnya. 
      • Saraf yang sehat akan menghantarkan impuls listrik lebih cepat dan lebih kuat bila dibandingkan saraf yang rusak. Jumlah amplitude potensial aksi saraf motorik yang berkurang > 50 % atau lebih mengindikasikan adanya kerusakan axon yang signifikan. Penilaian ini dibuat melalui pemeriksaan NCS dari axon saraf motorik.
      • NCS/EMG  khususnya berguna untuk membedakan radikulopati cervical dengan kelainan neuropati lainnya yang ditemukan (misal, ulnar nerve entrapment, carpal tunnel syndrome, neuropati perifer, plexopathy).
      • Kelemahannya, radikulopati cervical yang hanya mengenai axon saraf sensorik saja (misal, tanpa adanya keterlibatan axon saraf motorik) jarang dapat dideteksi dengan pemeriksaan elektrodiagnostik.  
      • Sebagai tambahan, pemeriksaan NCSs saraf motorik tidak mengevaluasi radix saraf level vertebra C6 dan C7 atau level vertebra diatasnya, dimana merupakan level saraf yang paling sering terkena gangguan.
      • Tidak seperti pemeriksaan jarum EMG (dimana meliputi evaluasi intramuskular dan merupakan pemeriksaan diagnostik yang dapat diterima dengan baik ), pemeriksaan EMG superfisial secara umum tidak memiliki peranan dalam diagnosis radikulopati.14,31
  • Pemeriksaan Somatosensory evoked potentials (SEP) dapat mengevaluasi konduksi saraf sensorik perifer dan sentral.
    • Pemeriksaan SEPs tungkai bawah meliputi saraf tibial dan peroneal, yang dapat menilai konduksi saraf medula spinalis, lebih sensitif dalam mendiagnosa mielopati dibandingkan SEPs pada tungkai atas dan ulnar.
    • Dermatomal evoked potentials telah digunakan untuk mendeteksi radikulopati cervical tetapi masih menjadi kontroversi.29,31

Tidak semua HNP menimbulkan gejala. Pada beberapa orang, diagnosa ditemukan secara kebetulan setelah dilakukan pemeriksaan X-ray untuk indikasi yang berbeda.29,31

Klasifikasi lain dari neck and arm pain menurut Macnab38:

1. Visceenic

Lesi di daerah faring, laring dan trakea bagian atas dan esofagus dapat menimbulkan rasa nyeri di daerah leher

2. Vasculogenic

Angina pectoris dan rasa nyeri dari infark jantung akibat oklusi arteri koroner dapat dialihkan ke daerah leher, bahu atau menjalar  sampai ke lengan atas pada satu atau dua tangan. Oklusi pada arteri karotis juga dapat menimbulkan rasa nyeri di daerah leher.

3. Neurogenic

Neoplasma pada medula spinalis dapat menimbulkan gejala yang menyerupai central herniation pada diskus intervertebralis daerah cervical. Neoplasma yang terletak di bagian apex paru (pancoast’s tumor) dapat menyebabkan penekanan pada pleksus brachialis sehingga menimbulkan gejala nyeri radicular yang menyerupai gejala kompresi radix saraf akibat cervical spondylosis.

4. Spondylogenic

                a. Osseous lesions

                                Trauma: komplikasi akibat fraktur dan dislokasi

                                Infeksi : pyogenic osteomyelitis, tuberculous osteomyelitis

                                Inflamasi non spesifik : ankylosing spondylitis

                                Neoplasma : primer dan sekunder

                                Disseminated bone disorders: eosinophilic granuloma

                                Metabolic bone disease : osteoporosis, osteomalacia, ochronosis

                b. Soft tissue lesions

                                Myofascial lesions: muscle strains, tendinitis

                                Intervertebral disc lesions: segmental instability, segmental narrowing, HNP

                                Facet joint lesions: degenerative joint disease (cervical spondylosis)

5. Psychogenic

Menurut penelitian, beberapa pasien yang mengeluh adanya rasa nyeri di daerah leher dan lengan ternyata memiliki emosi yang tidak stabil atau neurosis, tetapi bukan berarti selalu rasa nyeri yang dirasakannya hanya khayalannya saja ; bahkan sesungguhnya pada pasien tersebut terdapat penyakit organik yang mendasari yang dikombinasi dengan faktor psikogenik. Oleh karena itu, meskipun rasa nyeri di daerah leher yang dapat atau tanpa disertai rasa nyeri di daerah lengan, terkadang merupakan manifestasi dari penyakit psikosomatik, tetapi penyebab organik rasa nyeri tetap harus dicari. Sebagai tambahan, faktor psikologik dari pasien tersebut juga harus diidentifikasi dan diberikan penatalaksanaan lebih lanjut.

  • TERAPI

Terapi meliputi terapi konservatif dan terapi bedah. Terapi konservatif meliputi bedrest, terapi fisik, chiropractic manipulation, blok saraf, pemberian steroid, analgetik dll. Pada sebagian besar pasien, terapi konservatif atau non-bedah dapat secara efektif mengurangi gejala yang timbul. Jika gejala tidak membaik dengan terapi konservatif, maka dapat dipertimbangkan terapi bedah dekompresi.5,30 

       TERAPI NON-BEDAH

v.  Terapi medikamentosa

Obat-obat antiinflamasi non-steroid (AINS) merupakan intervensi farmakologik tahap pertama pada sebagian besar kelainan cervical. Obat AINS dapat mengurangi rasa nyeri pada dosis kecil dan mengurangi efek inflamasi pada dosis besar.

Diperlukan kadar terapeutik obat AINS yang sesuai dalam plasma untuk memperoleh efek anti-inflamasi yang diinginkan. Pemberian dosis obat AINS sekali sehari dapat meningkatkan compliance dan meningkatkan kemungkinan tercapainya kadar terapeutik.

Kontrol efek inflamasi merupakan hal yang pokok dalam penatalaksanaan radikulopati cervical. Obat aspirin jarang direkomendasikan karena efeknya yaitu terikat secara irreversibel pada enzim siklooksigenase dan menimbulkan gastritis, diperlukan dosis yang besar untuk mendapatkan efek antiinflamasi. Efek samping obat AINS yang lainnya berupa toksisitas multiorgan, meliputi ulkus peptik, insufisiensi renal dan disfungsi hepar. Obat AINS terbaru golongan inhibitor cyclo-oxygenase isomer tipe 2 (COX-2) dapat memberikan efek analgesik atau antiinflamasi tanpa menimbulkan toksisitas multiorgan. Obat golongan muscle relaxants dapat meningkatkan efek analgesik dari obat golongan AINS dan tidak diperlukan untuk mengontrol spasme otot. 31

 

Obat Corticosteroid oral dapat digunakan untuk mengatasi efek inflamasi akibat radikulopati cervical.

Obat golongan Tricyclic antidepressants (TCAs) dapat mengurangi rasa nyeri dan mengurangi nonrestorative sleep.

Obat golongan opioid dapat diberikan secara oral, transdermal, rectal atau sublingual dengan pengawasan ketat.

 

Terapi fisik (Physical Therapy)

 Tujuan dari terapi fisik ini adalah untuk menghilangkan rasa nyeri, menormalkan pergerakan vertebra, dan memperbaiki kontrol neuromuskular. Terapi fisik seperti misalnya Ice and heat therapy, massage, stretching, dan neck traction dapat membantu mengurangi rasa nyeri dan meningkatkan fleksibilitas. Terapi non-bedah efektif dalam penatalaksanaan HNP pada 90 % kasus. 23,29,39

 Istirahat

Dengan mengistirahatkan sendi dan otot yang menjadi sumber rasa nyeri dapat berguna untuk membantu proses penyembuhan. Jika rasa nyeri masih dirasakan pada waktu melakukan aktivitas atau pergerakan, hal ini menandakan masih adanya iritasi yang sedang berlangsung. Oleh karena itu sebaiknya semua gerakan dan aktivitas yang dapat meningkatkan rasa nyeri sebaiknya dihindari. Dokter atau ahli terapi biasanya akan menganjurkan untuk memakai soft atau hard neck collar untuk membatasi pergerakan leher.10

 

  • Pengaturan posisi

Ada berbagai cara khusus yang dapat diberikan oleh dokter atau ahli terapi untuk membantu mengistirahatkan kepala dan leher sehingga dapat mengurangi atau menghilangkan rasa nyeri yang timbul. Salah satu cara yang dilakukan adalah dengan menggunakan bantal khusus (contour pillow), untuk membantu menempatkan leher pada posisi yang nyaman pada waktu tidur atau beristirahat. Alat khusus seperti neck roll atau rolled towel dapat diletakkan di bawah bantal sehingga pada saat berbaring, alat tersebut dapat mengisi dan membantu menstabilkan kelengkungan pada leher.10

  • Ultrasound

Alat ultrasound dapat memproduksi gelombang frekuensi tinggi yang diarahkan ke tempat nyeri di leher. Dengan melewati jaringan tubuh, gelombang ini dapat menggetarkan molekul-molekul. Hal ini dapat menyebabkan gesekan dan rasa hangat ketika gelombang melewati jaringan. Sisa dari gelombang akan diubah menjadi energi panas di dalam jaringan tubuh yang lebih dalam. Efek panas ini membantu membersihkan area yang menjadi sumber rasa nyeri dan mensuplai darah yang kaya nutrisi dan oksigen.10

  • Phoresis

Terdapat dua metode yang dapat digunakan para ahli terapi untuk mentransmisikan substansi melalui kulit. Phonophoresis menggunakan gelombang suara frekuensi tinggi untuk “mendorong” Corticosteroid (cortisone) melalui kulit. Iontophoresis menggunakan alat kecil yang memproduksi muatan listrik kecil, yang digunakan untuk membawa obat-obatan khususnya steroid melalui kulit. Steroid merupakan obat antiinflamasi yang sangat kuat yang berfungsi menghentikan reaksi kimiawi didalam tubuh yang menimbulkan rasa nyeri.10

  •  Electrical Stimulation

Terapi ini bertujuan menstimulasi saraf dengan mengirimkan impuls listrik melalui kulit. Electrical stimulation dapat mengurangi rasa nyeri dengan mengirimkan impuls sebagai ganti rasa nyeri. Dua orang peneliti ternama mengemukakan sebuah teori yang disebut Gait Theory.  Teori ini mengatakan bahwa jika kita merasakan sensasi selain rasa nyeri, seperti rasa seperti digosok (rubbing), dipijat (massage), atau impuls listrik yang menjalar, maka kolumna spinalis akan menutup gerbang rasa nyeri sehingga tidak terjadi penjalaran rasa nyeri ke otak. 

  •  Soft tissue mobilization/massage

Massage telah terbukti mampu megurangi rasa nyeri dan spasme otot dengan merelaksasikan otot, membawa aliran darah kaya oksigen dan nutrisi dan dengan membersihkan area yang terkena iritasi kimiawi yang timbul akibat reaksi peradangan. Para ahli terapi fisik memiliki berbagai cara berbeda dalam melakukan mobilisasi atau massage, yang dapat meliputi effleurage (merupakan salah satu teknik pelepasan miofasial yang membantu memperbaiki pergerakan yang normal), Strain-counter-strain (merupakan salah satu bentuk terapi  yang khususnya berguna jika terdapat sumber rasa nyeri yang menjadi penyebab keterbatasan gerak otot). Terapi ini biasanya dilakukan dengan meletakkan otot pada posisi tertentu, biasanya pada tempat serat otot yang paling pendek. Posisi ini dipertahankan selama mungkin untuk mempengaruhi aliran sinyal listrik saraf ke otot. Salah satu bentuk terapi lainnya, adalah dengan muscle energy technique.

  •  Joint mobilization

Teknik ini dilakukan dengan cara memberikan tekanan dan pergerakan secara bertahap oleh para ahli terapi fisik yang berpengalaman. Penekanan perlahan yang dilakukan secara bertahap dapat membantu melumasi permukaan sendi, mengurangi kekakuan, dan membantu pengerakan dengan mengurangi rasa nyeri. Rasa nyeri dapat menimbulkan spasme pada otot, karena otot berusaha menjaga sendi yang menimbulkan rasa nyeri, sehingga membatasi pergerakan leher. Dengan memberikan tekanan secara perlahan atau mobilisasi, ahli terapi berusaha untuk menghentikan aliran sensasi rasa nyeri sehingga dapat membuat otot menjadi relaks. Setelah rasa nyeri berkurang, maka dapat dilakukan mobilisasi tahap selanjutnya untuk membantu memperpanjang jaringan di sekitar sendi sehingga membantu mengembalikan pergerakan normal khususnya di leher.10

  •  Olahraga (Exercises)

Olahraga merupakan hal yang penting selama masa penyembuhan akibat HNP. Ada berbagai tipe olahraga yang dapat dilakukan. Pada tahap awal, ketika rasa nyeri masih terasa di daerah leher, olahraga tertentu dapat dilakukan untuk mengurangi rasa nyeri. Salah satunya dengan menempatkan leher pada posisi tertentu, sehingga dapat mengurangi penekanan pada daerah nyeri. Cara menemukan posisi yang tepat dapat dengan menggunakan alat seperti bantal, rolled towel, atau commercial neck roll. Pada kasus-kasus dengan rasa nyeri yang signifikan, maka dapat dilakukan olahraga pernapasan.

