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Aspek Neurologik Gangguan Berjalan

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Aspek Neurologik Gangguan Berjalan ASPEK NEUROLOGIK GANGGUAN BERJALAN Dr ISKANDAR JAPARDI Fakultas Kedokteran Bagian Bedah Universitas Sumatera Utara PENDAHULUAN Berjalan/gait ada suatu proses kompleks yang dipengaruhi oleh sejumlah mekanisme tubuh dan merupakan hasil dari kerjasama dari berbagai jenis refleks. Berjalan secara normal biasanya tidak menarik perhatian. Gangguan berjalan dapat dijumpai pada berbagai keadaan. Faktor-faktor mekanis seperti penyakit pada otot, tulang, tendon, dan sendi berperan penting pada terjadinya gangguan berjalan. Penyakit pada susunan saraf sangat sering menyebabkan gangguan berjalan, dan kadang-kadang hanya dengan memperhatikan cara berjalan saja dapat ditentukan adanya penyakit pada susunan saraf. Gangguan berjalan dapat merupakan akibat gangguan sistem motorik dari berbagai tingkatan (korteks motorik dan jaras dosendensnya, kompleks ekstra piramidal, serebelum, sel-sel kornu enterior, saraf motorik perifer atau otot). Gangguan lain yang juga dapat menyebabkan gangguan/perubahan cara berjalan adalah gangguan psiko motor (hiteria dan malingering), gangguan kompleks vestibuler, gangguan pada saraf sensorik, kolumna posterior, dan jaras averen serebeler. ANATOMI DAN FISIOLOGI BERJALAN Proses berjalan merupakan suatu proses yang kompleks yang membutuhkan keutuhan berbagai struktur dan mekanisme saraf. Struktur dan mekanisme saraf ini menyelenggarakan pengaturan untuk proses berjalan. Korteks motorik Korteks motorik primer (area Brodmann 4) terletak pada gyrus presentalis lobus frontalis, terbentang dari fisura lateralis hingga batas dorsal hemisfer dan sebagian permukaan media lobus frontalis rostal dari lobulus parasentralis. Korteks motorik primer berhubungan dengan penampilan gerakan. Disebelah rostal area motorik primer tedapat kortesk premotor (area Brodmann 6). Pada permukaan lateral hemisper yang berhubungan dengan pemuliaan (inisiasi) gerakan. Area motorik tambahan terdapat pada aspek medial dari area 6 pada penampang sagital, rostal dari lobulus parasentral. Area ini aktif selama persiapan gerakan setelah inisasi gerakan. Fungsi area ini terutama berhubungan dengan gerakan kompleks pada anggota gerak termsuk gerakan anggota gerak bersama pada kedua sisi tubuh. Jaras jaras desenden dari korteks serebri yang mempengaruhi aktivitas motorik. Traktus kortikospinalis (piramidalis) Jaras ini mulanya dianggap sebagai yang memulai dan mengendalikan setiap aktifitas otot volunter. Kemudian diketahui bahwa jaras ini terutama berhubungan dengan gerakan terlatih dari otot-otot distal anggota gerak dan 2002 digitized by USU digital library 1 dengan fasilitasi α, β dan τ motorneuron. Sepertiga akson-akson dari jaras ini berasal dari koryeks motorik primer (area 4 dan 6) sepertiga lainnya dari area promotor dan area motorik tambahan, dan sepertiga sisanya berasal dari lobus parietalis (area 3, 1 dan 2). Traktus kortikospinalis kemudian berjalan kedistal yang kemudian terbagi menajdi traktus kortikospinalis lateralis (90%) dantraktus kortikospinalis ventralis. Traktus kortikospinalis laterralis berjalan pada funikulus lateralis medula spinalis danmengadakan sinaps pada aspek lateral lamina IV hingga VIII. Banyak sel-sel pada lamina ini adalah interneuron yang mengadukan sinaps dengan α, dan τ motor neuron pada lamina IX. Traktus kortikospinalis menimbulkan pengaruh fasilitasi dan inhibisi pada interneuron spinal dan motor neuron. Aktivasi traktus kortikospinalis umumnya menimbulkan potensial eksitatorik postsinaptik pada interneuron dan motorneuron dari otot-otot pleksor dan potensial inhibitorik postsinaptek pada otot-otot ekstensor. Traktus kortikorubral dan rubrospinal Dari korteks serebri serabut-serabut menuju ke nukleus rubra ipsilateral pada tegmentum mesensefalon. Traktus rubrospinal berasal dari nukleus ruber yang mnyilang garis tengah pada persilangan tegmental ventral dan turun melalui tegmentum pons lateral dan messensepalon menuju medula spinalis. Pada medula spinalis jaras ini terdapat dibagian arterior traktus kortikospinalis lateralis pada funikulus lateralis. Serabut-serabutnya bersinaps pada setiap tingkatan medula spinalis pada aspek lateral lamina V, VI dan VIII. Fungsi traktus ini memfasilitasi fleksor dan inhibisi ekstensor motor neuron α, β dan τ, terutama yang mensarafi bagian distal lengan. Traktus vestibulospinal Traktus vestibulospinal ini berjalan menuju funikulus anterior dan bersinaps dengan sel-sel pada lamina VII dan VIII. Trtaktus vestribulospinal lateral berjalan pada seluruh panjang medula spinalis, sedangkan trkatus vestibulospinal medial berjalan hingga setinggi bagian atas torakal. Stimulasi traktus vestibulosspinal lateral mencetuskan potensial eksitatorik postsinaptik pada motor neuron ekstensor yang mensarafi otot-otot