Diagnosis of Neuropathy

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in Primary Care Setting
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Candida Isabel Lopes Sam
Neurology Department, dr. Tjark Corneille Hillers Hospital

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 TOPIK BAHASAN
• DEFINISI
• FIVE QUESTION APPROACH
– Fiber Type, Pattern of distribution, Temporal
course, Key features, Pathology
• ALGORITMA DIAGNOSIS NEUROPATI
• KESIMPULAN

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 DEFINISI
Neuropati adalah gangguan saraf perifer yang meliputi kelemahan
motorik, gangguan sensorik, gangguan otonom dan melemahnya refleks
tendon yang dapat bersifat akut atau kronik.

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 NEUROPHATY: PERIFER & CENTRAL
PERIFER • PERIFER CENTRAL
• CENTRAL
• Gangguan sensorik meliputi: Biasanya disertai gejala lain seperti
 Parestesia, nyeri, terbakar, • Sulit bicara
 Penurunan rasa raba, vibrasi • Diplopia, ataxia
dan posisi. • Kelemahan nervus cranialis
• Hilangnya sensasi (getar, posisi, • Pada kasus mielopati didapatkan
proprioseptif, suhu, dan nyeri)  Penurunan fungsi digestif dan
pada bagian distal ekstremitas kandung kemih
• Gangguan motorik: otot lemah  Refleks patologis positif
• Refleks tendon menurun Tonus otot spastik
• Fasikulasi
• Asimetris

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 DIAGNOSIS NEUROPATI PERIFER

• ANAMNESIS
• PEMERIKSAAN FISIK
• PEMERIKSAAN PENUNJANG
 Laboratorium
 Pemeriksaan elektrodiagnostik
 Kuesioner

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern of distribution
motorik, sensorik, distal atau proksimal,
otonom, kombinasi simetris atau asimetris

5. Pathology
3. Temporal course
akson, demielinasi
akut, kronis, progresif,
4. Key features bertahap, remisi, kambuhan

toksik, gizi, keganasan, HANDS ON WORKSHOP

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern of distribution

5. Pathology
motorik,
sensorik, 3. Temporal course
otonom,
4. Key features
kombinasi
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 NEUROPATI MOTORIK
Gejala Motorik:
• Positif : Kram otot, fasikulasi, myokymia, tremor
• Negatif : Kelemahan ekstensor kaki, distal lebih awal
Manifestasi Klinis:
• Kelemahan progresif
• Kesulitan berjalan (jatuh, tersandung)
• Kesulitan bernapas
• Penurunan berat badan
• Atropi kaki atau pergelangan tangan
• Refleks fisiologis menurun/hilang

Mungkin terjadi pada:

• Immune neuropathies
• Heriditary motor sensory neuropathies
• Acute intermittent porphyria

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 NEUROPATI SENSORIK
Gejala Sensorik
Positif :
• Nyeri, rasa tertusuk, terbakar
• Paresthesia: sensasi tidak menyenangkan yang muncul secara spontan tanpa
rangsangan yang jelas
• Allodynia: persepsi rangsangan non nyeri sebagai nyeri
• Hiperalgesia: hipersensitivitas yang menyakitkan terhadap rangsangan
• Nyeri neuropatik: keluhan utama dari banyak neuropati
• Mati rasa

Mungkin terjadi pada :

• Lepromatous leprosy
• Diabetes mellitus
• HIV & antiretroviral therapy neuropathy

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 Neuropathic Pain

Positive Sign Negative Sign

Numbness

Painfull ≥ 4
Non Painfull < 4

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 NEUROPATI AUTONOM
Manifestasi Klinis:
• Hipotensi postural
• Retensi urin
• Disfungsi ereksi
• Diare/sembelit
• Keringat berkurang
• Gangguan respon pupil
• Aritmia jantung

Mungkin Terjadi Pada:

• Diabetes
• Amiloidosis
• Sindrom Guillain-Barre

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 Kehilangan Fungsi Gangguan Fungsi
Gejala (-) Gejala (+)
Sensory ↓ Vibration, ↓ Proprioception Paresthesias
“Large Fiber” Hyporeflexia Sensory ataxia