Tahap olahraga berikutnya memfokuskan pada kekuatan otot-otot leher karena otot-otot ini dapat membantu menstabilkan vertebra agar tetap pada posisinya (stabilization training). Segera setelah kekuatan otot-otot leher meningkat, maka diperlukan latihan koordinasi sehingga dapat mengurangi resiko terjadinya trauma kembali. Fokus terakhir adalah dengan fitness training, melalui fitness training dapat meningkatkan efektivitas otot dapat memperoleh nutrisi dan oksigen dari darah. Setelah otot menggunakan nutrisi dan oksigen, dapat terjadi pembentukan zat sisa metabolisme yang dapat menimbulkan rasa nyeri, maka latihan ini dapat meningkatkan kemampuan otot untuk membersihkan zat sisa metabolisme ini. Olahraga juga dapat menstimulasi pelepasan endorfin ke dalam darah. Hormon ini berperan sebagai zat pengurang rasa nyeri. Jalan santai, stationary cycling, dan arm cycling merupakan contoh olahraga yang dapat memperbaiki fungsi hati dan ginjal. Olahraga mungkin tidak menyembuhkan HNP, tetapi dapat membantu mengontrol rasa nyeri dan stress yang menyertainya.10,23

              

Gambar 38. Exercise21

  • Ice/Heat Therapy

Dalam 24 sampai 48 jam pertama, cold therapy (misalnya dengan es) dapat membantu mengurangi pembengkakan, spasme otot dan rasa nyeri dengan mengurangi aliran darah. Es membuat vasokonstriksi pembuluh darah. Hal ini dapat membantu mengontrol reaksi inflamasi yang menimbulkan rasa nyeri. Ada berbagai cara penggunaan es misalnya dengan cold packs, ice bags, atau ice massage.  Cold packs atau ice bags biasanya diletakkan pada area yang nyeri selama 10 -15 menit. Ice massage (dapat dilakukan dengan menggunakan secangkir air yang telah dibekukan) biasanya dilakukan dengan menggosokkan es pada tempat nyeri selama tiga sampai 5 menit atau sampai terasa baal.10,29

Setelah  48 jam pertama, heat therapy dapat diberikan. Panas dapat meningkatkan aliran darah melalui vasodilatasi pembuluh darah untuk menghangatkan dan merelaksasikan jaringan lunak. Peningkatan aliran darah dapat membantu membersihkan iritasi toksin yang dapat mengumpul di jaringan akibat spasme otot dan trauma diskus. Selain itu juga dapat membantu membawa nutrisi dan oksigen sehingga dapat membantu proses penyembuhan luka. Sumber panas berupa moist hot pack, a heating pad, atau mandi atau berendam air hangat lebih menguntungkan daripada menggunakan krim yang hanya memberikan sensasi hangat.  Jangan memberikan sumber dingin atau panas langsung ke kulit; tetapi bungkus sumber panas atau dingin dengan handuk tebal selama 15 – 20 menit.10,29,33

  • McKenzie’s approach

Pada sebagian besar kelainan vertebra cervicalis, berbagai penelitian mendukung penggunaan terapi konservatif seperti metode McKenzie dan cervicothoracic stabilization programs, dikombinasi dengan senam aerobik. Sistem McKenzie mengidentifikasi 3 mekanisme sindrom yang menyebabkan rasa nyeri dan gangguan fungsi. Sindrom postural dapat menimbulkan rasa nyeri jika jaringan lunak normal diberikan beban terus menerus pada akhir ROM; tidak selalu ditemukan kelainan patologi. Penatalaksanaan bertujuan untuk mengoreksi postur tubuh. Sindrom disfungsi dapat menimbulkan rasa nyeri ketika pasien berusaha melakukan gerakan secara penuh, pada jaringan parut yang mengalami kontraktur.31

  • Butler’s approach

Teknik terapi Butler dapat memperbaiki gejala nyeri radicular dengan melakukan mobilisasi pada saraf yang terkena. Awalnya ahli terapi akan mengidentifikasi "adverse neural tension" yaitu mengevaluasi daya peregangan dan ruang gerak berdasarkan mekanisme patofisiologi dan respon fisiologis dari saraf yang terkena. Secara spesifik ahli terapi akan melakukan pemeriksaan neurodinamik untuk mengevaluasi saraf (misal mobilisasinya di sekitar diskus intervertebra) dan karakteristik fisiologisnya (misalnya responnya terhadap iskemia, peradangan). Kemudian ahli terapi akan memberikan terapi awal berupa mobilisasi pasif sebagai input terhadap sistem saraf pusat tanpa menimbulkan respon stres dan neurogenic massage untuk mengurangi pembengkakan perineural.

Dalam empat sampai enam minggu biasanya sebagian besar pasien akan mengalami perbaikan gejala setelah diberikan terapi fisik tanpa intervensi bedah, jika terapi konvensional gagal maka dapat dilakukan terapi bedah.23,31

 

Saat ini banyak Ahli Bedah Orthopedi mencoba pengobatan conservative untuk memperbaiki HNP dengan meregangkan jaraknya satu sama lain sehingga mengurangi tekanan pada syaraf yang terjepit dan alat ini disebut  DISK DR.

 

Disk Dr ini berguna menujang tulang belakang , fleksibel dan nyaman dipakai dan dari hasil X foto pada pengguna Disk Dr menunjukkan bahwa jarak discus L4 dan L5 bertambah 3 cm.  Disk Dr ini diciptakan untuk HNP Cervical dan Lumbal dan diciptakan oleh Ahli Bedah Orthopedi Rumah Sakit Seoul Paek Universitas Inje .

 

Hasil penelitihan yang dilakukan pada 328 kasus , 85 % mengalami perbaikkan kondisi dalam waktu 3 hari , dan 91 % mengalami hasil yang sangat memuaskan terutama untuk Kasus HNP ringan atau HNP yang menolak operasi baik bila ada kontra indikasi operasi atau penderita yang takut operasi

 

   

 

TERAPI BEDAH

Penelitian menunjukkan bahwa HNP cervical  dengan radikulopati dapat ditatalaksana secara konservatif. Terapi bedah merupakan indikasi jika terdapat disfungsi neurogenik usus atau kandung kemih akibat kompresi medula spinalis sehingga menyebabkan kehilangan fungsi yang signifikan (mielopati), perburukan fungsi neurologik (defisit neurologik yang progresif), atau rasa nyeri di daerah leher atau nyeri radicular dan kelemahan yang timbul terus menerus dan tidak hilang meskipun telah diberikan terapi konservatif (dalam 3 bulan).14,23,31,39

Indikasi terapi bedah yang lain adalah pada penyakit degeneratif, trauma, atau pada tulang vertebra yang tidak stabil. Rasa nyeri didaerah leher akibat kompresi saraf di daerah leher atau medula spinalis merupakan kondisi yang umumnya ditemukan dan memerlukan terapi bedah. Secara spesifik, terapi bedah menguntungkan untuk nyeri radicular, vertebra yang tidak stabil (spinal instability), mielopati progresif, atau kelemahan pada ekstremitas atas.6,14,31

Selama beberapa dekade terakhir, telah dilakukan berbagai penelitian untuk menemukan metode untuk menstabilkan vertebra tanpa menggunakan anterior plate. Salah satu yang ditemukan pada pertengahan tahun 1990an adalah Novus CSR system, metode ini menggunakan suatu alat yang disebut tantalum block yang berguna sebagai interbody spacer atau cages. Salah satu alat interbody cages yang telah terbukti sukses untuk interbody fusion adalah RABEA cage yang terbuat dari campuran titanium dan polimer yang bersifat radioopak yang disebut PEEK.40

 

Gambar 42. : RABEA interbody fusion cage made from PEEK40

Alat ini memiliki keuntungan yaitu meminimalkan penggunaan plate dan screw dan bone graft. Disamping keuntungan yang dapat diperoleh, metode ini memiliki kelemahan yaitu kurang stabil dan proses fusion yang kurang sempurna jika dilakukan pada multilevel procedures yang hanya menggunakan interbody spacer untuk stabilisasi. Jadi dengan kata lain prosedur ini hanya berfungsi sebagai fusion fashion daripada motionpreserving fashion.40

Menurut penelitian, anterior cervical discectomy yang diikuti dengan interbody fusion merupakan kombinasi terapi yang sesuai untuk cervical radiculopathy and disc injury dibandingkan dengan teknik anterior cervical discectomy saja. Dengan adanya kemajuan dalam minimally invasive discectomy techniques diharapkan dapat meningkatkan angka keberhasilan dalam teknik bedah pada daerah cervical. Pendekatan anterior (anterior approach) lainnya seperti   facetectomy atau foraminotomy telah dibuktikan berguna dalam membantu menstabilkan vertebra dan mengurangi rasa nyeri yang timbul. Keuntungan lain yang dapat diperoleh dengan anterior approach adalah dapat meminimalkan manipulasi intraoperatif pada struktur-struktur didalam kanalis spinalis sehingga dapat menimimalkan sekuele neurologik pasca operasi.40

ANTERIOR APPROACH

Anterior cervical discectomy and fusion

                    

Gambar 45. Anterior cervical fixation10

Rasa nyeri pada daerah leher dan lengan, dapat terjadi jika salah satunya disebabkan oleh herniasi diskus intervertebralis. Hal ini dapat terjadi secara tiba-tiba akibat trauma atau berjalan perlahan,akibat bagian tengah dari diskus intervertebralis yang memiliki konsistensi seperti gel menerobos atau terjadi ruptur pada jaringan ikat yang membatasinya (annulus fibrosus) dan menekan saraf. Ketika terjadi ruptur pada vertebra cervicalis, dapat terjadi penekanan pada satu atau lebih radix saraf (kompresi radix saraf) atau pada medula spinalis. Penekanan ini menyebabkan timbulnya gejala pada leher, lengan dan bahkan kaki.

Penekanan saraf juga dapat disebabkan karena adanya pertumbuhan tulang yang abnormal disebut osteofit (bone spurs).7 Anterior cervical discectomy merupakan teknik operasi yang dilakukan pada vertebra bagian atas untuk mengurangi tekanan pada satu atau lebih radix saraf atau pada medula spinalis. Spinal fusion merupakan upaya untuk menyatukan atau menggabungkan (fusion) satu atau lebih vertebra dengan tujuan untuk mengurangi rasa nyeri dan menstabilkan vertebra. Operasi ini biasanya dilakukan pada pasien berusia 20 – 45 tahun yang memiliki keluhan gejala akibat HNP.7,14,21 Masa operasinya berlangsung selama kurang lebih 2 – 6 jam. Lama operasi juga ditentukan oleh jumlah vertebra yang terkena, instrumen yang digunakan, dan berbagai faktor lain. Proses penyatuan (fusion) dianggap berhasil jika terjadi penyatuan tulang secara alami dan membentuk suatu massa yang solid. Untuk mencapai tujuan tersebut,maka digunakanlah bone graft atau produk biologis lainnya yang dapat menstimulasi pertumbuhan tulang. Terdapat berbagai macam produk biologis yang dapat digunakan untuk mencapai proses penyatuan yang sempurna, yaitu meliputi17 :

Bone graft replacement

  • Autogenous Bone Graft

Cangkok tulang (bone graft) yang diambil dari tulang pasien sendiri (autogenous bone graft) merupakan gold standard. Hal ini berarti pada waktu melakukan operasi, dokter bedah melakukan insisi di tempat yang berbeda dan mengambil potongan kecil tulang dari bagian tubuh yang tidak diperlukan. Umumnya, autogenous bone grafts diambil dari tulang panggul (pelvis) atau krista iliaca (iliac crest). Autogenous bone grafts mempunyai angka keberhasilan penyatuan tulang (fusion) yang baik. Banyak dokter bedah menyukai autogenous bone grafts karena tidak adanya resiko, reaksi penolakan dari tubuh karena berasal dari bagian tubuh pasien sendiri. Kerugiannya meliputi diperlukannya insisi tambahan, rasa nyeri bertambah, masa operasi bertambah serta meningkatkan resiko terjadinya kehilangan banyak darah. Komplikasi seperti ini terjadi pada 10 -35 % pasien dan bervariasi tingkat keparahannya. Kerugian lainnya ialah walaupun telah menggunakan tulang dari bagian tubuh pasien sendiri, angka keberhasilannya terkadang tidak mencapai 100 %, hal inilah yang menyebabkan para peneliti berupaya mengembangkan teknik lain.14

  • Allograft Bone Graft

Sebagai usaha untuk meminimalkan kerugian yang terjadi akibat autogenous bone grafts, maka dikembangkanlah berbagai teknik lain dengan menggunakan produk biologis atau bone graft replacement lainnya. Salah satunya ialah dengan menggunakan allograft bone. allograft bone graft merupakan tulang yang diambil dari kadaver atau individu yang sudah meninggal yang menjadi donor. Prosedur ini cukup sering digunakan pada berbagai bentuk spinal fusion dari cervical fusion sampai lumbal fusion. Kerugiannya ialah bahwa allograft bone graft tidak dapat menstimulasi pertumbuhan dan penyatuan tulang dengan baik. Berdasarkan penelitian yang telah dilakukan, walaupun telah dapat digunakan dengan sukses pada cervical spine fusion, tetapi bukan merupakan stimulator penyatuan tulang secara alamiah yang kuat pada thoracic atau lumbal fusion serta angka kegagalannya sangat tinggi.14

Mekanisme Bone graft

Bone graft dapat membantu terjadinya proses penyatuan atau pembentukan tulang melalui tiga mekanisme sebagai berikut:

1. Osteogenic Stimulation

Karena hanya sel hidup yang dapat membantu pembentukan tulang baru, maka kesuksesan prosedur cangkok tulang (Bone graft) bergantung pada tersedianya cukup sel pembentuk tulang (Osteosit) pada area yang akan dilakukan prosedur. Umumnya jaringan sehat disekitar area yang akan dicangkok mengandung sel pembentuk tulang yang cukup. Namun pada beberapa kondisi, jumlah sel tersebut tidak mencukupi misalnya akibat jaringan parut, tindakan bedah atau infeksi sebelumnya, bone gaps, dan area yang sebelumnya terkena terapi radiasi. Saat ini terdapat dua sumber sel pembentuk tulang yang didapatkan.