leher, punggung, anggota gerak. Stimulasi traktus vestibulospinal medial tidak mempengaruhi motor neuron anggota gerak. Jaras-jaras vestibulospinal berhubungan dengan postural tubuh saat gerakan kepala dan pemeliharaan tonus postural. Jaras sistem motorik yang berasal dari korteks serebri dan batang otak mencapai medula spinalis dan secara fugsional terdiri atas 2 sistem proyeksi umum, ventromedial dan lateral. Sistem ventromedial batang otak terdiri atas serabut- serabut yang berasal dari nukleus interstisial (Cajal), kolikulus superior, formasio retikularis (mesensefalik, pons, medula oblongata), dan inti vestibularis. Traktus yang terbentuk dari serabut ini berakhir pada aspek ventral dan medial kornu anterior (termasuk lamina VII dan VIII). Jaras ventromedial terutama berkaitan dengan pemeliharaan postur tegak, gerakan terintegrasi dari badan dan anggota gerak dan progresi gerakan anggota gerak. Jaras ini umumnya memfasilitasi aktifitas motor neuron yang berproyeksi pada otot-otot ekstensor dan meninginhibisi aktivitas motor neuron yang berproyeksi pada otot-otot fleksor. Sitem lateral batang otak terdiri atas serabut-serabut yang berasal dari nukleus rubber magnoseluler kontralateral yang menuju medula spinalis melalui traktus rubrosspinalis, dan serabut-serabut dari bagian ventrolateral tegmentum pontis kontralateral yang menuju medula spinalis melalui kolumna lateralis medula spinalis. Serabut jaras lateral ini berakhir pada aspek dorsal dan lateral kornu anterior, termasuk lamina V, VI dan VII. Jaras ini berhubungan dengan 2002 digitized by USU digital library 2 gerakan halus terutama tangan dan kaki. Jaras ini umumnya menfasilitasi aktifitas motorneuron untuk otot-otot fleksor dan menginhibisi aktivitas untuk otot-otot ekstensor. Serebelum Serbelum terletak di fossa posterior, dibelakang pons dan medula oblongata. Dipisahkan dari serebrum dibagian atasnya oleh tentorium serebeli. Serebelum terdiri atas 3 komponen anatomis utama yaitu, lobus flokulonodular (archi serebelum) lobus anterior (paleo serebelum) dan lobus posterior (neo serebelum). Lobus flokulonoduler menerima proyeksi terutama dari inti-inti vestibuler. Lobus anterior terutama pada bagian vermis menerima input dari jaras spinocerebelaris. Lobus posterior menerima proyeksi dari hemisfer serebri. Korteks serebelum terdiri atas 3 lapisan yaitu, lapisan molekuler, lapisan sel-sel purkinje dan lapisan granuler. Pada hemisfer serebri terdapat 4 pasang inti yaitu fastigial, globosus, emboliformis dan dentatus. Terdapat 3 pasang berkas proyeksi utama yaitu pedunkulus serebeli superior (brachium conjuncyivum), pedunkulus serebeli media (brachium pontis) dan pedunkulus serebeli inferior (corpus restiforme) Fungsi serebelum adalah sebagai pusat koordinasi untuk mempertahankan keseimbangan dan Tonus otot. Serebelum diperlukan untuk mempertahankan postur dan keseimbangan untuk berjalan dan berlari. Basal ganglia Basal ganglia adalah kompleks inti subkortika yang komponen utamanya terdiri atas nukleus kaudatus, putamen dan globus palidus. Komponen lain dari basal ganglia adalah kompleks inti amigdaloid dan klaustrum. Kompleks inti lain yang mempunyai hubungan erat dengan basal ganglia adalah nukleus subthalamikus dan substansia nigra. Kontrol aktivitas motorik dilakukan melalui berbagai sirkuit yang melibatkan basal ganglia, korteks serebri dan serebelum kemudian diteruskan melalui jaras motorik desendens yang selanjutnya mempengaruhi aktivitas lower motorneuron. Gerakan yang dipengaruhi oleh basal ganglia adalah yang berhubungan dengan postur, gerakan otomatis (ayunan tangan waktu berjalan), dan gerakan terampil. Basal ganglia diduga mempunyai peran dalam perencanaan gerakan dan sinergi gerakan. Medula spinalis Serabut-serabut dari traktus piramidalis dan berbagai jaras ekstrapiramidalis, dan serabut aferen yang memasuki medula spinalis melalui radiks posterior, berakhir pada badan sel atau dendrit dari α motor neuron besar dan kecil dan τ motor neuron secara langsung atau melalui interneuron dalam medula spinalis. Serabut saraf dengan diameter yang lebih besar (alpha-1) berjalan langsung menuju otot-otot ekstrafusal berakhir sebagai motor end plate. Serabut saraf dari τ motor neuron mensarafi muscle spindle. Unit dasar dalam pengorganisasian pada medula spinalis adalah refleks-refleks spinal. Refleks spinal ini mendapat pengaruh inhibisa dan eksitasi dari pusat-pusat yang lebih tinggi. Refleks spinal diaktivasi dan dipertahankan oleh stimulus eksternal. Terdapat suatu interaksi yang berkesinambungan antara input sensorik, eksitasi interneuron melalui jaras spinal dan supraspinal dan output motorik. Efek aktivitas pusat yang lebih tinggi adalah memodifikasi dan emngatur aktivitas 2002 digitized by USU digital library 3 dalam refleks spinal. Suatu lengkung refleks spinal terdiri atas suatu neuron sensorik, satu atau
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