Sensory ↓ Pain, ↓ Temperature Dysesthesias, Allodynia

“Small Fiber”
Motor nerves Wasting, Hypotonia, Weakness Fasciculation
”Large fibre” Hyporeflexia, Orthopedic Cramps
deformity
Autonomic nerves ↓ Sweating Hypotension Urinary ↑ Sweating
retention Impotence Hypertension
Vascular color changes

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern of distribution

5. Pathology
distal3.vs proksimal
Temporal course
simetris vs asimetris
4. Key features
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 MONONEUROPATI
Lesi fokal yang melibatkan saraf tunggal
Trauma langsung, lesi vaskular, kompresi
Carpal tunnel syndrome
Manifestasi Klinis:
• Nyeri, kesemutan, parestesia pada
palmar tangan dan jari
• Kelemahan otot tenar dan atropi otot
abductor pollicis brevis
• Nyeri dapat meluas ke lengan dan bahu
• Tes Tinel dan Phalen positif.

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 POLINEUROPATI

Defisit Motorik & Sensorik Simetris

• Subakut
• Paraestesia
• Mati rasa
• Rasa terbakar
• Hilangnya rasa getaran dan posisi
• Ataksia

Kaki biasanya terpengaruh terlebih dahulu

Glove & Stocking Paraesthesia

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 MONONEUROPATI MULTIPLEKS
• Kerusakan beberapa saraf: tidak
berdekatan, serentak & serial
• Distribusi: acak & multifokal
• Sering berkembang dengan cepat
Penyebab
• Iskemia yang disebabkan oleh vaskulitis
• Mikroangiopati pada diabetes melitus
• Infiltrasi neoplastik, leukemia, infeksi,
granulomatosa, kusta dan sarkoidosis.

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 MONONEUROPATI MULTIPLEKS
• Kerusakan beberapa saraf: tidak
berdekatan, serentak & serial
• Distribusi: acak & multifokal
• Sering berkembang dengan cepat
Penyebab
• Iskemia yang disebabkan oleh vaskulitis
• Mikroangiopati pada diabetes melitus
• Infiltrasi neoplastik, leukemia, infeksi,
granulomatosa, kusta dan sarkoidosis.

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern
akut,of distribution
subakut,
kronis, progresif,
remisi, kambuhan

5. Pathology
3. Temporal course

4. Key features
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• Akut : 4 minggu
• Subakut : 4 – 8 minggu
• Kronik : > 8 minggu
• Kambuh, Progresif, Remisi

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern of distribution

5. Pathology
3. Temporal course
toksik, gizi,
4. Key features keganasan,
penyakit
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 PENYEBAB NEUROPATI
Diabetes
Alcoholism
Vitamin deficiency
– B12
Infective/inherited
– Guillain-Barre
Drugs – e.g. isoniazid

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 PENYEBAB NEUROPATI
Penyebab Utama:
 Neuropati Diabetes
 Nutrisi, termasuk alkohol (defisiensi B1)

Penyebab Lain:
 Infeksi: HIV, kusta, difteri, tetanus, botulisme
 Keracunan logam berat: timbal, merkuri
 Keganasan
 Metabolik: hipotiroidisme, gagal hati, gagal ginjal
 Polineuritis pascainfeksi: Sindrom Guillain-Barre
 Sarkoidosis
 Obat-obatan: isoniazid, vincrinstine, fenitoin, emas, kelebihan vit. B6
 Bawaan: sindrom Gigi Charcot-Marie

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 Diabetic Neuropathy
Berkaitan langsung dengan durasi dan tingkat pengendalian kelainan
metabolik
Akibat kelainan metabolisme dan akumulasi fruktosa & sorbitol
dalam sel Swann
Manifestasi klinis:
 Simetris terutama neuropati sensorik
 Nyeri neuropati, akut
 Mononeuropati dan multipleks mononeuritis
 Amiotrofi diabetik
 Neuropati otonom

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 Alcoholic Neuropathy
Penyalahgunaan alkohol kronis
menyebabkan polineuropati
 Nyeri betis sering terjadi
Kekurangan tiamin krn alkoholisme
menyebabkan neuropati
 Sindrom Wernicke Korsakoss
 Presentasi Umum: ataxia, perubahan
kognitif, delirium tremens, hipotermia,
hipotensi