2. Osteoconductive Stimulation

Osteoconductive berarti kemampuan suatu substansi atau bahan sebagai media bagi sel tulang untuk menempel, migrasi, tumbuh dan membelah diri. Melalui mekanisme ini, respon penyembuhan tulang terjadi melalui konduksi ke tempat cangkok. Bahan-bahan yang bersifat osteoconductive, mempermudah sel pembentuk tulang untuk mengisi celah yang akan digunakan untuk cangkok tulang, selain itu juga berfungsi sebagai spacer, sehingga mencegah agar jaringan disekitarnya tumbuh ke dalam tempat cangkok tulang. Bahan-bahan ini tidak mempercepat proses penyembuhan tulang sebaik transplantasi tulang.

3. Osteoinductive Stimulation

Merupakan mekanisme induksi pembentukan tulang berdasarkan kapasitas zat-zat kimia normal didalam tubuh yang dapat menstimulasi stem cells untuk tumbuh membentuk jaringan tulang yang sehat. Sebagian besar zat kimia tersebut berupa molekul protein yang dikenal sebagai "peptide growth factors" atau "cytokines”. Metode ini sampai saat ini masih menjadi penelitian lebih lanjut, salah satu penelitian yang terbaru adalah Bone Morphogenetic Proteins (BMP) yang mempunyai efek yang kuat dalam menstimulasi pembentukan tulang baru. Berbagai growth factors lain yang masih dalam penelitian adalah Epidermal Growth Factor (EGF), Platelet Derived Growth Factor (PDGF), Fibroblast Growth Factors (FGFs), Parathyroid Hormone Related Peptide (PTHrp), Insulin-like Growth Factors (IGFs), and Transforming Growth Factor-Beta (TGF-B).14

  • Bone-Morphogenetic Proteins (BMP)

BMP termasuk kedalam growth and differentiation factors. Merupakan protein tulang buatan yang berfungsi untuk menstimulasi sel-sel pembentuk tulang untuk membentuk tulang. BMP biasanya digunakan pada prosedur bedah yang memerlukan spinal fusion dan stimulasi pertumbuhan tulang. Materi ini merupakan stimulus pembentukan tulang yang sangat kuat dan dapat digunakan sebagai graft replacements. BMP pertama kali ditemukan oleh seorang, dokter bedah ortopedi di Amerika Serikat bernama Dr. Marshall Urist. Melalui penelitian yang dilakukannnya, ia berhasil mengidentifikasi campuran protein yang berhasil diisolasi dari sumsum tulang, yang mengalami aktivasi ketika terjadi kerusakan tulang.

Indikasi utama pada terapi dengan menggunakan BMP ialah pada penyakit degeneratif. Berdasarkan penelitian, keuntungan menggunakan BMP dibandingkan menggunakan tulang panggul pasien sendiri seperti yang umumnya digunakan pada prosedur bedah spinal fusion ialah angka kesuksesannya lebih tinggi dalam proses fusion daripada penggunaan tulang panggul, masa operasi menjadi lebih pendek serta proses penyembuhannya lebih cepat. Keuntungan lainnya adalah dengan menggunakan BMP, maka dokter bedah tidak perlu mengambil tulang  panggul, sehingga dapat mencegah timbulnya komplikasi lain seperti rasa nyeri, kehilangan darah, infeksi dan kerusakan saraf pada tempat pengangkatan.14

 

Gambar 46. Interbody Cage dan spacers6,36,41

Teknik operasi :

Pada operasi ini, vertebra cervicalis diakses melalui insisi kecil di bagian depan leher. Setelah jaringan lunak di daerah leher dipisahkan, diskus intervertebralis dan bone spurs diangkat. Rongga yang ditinggalkan dapat dibiarkan terbuka atau diisi dengan dengan tulang kecil (bone graft). Kemudian seiring dengan berjalannya waktu, maka vertebra akan mengalami penggabungan (fusion) kembali. Jika digunakan, maka cangkok tulang (bone graft) dapat diambil dari bone bank dan tidak akan mengalami reaksi penolakan oleh tubuh,karena avaskular (tidak mengandung sel darah merah). Pada beberapa keadaan tertentu, bone graft dapat diambil dari tulang panggul.7

  • Incision

Operasi anterior cervical fusion dilakukan dengan pasien berbaring terlentang. Dibuat insisi kecil (+ 2 inch) dibagian depan leher.7    

  • Exposure and Removal of the Cervical Disc           

Setelah retractor digunakan untuk menyingkirkan lemak dan otot, kemudian dicari diskus intervertebralis. Digunakan jarum yang dimasukkan ke dalam diskus intervertebralis yang mengalami herniasi, kemudian dilakukan pemeriksaan X-ray untuk membantu mengidentifikasi diskus intervertebralis yang mengalami herniasi. Setelah ditemukan kemudian diangkat dengan menggunakan forceps.7,21

Kemudian digunakan bor bedah untuk memperlebar ruang diskus intervertebralis, sehingga mempermudah dokter bedah untuk mengosongkan ruang intervertebra sepenuhnya sehingga yang tertinggal hanya ligamen saja.7 

  • Placement of the Bone Graft

Cangkok tulang (bone graft) diletakkan pada ruang diskus intervertebralis, dimana nantinya akan terjadi penggabungan (fusion) dengan vertebra di sekitarnya.7

                     

  • Adding Stability: Fusion

Fusi biasanya dilakukan dengan cangkok tulang (bone graft), tetapi terkadang ditambahkan juga plat logam (metal plates). Plat logam membantu stabilitas vertebra cervicalis dan membantu proses penyembuhan.7

                      

  • Incision Closure      

Operasi selesai setelah insisi ditutup dengan jahitan.

Biasanya setelah dilakukan prosedur operasi ini, pasien diharuskan menggunakan neck brace selama enam minggu.14

Gambar 48. Cervical spine injuries with proposed spinal fusion surgery43

Graft exstender

  • Demineralized Bone Matrix

Terkadang dapat dilakukan demineralisasi pada allograft bone. Demineralisasi merupakan proses dimana beberapa protein yang dapat menstimulasi pembentukan tulang diekstraksi dari tulang. Protein kemudian diproses dan tersedia dalam berbagai bentuk (demineralized bone matrix). Walaupun telah dibuktikan sukses digunakan pada hewan percobaan, belum ada bukti bahwa  demineralized bone matrix dapat menjadi stimulus yang kuat dalam proses penyatuan vertebra manusia. Oleh karena itu, demineralized bone matrix hanya direkomendasikan sebagai pelengkap (bone graft extender) dari autogenous bone grafts dan bukan sebagai bone graft replacement.14

  • Produk darah

Penelitian lain yang telah dikembangkan ialah penggunaan produk darah misalnya platelet gels yang diambil dari darah pasien sendiri. Materi seperti gel ini diambil dengan mengisolasi suatu konsentrat trombosit, yang merupakan faktor pembekuan darah yang penting, dari darah pasien sendiri. Platelet gel mengandung berbagai faktor pertumbuhan yang dapat membantu pembentukan tulang dan dapat berperan penting dalam proses pembentukan dan pematangan dari spinal fusion. Keuntungan dari penggunaan produk ini adalah bahwa produk ini mudah didapatkan dari darah pasien sendiri dengan sedikit komplikasi. Kekurangannya adalah bahwa produk ini tidak mengandung osteoinductive proteins, yang berarti bahwa produk ini bukan merupakan stimulus yang kuat dalam menginduksi pembentukan tulang. Produk ini dapat digunakan sebagai graft extenders tetapi bukan graft replacements.14

-   Artificial Disc Surgery

Metallic Cervical Disc Replacements

Penemuan terbaru saat ini mengenai pengetahuan tentang biomekanik pada vertebra cervical dan penggunaan jangka panjang biomaterial telah banyak membantu perkembangan cervical disc replacement systems. Integritas ligamen dan facet joint merupakan hal yang penting untuk dipertahankan, agar stabilitas fungsional dapat tetap dipertahankan. Saat ini, hanya ada empat macam artificial disc yang tersedia secara komersial. The Prestige Cervical Disc yang dahulu disebut Cummins Disc, Frenchay atau Bristol Disc merupakan suatu tipe ball and socket, yang terbuat dari baja atau titanium, dan saat ini hanya bisa digunakan untuk terapi pada satu level vertebra saja karena dibutuhkan pemasangan screw pada level vertebra yang berdekatan.

The Bryan Cervical Disc merupakan artificial disc yang terbuat dari campuran polyurethane nucleus dengan titanium. Artificial disc ini pertama kali ditemukan oleh Dr. Vincent Bryan dan diproduksi pertama kali pada tahun 2000 di Belgia. Pada tahun 2002, Dr. Bryan melaporkan bahwa pada 97 pasien yang dilakukan terapi bedah anterior cervical discectomy dan kemudian dipasang Bryan disc selama satu sampai dua tahun, memiliki angka kesuksesan yang berkisar antara 75 – 80 %. Komplikasi yang mungkin terjadi meliputi temporary dysphonia, nyeri persisten dan hematom. The PCM disc (Porous Coated Motion disc) terbuat dari campuran logam kobalt dan krom dengan polyethylene spacer.40

 

Gambar 49.: Low Profile PCM Cervical Arthroplasty. (Cervitech. 2003.)40

PCM disc yang didesain oleh Dr. McAfee dan Prodisc-Cervical merupakan dua penemuan yang terbaru sehingga informasi mengenai keduanya masih sangat sedikit. Pada tahun 1998, Dr. Cummins dan  Wigfield melaporkan dua puluh orang pasien yang diterapi dengan menggunakan artificial disc memberikan hasil yang lebih baik.14,40

 

Gambar 50.: Prestige Disc Replacement System

Non-metallic Cervical Disc Replacements

Walaupun perkembangannya, tidak semaju metallic Cervical Disc Replacements, tetapi penelitian mengenai Non-metallic Cervical Disc Replacements masih terus berjalan selama bertahun-tahun dengan upaya untuk memproduksi artificial disc dengan bahan-bahan yang mirip dengan jaringan yang normal. Penelitian mengenai hal ini sudah dimulai sejak tahun 1990an dan salah satu penemuan terbarunya adalah Acroflex device dengan menggunakan polyolefin rubber. Secara in vivo, alat ini tidak mempunyai efek jangka panjang yang baik. Seorang peneliti bernama Kadoya telah menemukan penelitian dengan menggunakan bahan triaxial three-dimensional buatan pabrik yang dibentuk oleh campuran suatu materi dengan berat molekul tinggi yaitu filamen polyethylene yang dilapisi dengan polyethylene densitas rendah sehingga memungkinkan untuk adhesi dengan hydroxy-appetite or appetite-wollastonite glass ceramics. Nonmetallic disc ini didesain untuk menggantikan bagian nucleus pulposus dan annulus fibrosus dari diskus intervertebralis dan terbukti tidak menimbulkan perubahan biomekanik yang bermakna.40 Pada tahun 1990, Bao dan Hingham melakukan penelitian dengan menggunakan materi hydrogel untuk menggantikan bagian nucleus pulposus dari diskus intervertebralis.40

