Syndroma Plexus Sacralis

Friday, 29/12/2017 Ilmu Kesehatan 513 comments

SINDROMA PLEXUS SACRALIS

Pendahuluan

Keluhan nyeri pada regio gluteal atau sacroilinea merupakan gejala multi interpretasi. Interpretasi dapat dilihat dari berbagai aspek yang terkait dengan suatu sistem. Kajian pada suatu sistem tidak dapat dilihat atau diperhatikan pada salah satu komponen (struktur saja agar akurasi analisis menentukan problematic sesuai dengan kausa impairment. Di sini saya akan coba analisis problematik sindroma plexus sacralis dari aspek anatomi topografi sebagai landasan intervensi fisioterapis praktis dapat dipakai sebagai acuan khusus. Tentunya masih banyak kajian lain dari sudut pandang yang lain pula.

Kajian anatomi

Plexus sacralis dibentuk oleh rami sentralis pada spinal nerve L5 dan S3, maupun lumbosacral trunk L4. Plexus sacralis (L4-L5, S1-S3), yang mensuplai kaki dan pelvic girdle, berbeda dengan pudendal plexus (S2-S4), yang menginervasi organ genital dan pelvis. Pudendal plexus mengeluarkan serabut-serabut di regio pelvis kecil (rectales medii, vesicales inferiors, vaginales, musculi levatoris, dan musculi coccygei nerve), dan pudendal nerve. (pudendal nerve adalah saraf sensoris dan motoris utama di perineum). Selain itu, ada coccygeus plexus, yang mensuplai otot ischiococcygeus dan levator ani. Plexus sacralis dihubungkan dengan lumbar plexus oleh lumbosacral trunk (serabut-serabut dari akar L4), sehingga kedua plexus tersebut dikombinasikan sebagai lumbosacral plexus

Cabang-cabang langsung dari plexus sacralis adalah sbb:
• Saraf ke otot obturator internus (L5-S2);
• Saraf ke otot piriformis (S1-S2);
• Saraf ke otot quadratus femoris (L4-S1);
• Cabang-cabang ke otot gemellus superior dan inferior.
Selain itu, berikut ini saraf-saraf besar yang muncul dari plexus sacralis:
• Saraf superior gluteal (L4-S1);
• Saraf inferior gluteal (L5-S2);
• Saraf posterior femoral (S1-S3);
• Sciatic nerve (L4-S3), dibagi menjadi:
- Saraf peroneal (L4-S2),
- Saraf tibial (L4-S3).

Kesimpulan

Plexus sacralis:
• Terdiri dari vertebrae lumbosacral (L4) dan cabang-cabang ventral dari spinal nerve L5-S3;
• Inervasi pelvis, bagian posterior dari kaki, dan mayoritas telapak kai;
• Saraf yang paling penting adalah ciatic nerve, yang berhubungan dengan otot piriformis.

Hubungan topografi
• Lumbosacral trunk muncul di bagian medial dari psoas major muscle dan turun ke bagian pinggir pelvis di sisi anterior dari sacroiliac joint.
• Dilapisi oleh parietal pelvic fascia (fascia pelvis parietalis), letaknya di dinding posterior dari rongga pelvis di depan otot piriformis.
• Letaknya di belakang iliac vessels (internal iliac artery dan pembuluh darah) dan ureter.

Dari sudut pandang terapi manual, penting untuk diketahui bahwa kompresi di regio plexus sacralis (terutama L5 dan S1) bisa disebabkan oleh tumor atau herniated disk. Plexus itu sendiri bisa di inflitrasi oleh tumor di organ pelvis. Nyeri (sciatica tanpa penyebab mekanis) kadang-kadang hanya tanda klinis yang bisa membantu menentukan penyebab yang benar. Karena posisinya, plexus sacralis dilindungi dari trauma. Tetapi, lesi saraf bisa terjadi (pada ibu) setelah persalinan dengan operasi atau akibat tekaan dari kepala bayi. Berdasarkan Lazorthes, pasien perempuan bisa menderita paresis atau paralysis di lutut.
Fraktur pelvis, dan khususnya sacral fracture, bisa menyebabkan kerusakan di semua bagian lumbosacral plexus. Cidera di akar L4-S1 menyebabkan paralysis otot di ekstremitas bawah. Selain itu, disfungsi otot di bladder dan rectum, maupun berkurangnya sensitivitas di regio genital dan anal, bisa terjadi.

Konsekuensi praktis

Plexus sacralis dihubungkan dengan otot piriformis oleh fascia dan milik bagian tubuh yang sama. Oleh karena itu, setiap gerakan stretching di piriformis memberikan efek pada plexus sacralis.

