VESTIBULAR NEURONITIS

Vestibular neuronitis is an acute vestibular syndrome due to inflammation of the vestibular nerve characterized by the typical symptoms of acute rotatory vertigo accompanied by nausea, vomiting, and symptoms of balance disorders. The incidence of vestibular neuronitis is about 3.5 per 100,000 people. The exact etiology of this vestibular neuronitis is unknown. However, based on existing evidence, vestibular neuronitis is associated with viral infections of the upper respiratory tract and herpes zoster infection. The clinical manifestations of vestibular neuronitis are persistent rotatory vertigo accompanied by oscillopsia, horizontal-rotatory peripheral vestibular spontaneous nystagmus on the healthy side, and a tendency to fall on the affected side. Diagnosis of vestibular neuronitis can be made by clinical diagnosis, through history, physical examination, and special examinations. Through these examinations, the differential diagnosis of vestibular neuronitis should be excluded, such as Meniere's disease, labyrinthitis, benign paroxysmal positional vertigo, and vertigo due to central lesions such as cerebellar infarction. Management of vestibular neuronitis is in the form of symptomatic therapy with vestibular suppressants, antivertigo, and redirect to relieve the symptoms that arise, then causative therapy can be done by administering corticosteroids, and in patients, physiotherapy can be done to improve vestibular function.

MEDICAL REHABILITATION MANAGEMENT OF CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy in the upper extrimity, is a clinical syndrome characterized by a tingling sensation, numbness, pain, or weakness in the hand and wrist radiating up to the arm. This condition is a major cause of absenteeism, reduced productivity, and financial loss among various neuropathy due to median nerve compression. This paper, medical rehabilitation of CTS is viewed. Medical rehabilitation of CTS aimed to reduce pain, reduce clamping of the carpal tunnel, sensory and motor reeducation so that hand function improves and can perform activities of daily living. Treatment options can be given includes exercise therapy, ultrasound diathermy, low level laser therapy (LLLT), and shock wave therapy (SWT).

CENTRAL VERTIGO

Central vertigo is a symptom characterized by a feeling of changes in body position or environment as a result of diseases originating from the central nervous system. Central vertigo is caused by a disease that extend from vestibular nuclei in medulla oblongata to ocular motor nuclei and integration system in mesencephalon to vestibulocerebellum, thalamus and vestibular cortex in temporoparietal and the neuronal pathway which mediate VOR (vestibulo-ocular reflex). The diseases can be vestibular migrain, TIA (Transient Ischemic Attack), Vertebrobasilar ischemic stroke, multiple sclerosis, tumor in cerebelopontine angle and congenital malformation like Dandy Walker Syndrome. Central vertigo can be diagnosed by performing several special tests. This examination can also distinguish central vertigo from its differential diagnosis, namely peripheral vertigo. Management of central vertigo can be in the form of acute attack management and specific management according to the cause.

COMPLICATED MIGRAINE

Migraine is a chronic paroxysmal neurological disease characterized by attacks of moderate or severe headache accompanied by reversible neurologic and systemic symptoms. Although not life threatening, migraine can cause disability in the productive population. Migraine sufferers generally have a family history of migraine so that migraine is considered a genetic disease. Endogenous psychological factors such as stress or fatigue are the main triggers for migraine. Migraine pathophysiology involves various parts of the brain so that migraine symptoms are complex. Management of acute migraine can be done pharmacologically and non-pharmacologically. Migraine preventive management is needed if the patient has a chronic migraine or does not respond to abortive treatment.

COMPARISON OF HYDRODISECTION INJECTION BETWEEN TRIAMCINOLONE ACETONIDE VERSUS DEXAMETHASONE IN CARPAL TUNNEL SYNDROME

Background: Carpal tunnel syndrome (CTS) is the most common nontraumatic peripheral neuropathy, which is caused by suppression of the median nerve below the transverse carpi ligament. Local corticosteroid injection is considered the fastest and most effective method for improving symptoms that occur in CTS. There are several corticosteroid agents that can be used, but there are no objective standards that can explain the most ideal drugs. Objective: To compare the effectiveness of hydrodisection injection therapy of triamcinolone acetonide versus dexamethasone on carpal tunnel syndrome. Methods: This study involved 30 participants who were diagnosed with CTS and fulfilled the inclusion criteria and no exclusion criteria were obtained. Participants were divided into two treatment groups; the first group (n = 15) injected with Triamcinolone Acetonide (TCA) 10mg / 1ml and lidocaine 1% 1 ml and the second group (n = 15) injected with Dexamethasone 4mg / 0.8ml and lidocaine 1% 1 ml. The NRS, FSS, and SSS parameters were assessed before injection and 4 weeks after injection in each agent. Then compared these parameters at 4 weeks after injection compared to the TCA group with the dexamethasone group. Results: NRS score before and 4 weeks after TCA injection (sig 0.000; p <0.05), SSS (sig 0.001; p <0.05) and FSS (sig 0.020; p <0.05), and NRS score before and 4 weeks after dexamethasone injection (sig 0.001; p <0.05), SSS (sig 0,000; p <0.05) and FSS (sig 0,000; p <0.05). At 4 weeks after injection of TCA compared to dexamethasone there were no significant results on NRS (sig 0.237; p> 0.05) and FSS (sig 0.119; p> 0.05), while SSS values were significantly different (sig 0.027; p <0.05). Conclusion: Significant improvement in NRS, FSS and SSS score was obtained at 4 weeks after hydrodisection injection, both with TCA and dexamethasone. At 4 weeks after TCA injection compared to dexamethasone, there were no significant differences in NRS and FSS scores, whereas SSS score differed significantly. Both injection agents are equally effective in treating CTS, but dexamethasone produces a better improvement in SSS score.