Pada tahap awal penelitiannya, mereka menemukan bahwa hydrogel nucleus implant dapat menyerupai fungsi jaringan nucleus pulposus untuk mengabsorbsi dan melepas air. Seiring dengan hal ini, Ray dkk melakukan penelitian dengan menggunakan prosthetic disc nucleus (PDN) yang tersusun dari inti hydrogel berbentuk silinder dan bagian terluar yang terbuat dari inelastic polyethylene fiber. Angka kesuksesan dari penggunaan artificial disc ini masih bervariasi. Dengan menggunakan karakteristik desain yang diciptakan oleh Lee dan dikombinasikan dengan materi hydrogel yang ditemukan pertama kali oleh Bao, Neudisc berupaya untuk membuat komponen hydrogel yang dibentuk sesuai dengan struktur nucleus pulposus yang normal dan dikombinasi dengan polimer untuk mengembangkannya.40

 

Gambar 51.: NeuDisc - A polyacrylonitrile reinforced/constrained swellable hydrogel implant.40

Namun tidak semua orang dapat dilakukan operasi ini, ada berbagai kriteria spesifik yaitu hanya ada satu level vertebra yang mengalami herniasi, sudah menjalani terapi atau perawatan sebelumnya selama 6 bulan yang meliputi  terapi fisik, terapi medikamentosa, atau memakai neck brace, tanpa tanda-tanda perbaikan, harus dalam kondisi sehat tanpa tanda-tanda infeksi, osteoporosis, atau arthritis. Ada berbagai tipe diskus intervertebralis buatan (Artificial Disc), tetapi memiliki prinsip kegunaan yang sama yaitu mengisi ruang diskus intervertebralis agar tetap terbuka dan memungkinkan pergerakan vertebra yang normal. Beberapa tipe artificial discs lainnya yang terbuat dari bahan polimer dengan dilapisi bahan titanium, Charité Disc, PDN Prosthetic Disc Nucleus, Acroflex Disc, dan Articulating Discs.14,40

       

PRODISC-C®                                    CHARITÉ®                                             Bryan®

               

Gambar 52. Berbagai macam cervical artificial disc 6

Prosedur ini dilakukan melalui bagian anterior vertebra dengan insisi kecil pada level vertebra yang terkena. Operasi berlangsung selama satu setengah sampai dua jam Keuntungan dari penggunaan Artificial Disc ialah waktu penyembuhan lebih cepat (jadi tidak perlu menunggu sampai terjadi proses penyatuan tulang (fusion), mobilitas lebih cepat dicapai pasca bedah (pasien boleh atau tidak usah memakai cervical collar), beban tekanan berkurang pada level diskus intervertebralis yang berdekatan, dan tidak perlu menggunakan bone graft. Tentu saja, pasien belum boleh melakukan aktivitas yang terlalu berat sampai lukanya telah sembuh sempurna dan artificial disc telah menempel sempurna dengan tulang.14

                

Gambar 54.        

Intraoperative Placement of Artificial Cervical Disc6

Percutaneous nuclear replacement

Salah satu teknik percutaneous nuclear replacement yang telah diperkenalkan adalah balloon type devices. Distraction Discarthroplasty (DDA) merupakan salah satu teknik dengan menggunakan distractor yang terbuat dari silikon yang diletakkan melalui kanul ke dalam diskus intervertebralis melalui endoskopi, kemudian dikembangkan dengan larutan saline dan kemudian dibiarkan sampai terbentuk kapsul fibrosa atau membran pseudo-annular. Penelitian telah dilakukan pada empat pasien yang diberikan terapi pemasangan DDA balloons pada salah satu level vertebra di regio lumbal dan menunjukkan hasil yang positif.40

Kontraindikasi pemasangan artificial disc adalah44:

- Alergi terhadap komponen pembuat artificial disc

- Metabolic bone disease misalnya osteoporosis, paget’s disease,    osteomalacia, ankylosing spondylitis dll

- Rasa nyeri di daerah leher atau lengan dengan etiologi yang tidak   diketahui

- Severe facet joint disease

- Cervical spinal stenosis

- Penyakit sistemik misalnya DM, AIDS, Rheumatoid Arthritis dll

- Pemakaian obat-obatan yang dapat menganggu proses penyembuhan    tulang atau jaringan lunak

- Keganasan   

 

Gambar 57. Foto X-ray AP, lateral, fleksi dan extensi (pasca operasi total disc arthroplasty) menunjukkan adanya pergerakan yang normal.6

Komplikasi yang mungkin terjadi:

  • Hambatan proses penyatuan (Delayed Union atau Nonunion)
  • Hardware Fracture
  • Implant Migration
  • Pseudarthrosis (false joint)
  • Transitional Syndrome (adjacent segment disease, fusion disease)
  • Lain-lain14

• Reaksi alergi  

• Perdarahan dan gangguan pembuluh darah lainnya 

• Infeksi  

• Paralisis

• Efek samping akibat anestesi

• Kerusakan saraf atau medula spinalis

• Kebocoran cairan serebrospinal akibat robekan pada lapisan duramater

 

Anterior Cervical Plates

Anterior Cervical Plates diletakkan pada bagian depan  dari dua atau lebih vertebra, yang berfungsi untuk14:

1. Meningkatkan stabilitas vertebra cervical segera pasca operasi

    dan selama  masa  penyembuhan

2. Meningkatkan kesuksesan penyatuan tulang yang sempurna    

    (solid fusion)

3. Membantu mengurangi waktu yang diperlukan pasien untuk

    memakai cervical  collar setelah operasi.

Plates dipasang dengan menggunakan sekrup yang dipasang pada vertebra yang berdekatan untuk mempertahankan agar plate tetap dalam posisi yang diinginkan. Baik plates dan sekrup,keduanya mempunyai disain dan ukuran yang berbeda-beda. Sebagian besar plates terbuat dari logam (terutama titanium), tetapi ada juga yang terbuat dari plastik. Beberapa plates yang terbaru terbuat dari campuran material yang dapat melebur setelah terjadi proses penyatuan tulang.14

 

Gambar 58. Screw dan plates6

       

Gambar 59. Pemasangan screw dan plates6

Cervical corpectomy

Terkadang materi diskus intervertebralis yang mengalami herniasi terperangkap diantara korpus vertebra dengan medula spinalis, dan tidak dapat diangkat dengan prosedur discectomy. Pada kondisi ini,maka seluruh korpus vertebra harus diangkat, agar dapat memperoleh akses ke diskus intervertebralis yang mengalami herniasi. Prosedur ini disebut corpectomy.14

Cervical corpectomy merupakan operasi yang dilakukan untuk mengangkat sebagian vertebra dan diskus intervertebralis  yang berdekatan untuk mendekompresi medula spinalis dan saraf spinal lainnya. Prosedur ini biasanya digunakan untuk mengurangi tekanan pada medula spinalis akibat spinal stenosis yang disebabkan oleh bone spurs. Kemudian dapat dilakukan pemasangan bone graft dengan atau tanpa metal plate and screws untuk menjaga stabilitas vertebra.  Pasien biasanya hanya dirawat selama 24 – 48 jam setelah itu diperbolehkan pulang.21,45

Teknik operasi

Insisi

Pasien diposisikan pada posisi terlentang. Jika digunakan bone graft, maka dibuat insisi juga di daerah panggul, untuk mengambil cangkok tulang dari krista iliaca. Untuk prosedur corpectomy, maka dapat dibuat insisi kecil di daerah leher (insisi yang lebar mungkin diperlukan pada prosedur multiple corpectomies.45

Decompression

Vertebra cervical diidentifikasi dengan membuka lapisan jaringan yang normal kemudian ditahan dengan menggunakan retractor. Kemudian dokter bedah akan memasukkan jarum ke dalam diskus intervertebralis dan melakukan pemeriksaan X-ray untuk menentukan lokasi yang tepat. Setelah itu dokter bedah akan memotong ligamen longitudinal anterior di bagian depan kolumna spinalis. Kemudian digunakan instrumen khusus untuk mengangkat sebagian diskus intervertebralis. Diskus intervertebralis yang terletak di bagian atas dan bawah dari vertebra yang terkena diangkat. Bagian tengah dari vertebra juga diangkat (sebagian dari vertebra tersebut dapat disimpan untuk digunakan pada fusion) menggunakan instrumen pemotong khusus dan bor untuk mendekompresi medula spinalis atau radix saraf yang terjepit.21,45


Reconstruction

                     

Gambar 61. Tahap reconstruction.46

Sebelum dilakukan pemasangan bone graft maka dilakukan traksi pada leher. Bone graft diletakkan di daerah diskus intervertebralis, yang berfungsi sebagai penopang pada bagian depan vertebra. Seiring dengan waktu, bone graft tersebut  akan mengalami proses penyatuan (fusion) dengan vertebra di dekatnya. Tulang yang diambil dari bone bank (allograft) juga dapat digunakan sebagai pengganti autograft. Sebuah plat logam dan screw sering digunakan untuk menopang dan membantu proses fusion.21,45

Penutupan

Biasa digunakan benang jahit yang dapat diserap atau terkadang skin staples untuk menutup luka bekas insisi. Dapat atau tidak dilakukan pemasangan cervical collar pasca operasi. Kemudian dokter bedah akan melakukan follow up proses fusion dengan pemeriksaan X-ray pasca operasi.45

 

                       

Gambar 62. Anterior cervical discectomy, corpectomy and fusion43

Minimally Invasive Spine Surgery (MISS)

Minimally invasive surgery merupakan istilah yang sering didengungkan pada berbagai bidang spesialistik selama beberapa dekade terakhir ini. Metode ini tidak memerlukan insisi yang besar tetapi sebagai gantinya hanya memerlukan incisi kecil dan kemudian dimasukkan instrumen kecil seperti endoskopi selama operasi.29,40 Minimally Invasive Spine Surgery merupakan teknik operasi dengan insisi kecil, biasanya dengan bantuan endoskopi. Tujuan dari prosedur operasi ini adalah agar dapat memberikan penatalaksanaan terhadap kelainan pada diskus intervertebralis secara efektif dengan kerusakan otot dan jaringan sekitarnya yang minimal dan mencapai proses penyembuhan dengan cepat. Seperti telah disebutkan diatas, bahwa teknik operasi bedah di daerah cervical selalu tertinggal dengan teknik operasi bedah di daerah lumbal yang ditemukan pertama kali oleh peneliti yang bernama Hajikata dan kemudian dikembangkan oleh Kambin, Onik dan Yeung.14,40 Kemudian baru pada tahun 1990an, peneliti lain yaitu Chiu, Lee, Hoogland, Schiffer, Jho, Bonati dan Reuter menemukan teknik yang sama untuk daerah cervical. Para peneliti ini menggunakan anterior approach pada vertebra cervical, diikuti dengan penggunaan endoskopi dan terkadang dengan penggunaan laser untuk melakukan dekompresi.40

Baru-baru ini,peneliti lain seperti Fessler and Adamson telah melakukan percobaan dengan posterior minimally invasive approaches. Sebagian besar dasar prosedur anterior minimally invasive cervical discectomy adalah menggunakan small anterior annulotomy dengan cannula, fluoroscopy dan sering disertai juga dengan endoscopy assisted intradiscal positioning. Sebagai tambahan juga digunakan mechanical atau laser atau radiofrequency assisted disc removal and annular modulation. Pada tahun 1994, peneliti Chiu melakukan penelitian pada 400 kasus pasien dengan HNP cervical yang diterapi dengan cervical endoscopic discectomy and laser thermodiscoplasty dan didapatkan hasil angka keberhasilan mencapai 95 %.40

Keuntungan yang diperoleh dengan teknik ini adalah mengurangi lama waktu operasi, biaya, mempercepat masa penyembuhan, dan mempunyai prognosis yang lebih baik. Penggunaan laser pada terapi bedah daerah cervical juga menguntungkan. Di korea pada tahun 1993, seorang peneliti bernama Lee telah menggunakan Holmiun YAG laser sebagai terapi pada soft cervical disc herniations. Teknik ini menggunakan Holmium LAG laser untuk mengangkat HNP dan menyusutkan diskus intervertebralis yang mengalami herniasi pada pasien yang tidak mengalami perbaikan gejala dengan terapi konservatif. Kemudian saat ini juga telah ditemukan keuntungan tambahan dari minimally invasive surgery, yaitu bahwa prosedur ini dilakukan dengan anestesi lokal. Kemudian pada tahun 2001, Lee juga terbukti sukses melakukan percutaneous discectomy dengan kombinasi teknik manual dengan endoskopi yang disertai Holmium YAG laser discectomy, sehingga merupakan prosedur operasi yang aman dan efektif.40