Cabang
Cabang ventral
Saraf ke otot obturator internus
• Serabut motoris
• Serabut-serabut saraf dari L5, S1, dan S2.
• Meninggalkan pelvis – untuk memasuki regio gluteal – melalui greater sciatic foramen, di bagian inferior dari piriformis
• Melintasi ischial spine dan turun di antara sciatic nerve dan internal pudendal vessels
• Memberikan cabang ke otot gemellus superior
• Berputar di sekitar ischial spine, memasuki pelvis lagi melalui lesser sciatic foramen, dan bergerak ke otot obturator internus
• Mencapai otot obturator internus, yang menginervasi sisi medial.

Saraf ke quadratus femoris muscle
• Serabut motoris
• Serabut-serabut saraf dari L4, L5, dan S2
• Meninggalkan pelvis melalui greater sciatic foramen
• Turun di regio gluteal ke sciatic nerve, obturator internus, dan gemelli muscle
• Memasuki permukaan anterior di otot quadratus femoris
• Mensuplai gemellus inferior dan mengirimkan cabang ke hip joint

Cabang dorsal
Saraf ke piriformis
• Serabut motoris
• Berisi serabut-serabut saraf dari S1 dan S2
• Memasuki sisi anterior dari otot piriformis

Superior gluteal neve
• Serabut motoris
• Berisi serabut-serabut saraf dari L4, L5, dan S1
• Meninggalkan pelvis melalui greater sciatic foramen, di atas piriformis
• Terbagi menjadi cabang superior dan inferior, dan melintas di antara gluteus medius muscle dan gluteus minimus muscle yang diikuti oleh superior gluteal vessels
• Inervasi gluteal medius dan minimus muscle, maupun tensor fasciae latae muscle.

Konsekuensi klinis
Nyeri di bagian pantat setelah duduk biasanya berasal dari gluteus superior nerve. Nyeri ini bisa berlangsung lama dan tidak mempan diintervensi dengan fisioterapi; seringkali nyeri ini menyebar ke posterior hip region (retrotrochanteric). Bentuk neuritis ini sering disalah diagnose sebagai tendopathy pada gluteus medius muscle. Perempuan yang paling sering terserang. Secara klinis, neuritis ini sering berhubungan dengan disfungsi ginekologi dan urogenital. Permasalahan di regio pelvis mempengaruhi gluteal neurovascular bundles, dan menyebabkan beberapa keluhan. Dengan lesi di saraf, fisioterapis juga bisa mengamati Trendelenburg’s sign: aproximasi upper leg dan lateral trunk di hip joint tidak lagi memungkinkan untuk dilakukan. Ini terlihat seperti postur yang “ditopang oleh kaki” ketika berjalan dan berdiri. Ketika ketegangan dibebankan di kaki yang sakit, pelvis condong ke arah “kaki” yang sehat.

Inferior gluteal nerve
• Serabut motoris
• Berisi serabut-serabut saraf dari L5, S1, dan S2
• Meninggalkan pelvis melalui greater sciatic foramen, di sisi inferior dan piriformis
• Terbagi menjadi beberapa cabang
• Inervasi lapisan dalam gluteus maximus muscle

Posterior femoral cutaneous nerve
• Serabut sensoris
• Berisi serabut-serabut dari S1, S2, dan S3
• Meninggalkan pelvis melalui greater sciatic foramen yang diikuti dengan inferior gluteal nerve, arteri, dan pembuluh darah; sciatic nerve; pudendal nerve dan pudendal artery.
• Cabang gluteal: saraf bergerak ke dalam gluteus maximus muscle sampai subcutaneous layer di dorsal thigh, dimana ia bercabang ke dalam inferior cluneal nerve, yang meng-inervasi setengah bagian inferior dari pantat.
Cabang perineal: saraf mendistribusikan cabang-cabang ke sisi atas dan medial dari paha, melengkung ke depan dan di bawah ischial tuberosity, bergerak di bawah superficial fascia dari perineum ke kulit scrotum dan labia majora.
Cabang-cabang menurun ke belakang paha di antara biceps femoris muscle dan semitendinosus muscle. Masuk ke dalam fascia lata, meng-inervasi bagian tengah lutut dengan cabang-cabang terminalnya.

Konsekuensi klinis
Cutaneous nerve yang didistribusikan ke posterior hip atau lower buttock region biasanya memiliki origin yang umum, yang dulu disebut “small sciatic nerve”.

Sciatic nerve
Cabang plexus sacralis yang paling besar adalah sciatic nerve, yang terbagi menjadi fibular nerve dan tibial nerve.