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 Guillain-Barre Syndrome
 Polineuropati akut – peradangan akut atau neuropati postinfective
 Biasanya demielinasi tetapi bisa aksonal
 Monophasic: setelah infeksi Campylobacter jejuni dan CMV
 Infeksi menginduksi respons antibodi terhadap saraf perifer
 Kelumpuhan 1-3 minggu setelah infeksi
 Kelemahan otot tungkai distal dan/atau mati rasa distal
 Gejala berkembang secara proksimal
 Hilangnya refleks tendon
 Kelemahan otot wajah
 Disfungsi otonom - jarang
 Mungkin membutuhkan dukungan ventilasi
 Heparin diperlukan untuk mengurangi risiko trombosis
 Pemulihan spontan dimulai setelah beberapa minggu

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 FIVE QUESTION APPROACH
1. Fiber type 2. Pattern of distribution

5. Pathology
3. Temporal course
akson,
4. Key features
demielinasi
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 MEKANIS TERJADINYA NEUROPATI

Mekanisme degenerasi saraf tepi

 Demielinisasi: Sindrom Guillain-Barre
 Degenerasi aksonal: Neuropati toksik
 Degenerasi Wallerian [akson & mielin]:
Diabetes
 Kompresi: Carpal tunnel syndrome
 Infark: Diabetes
 Infiltrasi: Kusta, Granuloma

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 AXONAL DEMYELINATING NEURONAL
Distal > proksimal Proksimal = distal Non length dependent
Length dependent UE, LE, face
Slow evolution Akut/subakut Rapid
Dyssesthesia & distal Paraesthesia & Ataxia, paraesthesia
weakness weakness
Pain & temp affected > Vibrasi & propioseptik Vibrasi & propioseptik
vibrasi dan > nyeri dan panas > nyeri dan panas
propioseptik
Kelemahan ektremitas Kelemahan distal dan Propriosetif,
distal proksimal kelemahan
Distal arefleksi Arefleksi Arefleksi

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 AXONAL DEMYELINATING NEURONAL
Amplitudo affected > Velocity > amplitude Sensory ampliyudo
velocity affected
Radial > sural
Axonal degenerasi dan Demyelinasi & Axonal degenarasi
regenerasi remyelinisasi tanpa regenerasi
Slow recovery Rapid recovery Poor recovery
Penyebab: Penyebab: Penyebab:
Toxic GBS Sjogren’ s
Metabolik Diphtheria Cisplatin
HIV CIDP pyridoxin
Diabetes mellitus Diabetes mellitus
CMT MMN
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 PEMERIKSAAN PENUNJANG

 Urine: glukosa, protein

 Hematologi: FBC, ESR, vitamin B12, folat
 Biokimia: glukosa puasa, RFT, LFT, TSH
 Tes neurofisiologi
Studi konduksi saraf (NCS)
Elektromiografi (EMG)
 Biopsi saraf

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Score NSS: penilaian gejala klinis sensorik
maupun motorik dengan menggunakan
kuesioner

Nilai maksimum 10 poin

Derajat keparahan neuropati:

Ringan: skor (3-4)
Sedang: skor (5-6)
Berat: skor (7-10)

Metode penilaian NSS:

Mengamati gejala negatif neuropati:
rasa terbakar, tebal, kesemutan, rasa
lemah
Mengamati gejala positif neuropati:
nyeri, kram, lokasi & karakteristik
keluhan

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Score NDS: pemeriksaan klinis
sederhana yang menilai abnormalitas
refleks dan penilaian sensorik

Score maksimum 10:

mengindikasikan hilangnya secara total
sensorik dari semua modalitas dan
hilangnya refleks.

Derajat keparahan neuropati:

Ringan: skor (3-4)
Sedang: skor (5-6)
Berat: skor (7-10)

Score NDS ≥6: peningkatan risiko

ulkus pedis karena hilangnya sensasi.

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 KESIMPULAN
Pola klinis temuan neurologis pada neuropati: Polineuropati,
Mononeuropati, Mononeuropati multipel, Plexopathies

Gangguan fungsional: Motorik, Sensorik, Otonom, Campuran

Mode awitan: Akut, Subakut, Kronis, Kekambuhan

Terjadi oleh berbagai penyebab: Neuropati Diabetes dan Nutrisi

Diagnosis di Layanan Primer: anamnesis, pemeriksaan fisik, pemeriksaan

penunjang sederhana
- Five Question Approach
- Kuesioner

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