Chemonucleolysis atau penggunaan intradiscal Chymopapain sudah tidak digunakan lagi di Amerika Serikat saat ini. Namun demikian, beberapa ahli bedah telah menggunakan kombinasi penggunaan chemonucleolysis dosis kecil dengan prosedur endoscopic discectomy. Seorang peneliti bernama Hoogland di jerman pada tahun 1995 dilaporkan telah sukses melakukan  prosedur anterior cervical discectomy baru tanpa adanya komplikasi. Dia menggunakan kombinasi Chemonucleolysis dengan chymopapain dosis kecil 500 IU diikuti dengan automated percutaneous nucleotomy pada vertebra cervical. Perkembangan minimally invasive surgery didorong oleh adanya perkembangan dalam teknologi, salah satu teknologi terbaru yang ditemukan adalah nucleoplasty technology untuk terapi bedah daerah cervical. Teknologi ini dilakukan dengan membuat lubang dengan diameter kecil, kemudian dimasukkan suatu alat seperti elektroda ke bagian tengah diskus intervertebralis (coblation zone), kemudian dilakukan dekompresi diskus cervicalis dengan menghilangkan materi diskus intervertebralis yang mengalami herniasi. Teknik juga dapat disertai dengan penggunaan energi panas.40

          

Gambar 63. : Perc-DC cervical nucleoplasty device (www.reddinganesthesia.com)

Salah satu teknik operasi yang telah diterima secara luas adalah dengan YESS (Yeung Endoscopic Spine System) yang ditemukan oleh Dr. Yeung dan Richard Wolf. Dengan ditemukannya teknik ini maka akan didapatkan lapangan penglihatan yang baik pada waktu melakukan eksplorasi vertebra lumbal. Konsep yang sama juga telah diaplikasikan pada vertebra cervical berkat penemuan endoskopi oleh Clarus and Richard Wolf. Sebagian besar dari prosedur ini menggunakan teknik yang mirip dengan teknik yang dilakukan pada cervical discography. Dengan menggunakan penekanan secara digital pada bagian anterolateral dari vertebra cervical, kemudian mengeser selubung karotid (carotid sheath) dan m.sternocleidomastoid ke arah lateral dan jaringan paratrakeal ke arah medial, maka ditemukanlah zona aman untuk intervensi bedah. Maka melalui zona ini dibuat insisi kecil pada kulit leher dan kemudian dimasukan instrumen ke bagian tengah diskus intervertebralis. Dengan menggunakan teknik ini, angka kesuksesan minimally invasive cervical discectomy berkisar antara 75 – 95 %.40

 

Gambar 64.: Laser assisted endoscopic cervical discectomy40

Teknik lain dari Minimally invasive surgery yaitu  nonfusion cervical decompression juga telah dilakukan dengan posterior approach dengan hasil yang memuaskan. Pada tahun 2001, Adamson melaporkan penelitian pada hampir 100 pasien yang diberikan terapi unilateral endoscopic assisted posterior laminoforaminotomy yang dikombinasi dengan penggunaan microendoscopic , dengan angka kesuksesan lebih dari 90 %. Fessler dan Khoo melaporkan hasil yang sama pada 25 pasien dengan menggunakan teknik micro-endoscopic foraminotomy. Dan bahkan bila dibandingkan dengan teknik micro-endoscopic foraminotomy memiliki keuntungan yang lebih baik.40

-  Anterior endoscopic assisted cervical microdecompression (AECM)

Anterior endoscopic assisted cervical microdecompression (AECM) merupakan metode yang dilakukan dengan aplikasi  nonablative lower holmium laser energy untuk menyusutkan diskus intervertebralis (laser thermodiskoplasty) dan telah terbukti aman, tidak berbahaya, mudah dilakukan dan lebih efektif daripada terapi konvensional. Metode ini dapat mempertahankan pergerakan vertebra yang normal dan dapat menjadi metode alternatif untuk open cervical spinal discectomy surgery, serta dapat menjadi terapi dekompresi untuk stenosis spinal dan penyakit degeneratif diskus intervertebralis.29

Indikasi operasi AECM29:

-       HNP cervical atau foraminal disc lesion

-       Rasa nyeri di daerah leher yang menjalar sampai lengan (radicular pain)

-       Timbul gejala parestesia dan rasa baal

-       Pada pemeriksaan fisik ditemukan adanya defisit sensorik, kelemahan otot atau penurunan reflex-reflex pada ekstremitas atas yang berhubungan dengan level vertebra yang terkena

  • Severe intractable cervicogenic headache
  • Tidak ada perbaikan gejala setelah terapi konservatif selama minimal 12 minggu
  • Pada pemeriksaan radiologi (CT scan atau MRI) ditemukan hasil positif adanya HNP
  • Junctional disc herniation syndrome (JDHS) atau adjacent segmental disease (ASD) akibat operasi fusion sebelumnya
  • Positive discogram, electromyography and pain provocation test

Prosedur bedah

  • Anestesi

Prosedur ini dilakukan dengan anestesi lokal dengan disertai pemberian sedasi intravena atau terkadang dapat juga dilakukan dengan anestesi umum jika terdapat indikasi. Pada awal anestesi, biasa diberikan Ancef (Cefazolin) dengan dosis 2.0 g  dan Decadron (dexamethasone) dengan dosis 8.0 mg yang diberikan secara intravena. Untuk memudahkan palpasi esofagus oleh dokter anestesi, maka dimasukkan esophageal atau nasogastric tube. Denyut arteri karotis dapat diperkuat dengan pemberian obat simpatomimetik (misal efedrin) untuk meningkatkan tekanan sistolik (minimal 130 mmHg).29

  • Posisi pasien

Pasien berada pada posisi terlentang, kemudian leher diekstensikan dengan meletakkan gulungan handuk di bawah bahu. Kemudian kepala diikat dengan soft strap untuk menjaga stabilitas. Bahu secara perlahan agak ditarik ke bawah dengan menggunakan plester.Digunakan Digital C-arm fluoroscopy pada lapangan anteroposterior (AP) dan lateral untuk mengontrol peletakkan semua instrumen selama operasi.29

 

                                                      (A)                                                                                                                     (B)

 

                                                                                                    (C)

Gambar 65. (A) Patient positioning, (B) skin marking and localization, (C) placement of needle and portal of entry.48

  • Fluoroscopic and Neurophysiological Monitoring

Seperti yang telah disebutkan di atas digital C-arm fluoroscopy digunakan pada bidang AP and lateral untuk memonitor peletakkan semua instrumen selama operasi. Neurophysiological monitoring dengan menggunakan Bispectral Index™ (monitoring system surface EEG) dapat menentukan ketepatan agar anestesi dapat berjalan dengan optimal. Untuk keamanan neurophysiological monitoring, maka dapat digunakan  electromyography (EMG) dengan meletakkan jarum pada area tempat distribusi radix saraf dari level vertebra yang akan dilakukan tindakan operasi.29

  • Surgical Equipment and Instruments :
  • Endoscopic video tower with a tri-chip digital camera system equipped with digital video monitor, DVD recorder, light source, and photo printer.
  • Cervical endoscopic discectomy set (Karl Storz, Tuttlingen, Germany), including a 4-mm, 0° endoscope.
  • Cervical discectomy sets (2.5 mm and 3.5 mm) with short cervical discectomes.
  • 3.5-mm, 6° cervical operating endoscope.
  • Endoscopic grasping and cutting forceps.
  • Endoscopic probe, knife, rasp, and burr.
  • More aggressively toothed trephines used for spurs and spondylitic ridges at the anterior and posterior disc space
  • Holmium:YAG laser generator (Trimedyne, with a right-angle (side-firing)
  • Digital fluoroscopy equipment (C-arm) and monitor.

                                 

Gambar 68: Holmium YAG laser equipment for laser thermodiskoplasty. (A) Holmium YAG laser generator, (B) right angle (side firing) laser probe.

Teknik operasi

Localization and Portal of Entry

Untuk menentukan lokasi awal dengan pemeriksaan AP fluoroscopic x-rays, digunakan metal stylette yang diinjeksikan ke leher secara horizontal pada level vertebra yang akan dilakukan tindakan operasi. Batas-batas lokasi yang akan dilakukan tindakan pembedahan (operating portal) digambar di daerah leher dengan menggunakan pena khusus. Alternatif lain, untuk mengetahui level diskus intervertebralis lebih akurat adalah dengan injeksi 18-gauge needle ke dalam diskus intervertebralis dengan dibantu fluoroskopi.29

Surgical Technique

Batas lokasi pembedahan (operating portal) adalah batas medial dari otot sternocleidomastoid kanan. Di tempat ini dilakukan penekanan secara digital pada ruang antara otot dan trakea ke arah permukaan vertebra. Laring dan trakea kemudian digeser ke arah medial dan arteri karotis digeser ke lateral. Bagian anterior dari vertebra cervical dipalpasi dengan ujung jari. Kemudian 18-gauge spinal needle diinjeksikan secara transdermal ke dalam ruang diskus intervertebralis dan posisinya dikonfirmasi dengan menggunakan fluoroskopi. Dapat dilakukan pain provocation test dan discogram, jika pemeriksaan belum selesai dkerjakan sebelum operasi.  Setelah lokasi telah ditentukan dengan pasti, dibuat insisi kecil sepanjang 2-3 mm, kemudian melalui lubang insisi, dimasukkan guide wire stylette melalui jarum spinal yang tadi telah dimasukkan, kemudian jarum spinal diangkat. Kemudian dimasukkan jugacannula/dilator dengan diameter internal 2.5-mm atau 3.5-mm melalui stylette, ke dalam ruang diskus intervertebralis.29

         

                                      A                                                                                                                          B

 

                                                                           

                                                                                          C                                                                            

Gambar 69. Peletakkan jarum dan stylette pada anterior cervical microdiscectomy (A) tampak frontal, (B) potongan lateral, (C) potongan axial, (D) fluoroscopic X-ray lateral view: cervical discogram with placement of the stylette.

     

                                                (A)                                                                                                                                      (B)

     

                                                (C)                                                                                                                                  (D)

     

                                                (E)                                                                                                                                      (F)

Gambar 70: AECM for cervical disc decompression under fluoroscopic X-ray (A) with cutting forceps (B) curette, (C) discectome, (D) trephine, (E) burr, (F) side fire laser probe

 

Kemudian dimasukkan trephine untuk menggantikan dilator yang tadi telah dimasukkan dan digunakan untuk insisi annulus. Di bawah pemeriksaan fluoroskopi dan endoskopi,  digunakan mini-curettes dan forceps yang diikuti dengan discectome untuk membersihkan dan mengangkat fragmen diskus intervertebralis yang mengalami herniasi. Discectome menggunakan high-pressure irrigation-suction system dan guillotine-style cutting blade.  Kemudian dilakukan  “critical fan sweep maneuver” dengan sudut 25° - 50°. Semua manuver tetap dimonitor dengan menggunakan fluoroskopi dan endoskopi.29

     

                                                             (A)                                                                                    (B)

 

(C)

Gambar 71: AECM surgical technique

(A) for microdiscectomy with discectome

(B) “Fan sweep maneuver” of instrument increased disc removal, and laser

      application for disc tissue shrinkage, and tightening,

(C) laser thermodiskoplasty for disc shrinkage under endoscopy.29

The holmium:YAG laser with a right-angle (side-firing) probe membantu menghilangkan materi diskus intervertebralis yang mengalami herniasi. Efeknya dapat berupa penyusutan dan mengeraskan jaringan kolagen dan diskus intervertebralis. Endoskopi digunakan untuk penglihatan secara langsung. Dalam melakukan prosedur ini diperlukan perhatian lebih agar tidak terjadi cedera pada radix saraf, oleh karena itu dilakukan pengawasan dengan fluoroscopy, direct endoscopic visualization, dan EMG neurophysiological monitoring. Terakhir diinjeksikan Marcaine (0.25%) secara subkutan disekitar luka, lalu bekas luka insisi ditutup dengan perban.29

Postoperative Care

Pasca operasi pasien dirawat selama satu jam kemudian diperbolehkan pulang dan mandi pada hari berikutnya. Dapat dilakukan pemasangan soft cervical collar selama dua sampai tiga hari atau jika diperlukan. Obat analgesik dan muscle relaxants dapat diberikan jika diperlukan. Pada hari kedua pasca operasi, dapat dilakukan progressive neck exercise. Pasien diijinkan untuk kembali bekerja dalam satu sampai dua minggu, tetapi tidak diperkenankan melakukan pekerjaan berat atau berada dalam posisi duduk dalam waktu lama.29

DISC Nucleus Percutaneous Discectomy

 

 

 

     

 

 

 

 

 

      

 Gambar 74. Percutaneous Disc Decompression or Nucleoplasty.14,50

Merupakan salah satu metode Minimally Invasive Spine Surgery yaitu melakukan dekompresi saraf melalui kulit dengan (percutaneous) menggunakan jarum dengan pengawasan fluoroskopi. Pasien yang dapat dilakukan prosedur bedah ini adalah pasien dengan keluhan rasa nyeri yang timbul akibat herniasi diskus intervertebralis tanpa disertai kerusakan atau robekan dari dinding annulus fibrosus. Setelah diberikan anestesi topikal dan sedasi ringan, sebuah transmitter dimasukkan ke dalam diskus intervertebralis melalui kateter. Transmitter kemudian akan mengeluarkan gelombang yang menghasilkan gas terionisasi dengan temperatur rendah, yang akan memecah nucleus pulposus yang mengalami herniasi, yang kemudian akan diangkat dan dibersihkan.  Prosedur ini biasanya berlangsung selama 30 – 60 menit, lalu pasien diperbolehkan pulang.14,49,50