LOW BACK PAIN

Low back pain is the most common symptom found in the primary health care and is the number one cause of disability throughout worldwide. It is estimated that around 60 – 80% the world population will experience back pain during their lifespan. There are three different source of pain in the spine: axial-lumbosacral, radicular and reffered pain. All of these source brings different clinical presentations. Low back pain could be classified as acute, subacute and chronic low back pain. The pain could be nociceptive or neuropathic, the most common symptoms reported are “pressure pain” and “pain attack”. The physician should be aware of “red flags” symptoms that lead into more serious condition beside back pain and, therefore the patient has to be investigated to further examination whenever these symptoms present. The management of low back pain consist of severe modalities, both therapeutic and rehabilitative procedure. Oftentimes, the management needed multidisciplinary approach. It is important to general practitioners to identify and treat low back pain appropriately to reduce the burden of the disease and to prevent the disabilties caused by this condition.

PROFILE OF PRIMARY HEADACHE PATIENTS IN NEUROLOGICAL POLYCLINIC

Headache is the most common neurological disorder among all the symptoms of general health problems. Headaches are the most frequently complained of after back pain, which brings someone to the doctor and harms personal, family, social, quality of life, work, and finances. This study aims to find out the characteristics of primary headache patients in the neurological polyclinic, RSUD dr. Saiful Anwar Malang. The design of this research was an observational descriptive study of the filled headache questionnaire was to determine the characteristics of headache patients who visited the neurological polyclinic at dr. Saiful Anwar Malang with complaints of primary headache. The procedure of this research is to provide a questionnaire. The data analysis technique used is that the research variables will be presented in the frequency distribution table. The results of this research show that primary headache was more common in women as many as 19 people (61%) compared to male 12 people (39%). Most of the primary headache patients who came to the neurological clinic of Saiful Anwar Hospital were 30-60 years old. Tension-Type Headache (TTH) in this study had the highest percentage of 58%. In this study, cluster headache two patients all attacked women.

MENIERE’S DISEASE

Meniere’s disease is a disorder of the inner ear resulting in symptoms of episodic vertigo, tinnitus, hearing loss and aural pressure. Although the exact etiology is uncertain, it is associated with raised pressure in the endolymph of the inner ear (endolymphatic hydrops). The diagnosis of Meniere's disease is based on the clinical setting of the patient. This disease usually presents with unilateral ear symptoms but can be also bilateral. Meniere's disease attacks are usually random and episodic (approximately 6-11 per year), with periods of remission that can last from months to years. Investigations are audiometry, electronystagmogram, vestibular evoked myogenic potentials (VEMPs) and imaging.The management consist pharmacological and non pharmacological. Meniere's disease is initially progressive but fluctuates unexpectedly. It is difficult to distinguish natural resolutions from treatment effects.

CARPAL TUNNEL SYNDROME (DIAGNOSIS AND MANAGEMENT)

Carpal Tunnel Syndrome (CTS) is a neuropathy disease that affects the median nerve with an incidence of around 90%. Carpal Tunnel Syndrome appears in 3.8% of the general population, with the highest prevalence occurring in women. There are several risk factors associated with CTS, namely medical and non-medical factors. The mechanism of carpal tunnel syndrome until now is still very complex and is not known with certainty, but compression and traction factors in the median nerve are thought to be the most common cause of CTS. Carpal Tunnel Syndrome can manifest clinically with subjective signs such as paresthesia, proprioceptive changes, and paresis, as well as objective signs, such as changes in motor sensitivity and function, positive Tinel and Phallen tests, and thenar muscle atrophy. The diagnosis of Carpal Tunnel Syndrome is based on the classic symptoms of pain, numbness, tingling, and/or burning sensation in the distribution of the median nerve in the hand, as well as the abnormal function of the median nerve based on nerve conduction studies. Conservative therapy is an option. Especially in Carpal Tunnel Syndrome patients with mild to moderate symptoms. Conservative therapy can be given in the form of corticosteroid and physical therapy. Patients with severe CTS or whose symptoms have not improved after four to six months of conservative therapy should be considered for surgical treatment.

DIABETIC NEUROPATHIC PAIN

Diabetic Neuropathy is the most common complication from diabetes, which experienced in almost 90% diabetes patient. Evenly pain is one of the most common symptoms of diabetic neuropathic, but the pathophysiology mechanism of pain is not clearly known. The hyptosesis of toxicity of hyperglycemia on development of pain complication has been widely accepted globally, but there is other proposed hypothesis. Basic concept in management of painful diabetic neuropathic is exclusion of the other cause of painful peripheral neuropathy, improving glycemic control for prophylaxis therapy and medication use for alleviating pain. The first choice drug of therapy for alleviating pain are anticonvulsant, like pregabalin and gabapentin, and antidepressant, mainly that work on inhibiting serotonine and noradrenaline reuptake. In conclusion, the better understanding of painful diabetic neuropathic underlying mechanism can help to find a better management that improving the guideline quality in optimalizing pain control.