Anastomoses
Ada koneksi saraf ke lumbar plexus, pudendal plexus, dan pelvic sympathetic ganglia.

Treatment untuk plexus sacralis
Indikasi
• Hip pain
• Retrotrochanteric pain
• Nyeri dan congestion di regio pelvis
• Sciatic pain (sciatica)

Teknik treatment
Plexus sacralis dan sciatic nerve
Sulit untuk memisahkan satu sama lain karena keduanya bertemu di derajat tertentu. Untuk menangani plexus sacralis dengan tepat, sebaiknya menggunakan teknik yang diaplikasikan langsung ke jalur ischial, yang lokasinya di antara ischial tuberosity dan greater trochanter pada femur.
Plexus sacralis bentuknya menyerupai segitiga dengan dasarnya terletak di tiga foramen sacralis dan ujungnya menuju ke arah lateral ke saraf sciatic. Axis utama pada plexus sacralis melajur ke arah diagonal dari atas ke bawah, dari medial ke lateral, dan dari posterior ke anterior. Stretching di plexus sacralis memperbaiki longitudinal tension di peripheral nerve plexus, dan mempengaruhi bagian distal dari dura mater. Untuk fungsi yang optimal, dura memerlukan longitudinal tension yang permanen, serta mobilitas dan ekstensibilitas yang baik. Efek stretching bisa difasilitasi dengan lebih efektif di origin dari saraf sciatic dan bukan di plexus sacralis itu sendiri.

Teknik
Pasien di posisi terlentang dan tungkai ditekuk dengan flexi lutut. Letakkan satu jari telunjuk di atas ischial spine, yang letaknya tiga jari di atas ischial tuberosity. Usahakan untuk menggeser bagian cephalad dan medial dari jari, sejauh mungkin. Lebih mudah untuk menemukan titik koreksi pada pasien sciatica karena bisa dilihat dari nyeri yang muncul. Jari digunakan untuk menyentuh bagian yang nyeri dan spasme, tetapi pelan. Tekanan yang terlalu keras bisa meningkatkan inflamasi di sciatic nerve dan plexus sacralis. Untuk menggeser jari telunjuk atas dengan lebih mudah, pegang lutut yang ditekuk dengan tangan yang lain dan lakukan gerakan flexi-adduksi. Untuk meregangkan saraf, gerakkan kaki ke abduksi dan ekstensi, dan akhirnya medial rotation. Medial rotation sangat penting karena dengan mengikuti orientasi saraf, fisioterapis mencapai peregangan plexus sacralis dan sciatic nerve dengan lebih komplit. Selama geakan kaki, jari telunjuk menarik saraf sedikit ke arah lateral. Teknik ini mungkin terlihat sulit di awal, tetapi sangat efektif dan direkomendasikan.

Indikasi khusus
Teknik ini efektif dalam treatment saraf sciatic, dimana terjadi kerusakan pada disk. Teknik ini juga bisa diaplikasikan untuk kondisi berikut ini:
• Pelvic congestion;
• Dysmenorrheal;
• Stress-induced incontinence;
• BPH (benign prostate hypertrophy)

Superior gluteal nerve
Teknik
Posisi pasien terlentang, dan tungkai ditekuk dengan lutut fleksi. Jari telunjuk (upper hand) bergeser dari bagian pinggir luar graeter trochanter ke arah medial untuk merasakan insersi tendon di otot piriformis. Mengikuti bagian pinggir atas tendon ke dalam tissue. Untuk mensupport jari telunjuk, tahan lutut pasien dengan tangan yang lain dan geakkan hip joint, secara bergantian antara abduksi dan adduksi untuk merilekskan otot pantat. Fisioterapis bisa melakukan palpasi pada area yang sensitive terhadap tekanan di baian superior sampai bagian pinggir atas tendon di greater sciatic foramen. Ini adalah gluteal neurovascular bundle (gluteal artery dan pembuluh darah, dan gluteus superior nerve). Tekan area ini dengan ringan dan, secara bersamaan, gerakkan kaki ke fleksi, abduksi, dan lateral rotation dengan tangan yang lain. Pergantian antara muscle tension dan muscle relaxation baik dilakukan untuk mobilisasi saraf yang dilakukan di arah listening.

Konsekuensi praktis
Hanya ada perbedaan kecil antara manipulasi superior gluteal nerve dan manipulasi plexus sacralis. Perbedaan terletak pada seberapa dalam jari telunjuk bisa memasuki greater sciatic foramen. Ini artinya bahwa dua treatment dilakukan secara simultan.

Selamat mencoba. Semoga berguna untuk sesama terutama praktisi fisioterapi.

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