Salah satu bentuk percutaneous discectomy yang terbaru adalah DISC Nucleoplasty. DISC Nucleoplasty menggunakan teknologi plasma yang disebut Coblation® untuk memindahkan jaringan dari bagian tengah diskus intervertebralis. Selama prosedur alat DISC Nucleoplasty SpineWand dimasukkan dengan perantaraan jarum dan diletakkan pada bagian tengah dari diskus intervertebralis. Pengangkatan jaringan dari bagian tengah diskus intervertebralis berfungsi untuk mendekompresi diskus dan mengurangi tekanan akibat herniasi ke radix saraf sekitarnya.14,49,50

Teknik operasi49,50

-       Pasien dalam posisi terlentang (supine) dilakukan anestesi umum

-       Dengan menggunakan bantuan alat fluoroskopi, dimasukan kateter dengan perantaraan jarum kecil

-       Kemudian melalui kateter, dimasukkan microinstrument (sleeve) yang digunakan untuk melakukan insisi sepanjang 2 mm pada diskus intervertebralis

-       Setelah itu dilakukan penghancuran dan pengangkatan materi diskus intervertebralis yang mengalami herniasi dengan menggunakan microinstruments (forceps,currets,cutters,discectomy) dan suction

-       Digunakan sinar laser untuk mengerutkan diskus intervertebralis

-       Terakhir kateter diangkat, kemudian luka post-op ditutup dengan band-aid

Salah satu keuntungan dari penggunaan Coblation ialah dapat mendekompresi diskus intervertebralis sambil mempertahankan jaringan yang sehat. Hal ini disebabkan karena Coblation menggunakan energi plasma untuk membersihkan jaringan. Keuntungan lainnya ialah kerusakan jaringan yang ditimbulkannya minimal, dan waktu penyembuhannya lebih cepat dari biasanya Beberapa penelitian menunjukkan tingginya tingkat keberhasilannya, persentase rata-rata pengurangan rasa sakit adalah sebesar 55 – 60 %, serta angka kepuasan pasien sangat tinggi sebesar 90 %. DISC Nucleoplasty dapat dilakukan pada pasien dengan HNP dimana operasi bedah terbuka discectomy tidak dapat mengatasi masalah atau bukan merupakan terapi pilihan. Pada prosedur ini pasien tidak memerlukan anestesi umum, cukup menggunakan anestesi lokal atau dengan pemberian sedasi ringan serta hanya memakan waktu kurang lebih 30 menit.  Pasca operasi, pasien dapat langsung pulang ke rumah dengan disertai anjuran untuk menghindari mengangkat beban berat dan aktivitas yang melelahkan selama beberapa periode waktu tertentu. Pasien dapat kembali bekerja dalam satu sampai dua minggu.14,49,50,51

Anterior cervical microforaminotomy (Jho procedure).

Metode anterior discectomy with bone fusion memiliki efek samping gangguan pergerakan pada level diskus intervertebralis yang mengalami herniasi.  Sedangkan kelemahan pada metode posterior foraminotomyialah bahwa metode ini sering tidak menghilangkan material diskus intervertebralis yang mengalami herniasi secara efisien. Dalam rangka mengatasi berbagai masalah tersebut maka dikembangkan suatu pendekatan terapi bedah baru untuk HNP cervical yang dikembangkan oleh  Dr. Jho yang disebut “anterior cervical microforaminotomy (Jho procedure).5

Prosedur operasi ini dilakukan dengan insisi kulit kecil pada leher bagian anterior, setelah dilakukan anestesi umum. Pasien kemudian dimonitor dengan menggunakan Somatosensory evoked potentials (SSEPs). Posisi pasien mirip dengan metode pendekatan anterior konvensional, yaitu supine, kemudian diletakkan bantal panjang di belakang kedua bahu untuk mempertahankan  ekstensi dari vertebra cervical. Kemudian pada kedua bahu ditarik secara perlahan dan difiksasi kea rah kaudal dengan menggunakan isolasi agar mempermudah pemeriksaan rontgen pada pandangan lateral (intraoperative). Dibuat insisi transversal sepanjang 3 – 6 cm pada bagian anterior leher sejajar dengan garis kulit. Posisi kulit yang diinsisi sesuai dengan letak lesi radikulopati. Dua pertiga insisi awal dibuat medial dari otot sternocleidomastoideus dan sepertiga sisanya dibuat lateral dari batas medial otot sternocleidomastoideus.5,51

Kemudian lapisan jaringan subkutis dan otot platysma diinsisi sepanjang insisi kulit. Kombinasi gunting tajam dan tumpul digunakan untuk mengakses bagian anterior dari vertebra cervical dan menjaga arteri karotis dan otot sternocleidomastoid tetap di sebelah lateral dan trakea serta esofagus di sebelah medial. Fasia prevertebral kemudian dibuka dan bagian anterior dari vertebra cervical diekspos. Untuk memastikan level vertebra yang tepat maka dilakukan pemeriksaan rontgen pandangan lateral. Kemudian dipasang retractor pada m.longus colli. Setelah itu digunakan operating microscope, untuk mengeksisi bagian medial m.longus colli, agar dapat mengakses bagian medial dari prosessus transversus.

Arteri vertebralis terletak di bagian anterior dari prosessus transversus C7 dan terletak di bawah m.longus colli. Oleh karena itu, ketika melakukan operasi pada level vertebra C6-7, harus berhati-hati agar melukai arteri vertebralis ketika sedang memindahkan bagian medial m.longus colli. Karena terkadang arteri vertebralis melewati foramen transversum pada level yang berbeda, maka m.longus collu dinsisi secara hati-hati di bawah operating microscope. Setelah bagian medial dari prosessus transversus dari vertebra yang terletak di bagian atas dan bawah diskus intervertebralis yang mengalami herniasi terlihat, digunakan bor untuk membuat lubang pada facet joint sampai ke ligamentum longitudinal posterior.

Ukuran lubang yang dibuat biasanya berkisar panjang 5 – 6 mm dan lebar 7 – 8 mm. Ligamentum longitudinal posterior diinsisi untuk mendekompresi radix saraf atau medula spinalis yang terkompresi. Multiple anterior foraminotomies dapat dilakukan sesuai kebutuhan. Melalui lubang  dari anterior foraminotomi, kanalis spinalis dapat diperbesar pada bagian aksis longitudinal dengan memotong bagian posterior dari korpus vertebra. Perdarahan dari tulang dikontrol dengan aplikasi bone wax. Perdarahan dari lapisan epidural dari ligamentum longitudinal posterior dapat dikontrol dengan menggunakan koagulasi bipolar. Terakhir otot platysma dijahit dengan menggunakan benang jahit absorbable no 3-0, dan kemudian kulit dijahit dengan menggunakan jahitan subkutikular. Untuk mengatasi rasa nyeri pasca operasi, diberikan injeksi obat anestesi lokal secara subkutan. Tidak diperlukan penggunaan cervical collar. Walaupun prosedur ini dapat dilakukan pada pasien rawat jalan, tetapi pada pasien yang memiliki gejala mielopati, biasanya dianjurkan untuk rawat inap satu hari.51

Lama waktu operasi untuk satu level herniasi diskus intervertebralis adalah kurang lebih satu jam. Indikasi prosedur ini meliputi pasien yang menderita HNP cervical atau bone spurs yang menekan saraf sehingga menyebabkan rasa nyeri di leher dan nyeri menjalar ke satu atau dua lengan, gejala tidak membaik setelah pemberian terapi konservatif selama minimal tiga minggu.5

Keuntungan dari Jho procedure untuk HNP cervical adalah bahwa prosedur ini sedikit invasif karena prosedur ini mempertahankan struktur anatomi dan fungsi dari  diskus intervertebralis yang ada. Keuntungan lain adalah bahwa pasca operasi  pasien tidak perlu menggunakan cervical collar,sehingga pergerakan normal dari leher dapat didapatkan kembali dengan segera (sebagian besar dalam 4 – 6 minggu, pasien sudah dapat kembali bekerja seperti biasa) dan prosedur ini juga dapat dilakukan pada pasien rawat jalan.5

Alternatif lain “Jho Procedure”

1. Percutaneous endoscopic anterior cervical discectomy

Jika diskus intervertebralis yang mengalami herniasi merupakan fragmen yang lunak, makan fragmen diskus yang mengalami herniasi tersebut dapat diangkat via percutaneous endoscopic approach. Melalui insisi kulit kecil pada leher bagian anterior, diletakkan trocar kecil pada bagian anterior dari vertebra cervicalis melalui sampai ke diskus intervertebralis yang mengalami herniasi. Endoskopi kemudian dimasukkan melalui trocar. Melalui endoskopi direk maka fragmen diskus yang mengalami herniasi dieksisi. Berbeda dengan  Jho procedure yang telah dijelaskan di atas, metode operasi ini dilakukan melalui rongga diskus intervertebralis, oleh karena itu terjadi sebagian kerusakan pada daerah ini akibat prosedur operasi.5         

2. Posterior endoscopic foraminotomy

 Posterior foraminotomy merupakan terapi konvensional klasik untuk kelainan pada vertebra cervicalis. Metode terbaru pada teknik operasi ini adalah adanya penggunaan endoskopi sebagai ganti dari penggunaan mikroskop operasi.  Melalui insisi kulit kecil pada leher bagian posterior, diletakkan trocar kecil pada area dimana terdapat saraf yang terjepit. Dekompresi saraf dilakukan melalui foraminotomi endoskopi. Tidak seperti Jho procedure yang telah dijelaskan di atas, metode operasi ini tidak menghilangkan herniasi atau bone spur, tetapi menyediakan ruang di sebelah posterior untuk saraf yang terjepit. Teknik operasi ini juga tidak memerlukan bone fusion.5

TEKNOLOGI

METRx™ System

Salah satu penemuan alat terbaru adalah dengan menggunakan METRx™ System (Minimal Exposure Tubular Retractor) merupakan salah satu bentuk minimally invasive surgery dengan menggunakan alat rektraktor kecil (small tubular retractor) diantara serat otot. Otot tidak akan terkikis dari tulang vertebra, tetapi tetap menempel. Dokter bedah kemudian akan menggunakan mikroskop atau endoskopi untuk melihat saraf yang terjepit melalui alat retraktor tersebut, selanjutnya dilakukan dekompresi dengan menggunakan microsurgical instruments. Keuntungan dari penggunaan alat ini adalah hanya memerlukan insisi kecil, meminimalkan kerusakan pada otot (otot yang terkikis dari tempat menempelnya di tulang dapat meningkatkan rasa nyeri pasca operasi dan memperlama proses penyembuhan), dan mempercepat masa penyembuhan.29

Robotics

Ide penggunaan robot pada operasi berasal dari kegiatan di militer. Idenya bertujuan untuk mengembangkan teknologi dimana dokter bedah dapat melakukan operasi dari lokasi yang jauh pada tentara yang terluka di medan perang. Konsep ini telah berkembang menjadi penggunaan robot dalam melakukan pembedahan. Sebagai gantinya suatu lengan robot (endowrist® ,zeus®) melakukan prosedur bedah dengan dikendalikan oleh dokter bedah dari lokasi di dalam atau berdekatan dengan kamar operasi. Dokter bedah duduk didepan monitor yang menunjukkan gambaran pembesaran dari lapangan pembedahan. Sebuah komputer akan mengikuti pergerakan tangan dokter bedah. Dengan penggunaan komputer tersebut memiliki keuntungan yaitu pergerakan dapat dilakukan lebih terarah dengan meniadakan tremor kecil yang biasanya timbul pada tangan dokter bedah, yang dapat meningkatkan kesulitan dalam melakukan prosedur dengan mikroskop. Robot juga digunakan untuk membantu melakukan tugas yang membosankan atau melelahkan bagi manusia. Suatu lengan robot yang diaktifkan dengan suara disebut Aesop®, berfungsi memegang kamera dan endoskopi untuk membantu dokter bedah selama melakukan prosedur endoskopi.

Beberapa keuntungan lain dari Minimally Invasive Spine Surgery ialah14 :

  • dapat mengurangi komplikasi bedah
  • dapat mengurangi kehilangan darah yang banyak akibat prosedur bedah
  • dapat mengurangi penggunaan pain killer pasca operasi
  • dapat mencegah terjadinya fusion disease
  • dapat mengurangi lamanya rawat inap  (dapat dilakukan pada pasien rawat jalan)
  • dapat mempercepat proses penyembuhan sehingga dapat kembali melakukan aktivitas sehari-hari

POSTERIOR APPROACH

Posterior discectomy and fusion

Metode ini digunakan jika diskus invertervertebralis yang mengalami herniasi, pecah menjadi berbagai fragmen kecil yang terletak dengan kanalis spinalis . Operasi dilakukan dengan pasien posisi terlungkup dan leher ditekuk ke depan. Kemudian dilakukan insisi pada bagian belakang (posterior) leher. Kulit dan jaringan lunak kemudian dipisahkan untuk mencapai tulang vertebra. Kemudian digunakan pemeriksaan X-ray untuk mengidentifikasi diskus intervertebralis yang mengalami herniasi. Kemudian digunakan bor untuk memotong tulang lamina vertebra. Jika terdapat herniasi diskus intervertebralis di bagian tengah yang menekan medula spinalis (central herniation), maka dokter bedah biasanya akan memotong kedua tulang lamina vertebra, agar memudahkan lapangan penglihatan sekaligus memudahkan mengangkat diskus intervertebralis yang mengalami herniasi. Setelah itu, dibuat lubang kecil pada ligamentum flavum agar dapat memudahkan mencari tempat dimana terjadi penekanan saraf. Setelah ditemukan saraf spinal digeser secara perlahan ke atas, kemudian dilakukan pengangkatan HNP. Setelah selesai oto dan jaringan lunak dikembalikan ke tempatnya semula dan kemudian dilakukan penjahitan kulit.21

 

Gambar 78. Anterior and Posterior Cervical Decompression Spine Surgery47

Posterior Cervical Foraminotomy

Jika materi dari diskus intervertebralis atau bone spur menekan saraf ketika keluar melalui foramen maka dilakukan prosedur operasi foraminotomy. Foraminotomy ialah suatu prosedur bedah untuk memperlebar lubang foramen tempat keluarnya radix saraf dari medula spinalis (foramen neuralis), sehingga saraf dapat keluar tanpa terjepit sekaligus mengangkat bagian dari diskus intervertebralis yang menekan saraf. Selama prosedur foraminotomy, jaringan atau tulang yang menghambat jalur saraf dan menekan radix saraf disingkirkan. Biasanya pada pasien diberikan anestesi umum dan operasi dilakukan melalui insisi sepanjang 2-4 cm. Kemudian beberapa tulang dan ligamen pada salah satu bagian prosesus spinosus, pada perbatasan antara lamina vertebra dan  facet joint disingkirkan untuk membuat lapangan penglihatan menjadi lebih jelas. Setelah bagian saraf yang terkena dapat diidentifikasi, dengan menggunakan bor dan microinstruments,saluran tempat lewat saraf tersebut diperbesar (foraminotomy).14

Radix saraf tersebut kemudian diangkat secara perlahan dan jika terdapat herniasi maka hal ini dapat diketahui dengan palpasi. Setelah diidentifikasi, maka dilakukan insisi pada diskus intervertebralis yang mengalami herniasi dan sebagian kecil diskus intervertebralis diangkat (tidak seluruh diskus intervertebralis diangkat). Setelah itu diberikan kortison pada saraf yang terkena. Operasi biasanya memakan waktu 1 – 2 jam. Komplikasi yang sering adalah trauma terhadap satu atau lebih serabut saraf atau medula spinalis (1 – 2 % kasus). Sedangkan komplikasi yang lain seperti infeksi, perdarahan dll sama seperti prosedur bedah lainnya. Pada beberapa pasien ditemukan terjadinya herniasi berulang, baik pada level vertebra yang sama atau pada level vertebra yang berbeda. Dalam 1 -2 hari pasca operasi,pasien dapat pulang ke rumah dan sebagian besar pasien tidak memerlukan pemasangan neck collar pasca operasi. Posterior cervical foraminotomy bukan merupakan teknik operasi terpilih jika terdapat tanda dan gejala mielopati karena hal ini menandakan bahwa kompresi medula spinalis adalah akibat HNP yang terjadi pada bagian depan vertebra.14

 

Cervical Laminotomy, laminectomy dan laminoplasty

 

Gambar 80. Posterior cervical laminectomy18

Cervical laminotomy mempunyai prosedur yang  mirip dengan foraminotomy, tetapi meliputi membuat lubang pada tulang lamina vertebra, untuk membuat ruang yang lebih luas bagi medula spinalis. Sedangkan laminectomy berarti mengangkat sebagian atau seluruh tulang lamina vertebra untuk mengurangi tekanan pada medula spinalis. Prosedur ini biasanya diindikasikan jika terdapat penyakit degeneratif pada lebih dari tiga level vertebra cervical dengan disertai adanya kompresi medula spinalis di bagian anterior. Prosedur laminectomy dimulai dengan membuat insisi pada bagian belakang leher, kemudian otot beserta jaringan lunak lainnya digeser ke samping. Setelah itu dilakukan pemeriksaan X-ray untuk mengidentifikasi vertebra yang bermasalah. Kemudian dilakukan pemotongan satu sisi tulang lamina (pengangkatan tulang lamina secara keseluruhan pada vertebra cervical dapat menganggu stabilitas vertebra cervical) sedangkan sisi tulang lamina yang lainnya berfungsi sebagai engsel (hinge), hal ini akan memperluas kanalis spinalis. Bagian tulang lamina yang telah dipotong nantinya akan menyembuh dengan sendirinya. Pasca operasi biasanya dilakukan pemasangan neck collar. Sebagian besar pasien diperbolehkan setelah kondisinya stabil yaitu beberapa hari setelah operasi.14,21,39Laminoplasty berarti suatu prosedur bedah untuk membentuk lamina sehingga tercipta ruang yang lebih luas untuk medula spinalis. Prinsipnya yaitu mempertahankan dinding posterior dari kanalis spinalis serta mendekompresi kanalis spinalis dengan menggunakan teknik Z-plasty untuk tulang lamina. Laminaplasty biasanya diindikasikan untuk multilevel spondylotic myelopathy. Insiden terjadinya trauma pada medula spinalis akibat laminaplasty adalah 10 x lebih rendah dibandingkan dengan prosedur laminectomy. Kerusakan radix saraf merupakan komplikasi yang sering ditemukan (11 % kasus) akibat laminaplasty, hal ini disebabkan adanya traksi radix saraf disertai migrasi medula spinalis ke arah posterior.14,21,39 

Teknik posterior laminotomy-foraminotomy dapat dipertimbangkan untuk digunakan jika terdapat kontraindikasi dilakukan operasi pada bagian anterior leher seperti misalnya leher yang pendek dan tebal atau pasien telah melakukan operasi pada level vertebra yang sama sebelumnya. Komplikasi yang mungkin terjadi pada laminectomy adalah kyphosis, recalcitrant myofascial pain, dan sakit kepala. Ada berbagai tipe pilihan prosedur bedah yang tersedia. Pemilihan prosedur bedah yang sesuai berdasarkan kebutuhan , riwayat, usia, kondisi fisik secara umum, pekerjaan dan berbagai faktor lainnya.14,21,39

         

Komplikasi terapi bedah

a. Komplikasi akibat anestesi

b. Perdarahan

c. Blood Clots : Deep venous thrombosis (DVT) atau thrombophlebitis

d. Trauma pada struktur anatomi yang berdekatan (lapisan duramater,

    medula spinalis, saraf, esofagus, arteri karotis atau pita suara)

e. Gangguan sistem pernapasan

f. Infeksi

Tanda-tanda terjadinya infeksi meliputi14:

  • Luka post-op yang tampak hiperemis, panas, membengkak dan sukar sembuh
  • Pus atau nanah yang berwarna jernih atau kuning yang keluar dari tempat luka
  • Drainase luka yang menimbulkan bau tidak sedap
  • Peningkatan rasa sakit di tempat luka
  • Demam dan mengigil

g. Rasa nyeri yang menetap

       Terapi lain

  • Terapi fisik sebaiknya digunakan untuk mengurangi rasa nyeri hanya pada fase akut. Ketika fase akut sudah dilewati, maka modilitas terapi yang digunakan hendaknya sesuai dengan kebutuhan.31
    • Superficial heat modalities bertujuan merelaksasikan otot dan mengurangi rasa nyeri pada jaringan lunak.
    • Sebaliknya, deep-heating modalities (misal, ultrasound) sebaiknya dihindari penggunaannya pada radikulopati cervical akut karena dapat memperburuk reaksi inflamasi dan meningkatkan nyeri radicular dan kerusakan radix saraf.31
  • Chemonucleolysis merupakan salah satu metode alternatif yang dilakukan dengan memberikan injeksi enzim (chymopapain) ke dalam diskus intervertebralis yang mengalami herniasi untuk melarutkan nucleus pulposus yang mengalami herniasi.56
  • Cervical traction dapat mengurangi nyeri radicular akibat kompresi radix saraf. Traksi tidak memperbaiki nyeri akibat trauma pada jaringan lunak. Cervical traction dapat dilakukan dengan berbagai cara diantaranya dapat dengan menggunakan alat atau secara manualPemberian terapi dengan Hot packs, massage, dan/atau electrical stimulation dapat diberikan sebelum traksi untuk mengurangi rasa nyeri dan merelaksasikan otot-otot.10,31

Indikasi Cervical Traction 57:

  • spasme otot
  • penurunan ruang gerak (ranged of motion)
  • strains dan sprains yang sifatnya subakut atau kronik
  • tissue healing
  • Herniated Nucleus Pulposus (HNP)
  • penyakit sendi dan atau diskus degeneratif 
  • zygapophyseal facet joint dysfunction

 

Kontraindikasi Cervical Traction 57:

- Hipotensi atau hipertensi yang tidak terkontrol
- Hasil tes Vertebral Artery Insufficiency yang positif 
- Spinal fusion atau laminectomy
- Operasi abdomen yang baru saja dijalani, Hiatal hernia
- Infeksi aktif/keganasan, Lesi kulit
- Acute spine pain atau strain/sprain
- Hipermobilitas sendi (Joint hypermobility), osteoporosis berat
- Claustrophobia, kehamilan

  • Cervical collar yang lunak direkomendasikan untuk trauma jaringan lunak leher akut dan untuk periode waktu yang pendek (misalnya penggunaannya tidak melebihi 3 – 4 hari). Efek samping penggunaannya meliputi timbulnya keterbatasan ruang gerak leher dan kehilangan kekuatan leher jika collar dipakai terus-menerus dalam jangka waktu lama.31
    • Jika digunakan untuk radikulopati yang disebabkan oleh stenosis foramen, bagian yang lebar dari collar diletakkan di sebelah posterior dan bagian yang tipis diletakkan di sebelah anterior untuk membantu gerakan fleksi leher, mengurangi ekstensi, dan membuka foramen intervertebra.
    • Collars dapat dipakai selama melakukan aktivitas tertentu seperti tidur atau mengendarai dalam jangka waktu lama.
    • Meskipun jarang digunakan, Philadelphia collar dapat dipakai pada malam hari untuk menstabilkan posisi leher dalam keadaan fleksi, sehingga dapat mempertahankan foramen tetap terbuka.Berfungsi untuk membatasi pergerakan dan membantu leher menopang berat kepala serta dapat mempercepat proses penyembuhan.14,31
  • Manipulasi dan mobilisasi vertebra dapat memperbaiki ruang gerak normal dan mengurangi rasa sakit; namun demikian mekanisme teraupeutik masih belum jelas. Beberapa peneliti berpendapat  manipulasi terhadap sendi zygapophysial dapat memperbaiki sinyal aferen dari reseptor mekanik ke sistem saraf perifer dan sentral
    • Penghantaran sinyal aferen yang normal dapat memperbaiki tonus otot, menurunkan tegangan otot, dan menstimulasi metabolisme jaringan lokal yang lebih efektif. Modifikasi fisiologik tersebut selanjutnya dapat memperbaiki ruang gerak dan mengurangi rasa nyeri.
    • Beberapa penelitian menemukan adanya perbaikan jangka pendek pada pasien dengan trauma akut dan pada penderita cervicogenic headache dan radikulopati sekunder akibat herniasi diskus.
    • Belum ada bukti-bukti yang menunjukkan manipulasi tersebut dapat memberikan keuntungan jangka panjang, memperbaiki penyakit kronik atau mengubah perjalanan penyakit.31
  • Injeksi epidural cervical , saraf atau radix vertebra, z-joint, dan  saraf simpatis berperan sebagai sarana diagnostik dan terapeutik. Prosedur tersebut dapat menggunakan instrumen untuk menentukan struktur anatomi yang menyebabkan rasa nyeri (misal, radix saraf atau facet) dan merupakan terapi konservatif yang agresif.
  • Injeksi epidural cervical  digunakan untuk mengatasi nyeri radicular, meskipun beberapa literatur juga menunjukkan rasa nyeri aksial yang sudah berlangsung lama dan terkadang memerlukan intervensi bedah. Prosedur ini dapat dilakukan pada pasien rawat jalan dengan bantuan fluoroskopi.31,58      
    • Campuran obat anestesi dan Corticosteroid dapat diinjeksikan ke dalam ruang epidural (interlaminar) atau sepanjang radix saraf (transforaminal) setelah dilakukan pemeriksaan lokalisasi dengan fluoroskopi menggunakan kontras.
    • Obat anestesi dapat mengurangi rasa nyeri yang disebabkan oleh saraf simpatis.
    • Obat Corticosteroid dapat memberikan efek pengurangan rasa nyeri jangka panjang jika rasa nyeri berasal dari reaksi inflamasi yang hebat.31
    • Lapisan membran yang berfungsi melindungi medula spinalis dan radix saraf spinal disebut duramater. Rongga yang mengelilingi lapisan duramater disebut ruang epidural. Epidural steroid injection merupakan metode untuk menginjeksikan obat-obat antiinflamasi ke dalam ruang epidural untuk mengurangi reaksi inflamasi pada radix saraf, mengurangi rasa nyeri dan efek lain yang diharapkan adalah membantu proses penyembuhan. Metodeini dapat memberikan efek mengurangi rasa nyeri sementara atau menghilangkan rasa nyeri secara permanen sementara proses penyembuhan berlangsung.58
    • Perbaikan gejala dapat terjadi segera atau dalam dua minggu. Beberapa pasien dapat berespon dengan hanya satu injeksi, sedangkan yang lain memerlukan tiga injeksi yang diberikan selang-seling selama satu sampai tiga bulan proses penyembuhan.58
  • Pemeriksaan diagnostik blok saraf spinal atau ramus ventralis dilakukan dengan memberikan injeksi dosis kecil obat anestesi ekstraforamen pada salah satu level segmen vertebra (C5 atau C6) dan berguna dalam mengidentifikasi saraf yang terlibat.31
    • Identifikasi yang tepat mengenai saraf yang terlibat, dapat membantu dokter untuk memfokuskan pada protokol terapi yang lebih tepat.
    • Keluhan perubahan rasa nyeri pasien pasca pemberian injeksi dicatat untuk membantu memastikan ketepatan diagnosis.
    • Dalam literatur metode double injection digunakan untuk injeksi facet yang berguna memberikan informasi bagi dokter dalam menentukan diagnosis nyeri radicular dan membantu memastikan level saraf yang terlibat. Metode ini dapat membantu mengidentifikasi pada pasien dengan hasil tes false-positif atau memiliki kecenderungan memberikan respon terhadap pemberian plasebo dengan cara memberikan injeksi pada hari yang berbeda, efek perbaikan jangka pendek didapatkan dengan pemberian obat anestesi jangka pendek (misal lidokain) dan efek perbaikan jangka panjang dengan pemberian obat anestesi jangka panjang (misal bupivakain)31
  •  Efek samping dapat terjadi pada pemberian obat anestesi, Corticosteroid, dan zat warna kontras.31
    • Pemeriksaan masa pembekuan darah harus dilakukan sebelum dilakukan injeksi pada pasien dengan kecurigaan kelainan perdarahan.  Kompresi medula spinalis dapat terjadi jika terjadi perdarahan disertai dengan adanya stenosis vertebra relatif (misal diameter mid-sagital kurang dari 12 mm) dimana terdapat rongga kecil yang berpotensi sebagai tempat terjadinya hematom epidural
    • Obat-obatan antiinflamasi non steroid (AINS), termasuk diantaranya aspirin, harus dihentikan pemberiannya sebelum dilakukan prosedur karena efek sampingnya
    • Resiko efek samping lainnya meliputi kejang, spasme arteri vertebralis, infeksi, kuadriparesis sementara akibat obat anestesi dan henti napas (respiratory arrest)
    • Salah satu penelitian menunjukkan bahwa blok saraf cervical secara selektif dapat menurunkan angka morbiditas jika dilakukan dengan disertai pemeriksaan fluoroskopi dengan kontras.31
  •  Komplikasi sistem saraf pusat akibat pemberian injeksi steroid transforaminal yang meliputi trauma medula spinalis dan stroke sekarang menjadi perhatian bagi para dokter. Mekanisme trauma dipercaya akibat adanya oklusi pembuluh darah pada waktu pemberian Corticosteroid.31
    • Hodges dkk melaporkan 2 kasus dimana kerusakan medula spinalis terjadi akibat pemberian injeksi steroid pada lapisan epidural cervical tanpa disertai fluoroskopi; pasien karena telah diberikan sedasi intravena, tidak dapat merasakan dan mengeluh rasa nyeri dan parestesia selama dilakukannya prosedur
    • Komplikasi berat yang potensial terjadi akibat pemberian injeksi steroid transforaminal melalui ruang epidural di daerah cervical tidak dapat dianggap remeh. Prosedur tersebut harus dilakukan oleh dokter ahli dan disertai dengan fluoroskopi.31

KOMPLIKASI

Komplikasi dari kelainan vertebra cervical dapat meliputi nyeri radicular atau axial yang hebat. Herniasi diskus intervertebralis yang mendesak medula spinalis dapat menimbulkan gejala-gejala akibat mielopati berupa kelemahan, hiperreflexia, dan disfungsi neurogenik usus dan kandung kemih. Radikulopati dapat bermanifestasi sebagai kelemahan ekstremitas atas yang signifikan atau rasa baal.31

  • PROGNOSIS

Prognosis umumnya baik pada individu dengan HNP akibat perubahan degeneratif. Kondisi ini biasanya bersifat asimtomatik, kecuali individu tersebut terkena trauma pada segmen vertebra yang mengalami perubahan degeneratif. Selama individu tersebut dapat mempertahankan keseimbangan mekanik dan stabilitas, biasanya tidak akan menimbulkan gejala.39

  • PENCEGAHAN

Ada beberapa faktor resiko yang tidak dapat dimodifikasi seperti misalnya proses penuaan, tetapi ada juga faktor resiko yang dapat dimodifikasi untuk mencegah terjadinya cervical disc disease seperti pola hidup yang meliputi postur tubuh yang baik, olahraga secara teratur, diet teratur, dan berhenti merokok. Setelah sembuh dari operasi, ada berbagai anjuran yang dapat diikuti untuk mencegah terjadinya HNP:

  • Lakukan olahraga secara teratur (olahraga seperti berenang, bersepeda, jalan cepat merupakan olahraga yang tidak  memberikan beban tekanan pada tulang vertebra)
  • Hindari aktivitas yang dapat menyebabkan leher menjadi   hiperreflexi atau hiperekstensi (Para peneliti telah menemukan  cara untuk mengurangi stress dan rasa nyeri di daerah leher  yang    disebut dengan 3 R yaitu :Rest,Relaxation  dan Recovery)
  • Pertahankan postur tubuh yang baik (Terdapat tiga macam    kelengkungan normal pada tulang vertebra, dengan cara mempertahankan ketiga macam kelengkungan tersebut pada    waktu berdiri, duduk, atau bergerak merupakan dasar untuk   memperoleh postur tubuh yang sehat).
  • Berhenti merokok (karena merokok selain dapat menganggu   proses penyembuhan, juga dapat menyebabkan aterosklerosis,  yang dapat mempercepat proses degeneratif)
  • Hindari stress karena dapat menyebabkan ketegangan pada otot   (muscle  tension)

Pencegahan merupakan kunci untuk menghindari timbulnya rasa nyeri didaerah leher di masa-masa yang akan datang. Selalu ingat bahwa meskipun leher sifatnya sangat mobile, tetapi tetap mempunyai batasan.

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  25. Bailey,Ross.2001.Cervical spine  http://www.train.tcu.edu/ross/cspine.htm,
  26. Anonymous.Tanpa tahun.cervical spine http://www.uth.tmc.edu/radiology/test/er_primer/spine/spfrm.html,
  27. Anonymous. Tanpa tahun. Herniated nucleus pulposus. http://www.herbchina2000.com/therapies/MLH.shtml,
  28. Crenshaw.1971.Volume two: Campbell’s operative orthopaedics.Saint louis:Mosby company.pages 1044-1052
  29. Anonymous.Tanpa tahun. Cervical Herniated Disc or Ruptured Disc. Dikutip dari http://www.spineuniverse.com/ displayarticle.php/article265.html,
  30. Anonymous.2007.Cervical disc degeneration. http://www.spinalkinetics.com /cdd.html,
  31. Furman, Michael.2007.cervical disc disease. http://www.emedicine.com/pmr/topic25.htm,
  32. Kahn,charles.Medical College of Wisconsin.Cervical disc herniation. 2006, http://chorus.rad.mcw.edu/ doc/00875 .html,
  33. Tridico, grace.Tanpa tahun.Cervical herniated disc: symptoms and treatment. Dikutip dari http://www.angelfire.com/id/ multicultural/disc.html
  34. Dilin, william.2005.Spine basic:cervical herniated. Disc http://www.drdillin.com/education/basics_chd_sideimage.htm,
  35. Anonymous.2008.Differential Diagnosis Between Cervical Pain and Shoulder Pain. Dikutip dari http://www.acceleratedrehab. com/site/epage/58796_605.htm,
  36. Anonymous.Tanpa tahun.Posterior cervical foraminotomy.  http://adam.about.com/Surgery/100133.htm,
  37. Haight, Robert. 2001.Sideline Evaluation of Neck Pain Dikutip dari http://www.physsportsmed.com /issues/2001/03_01/shiple.htm
  38. Salter, robert.1999.Textbook of disorders and injuries of the musculoskeletal systems,Third edition.USA:Wiliam & wilkins company.Pages 285 – 286
  39. Windsor, Robert.2006.Cervical Disc Injuries. www.emedicine.com,
  40. Reuter,Merrill.Tanpa tahun.evolution of cervical disc surgery. Dikutip dari http://paincareholdings.com/articles/ An_Introspective_EVOLUTION_7-14-04.pdf,
  41. Anonymous.Tanpa tahun.Cervical spine surgery. http://www.brainspine.com/spine-surgery.html,
  42. Anonymous.Tanpa tahun. Anterior C5-6 discectomy and interbody fusion Dikutip dari http://attorneysmedicalservices. doereport.com /enlargeexhibit.php?ID=3619,
  43. Anonymous.Tanpa tahun.Anterior cervical discectomy. http://www.doereport.com/enlargeexhibit.php?ID=10976,
  44. Anonymous.2008.Cervical disc prosthesis. http://www.saspine.org/protocols/  p_cervical_disc_ prosthesis.htm
  45. Anonymous.Tanpa tahun.Corpectomy http://www.peloza.com/treatments/neck/corpectomy.html,
  46. Anonymous.Tanpa tahun.Anterior cervical corpectomy. http://www.lajollaspine.com/stde_cerv_corp.shtml,
  47. Anoymous.Tanpa tahun.Posterior cervical laminectomy. http://catalog.nucleusinc.com/imagesenlarged/1936W.jpg
  48. Chiu,john.2007.Anterior Endoscopic Assisted Cervical Microdecompression of Disc and foramen.  Dikutip dari
  49. http://www.californiaspineinstitutemedctr.com /articles/ScientificArticles /vol1n2_cervical.asp,
  50. Clifford,Thomas.Tanpa tahun.Percutaneous Endoscopic Cervical Discectomy. Dikutip dari http://www.spinecenter.com /papers/pcd/pcd.htm,
  51. 50. Anonymous.Tanpa tahun. Percutaneous Disc Decompression or Nucleoplasty. Dikutip dari http://www.uhseast.com/124574.cfm,
  52. Anonymous.2008.Wooridul Spine hospital. http://www.wooridul-spinehospital.com,
  53. Anonymous.Tanpa tahun. posterior endoscopic foraminotomy.Dikutip dari http://www.spineinstituteny.com/ treatments/spine.html,
  54. 52. Anonymous.Tanpa tahun.Ask a specialist how does a disc rupture.Dikutip dari http://www.asams.org/guidelines/ Completed/NEW%20HNP.htm,
  55. Anonymous.Tanpa tahun.Laminotomy. http://www.neurosurgery.ufl.edu/Patients/stenosis.shtml,
  56. Anonymous.Tanpa tahun.Laminoplasty. http://www.nycneurosurgery.com/practice/cervical_laminoplasty.htm,
  57. Anonymous.Tanpa tahun.Cervical laminoplasty. http://buffaloneuro.com/cervical/cervical_surgery_director.htm,
  58. Joseph,Thomas.2008.Herniated nucleus pulposus. http://www.nlm.nih.gov/medlineplus/ency/article/ 000442.htm
  59. Oestmann, eric. Tanpa tahu. Protocol for Pneumatic Cervical Traction.Dikutip dari http://www.glaciercross.com/medical _professionals/pdf/protocol_for_pneumatic_cervical_traction.pdf,
  60. Simotas, Alexander.2005.Cervical Radiculopathy: Nonoperative Treatments and Cervical Epidural Steroid Injection. Dikutip dari http://www.hss.edu/conditions_14617.asp,
  61. Schwartz, Seymour.1999.Principles of surgery.seventh edition:companion handbook.Singapore:McGraw-Hill. Pages 918- 921
  62. Apley,graham.1993.Apley’s system of orthopaedics and fractures.Seventh edition.Great Britain: Butterworth Heinemann. Pages 338-340

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