Neurologic Examination

Neurological Examination

Preoperative assessment

·       HPI

o   Onset, location, duration, severity, quality

o   characteristics: pain, motor weakness, numbness, N/V, diplopia, blurred vision, headache, bowel/bladder changed, loss of balance

o   aggravating, relieving

o   back pain better with walking, sitting or standing

o   prior therapy: medication, surgery, PT; injection (can be diagnostic)

o   prior evaluations

·       Past Medical History

o   Medications

o   Allergies

o   Surgical/hospitalizations

o   Cardiac, pulmonary, hepatic, renal, nutritional and metabolic risks

o   Stroke, MI, HTN, DM type II, CHF

o   History of any malignancies (especially those that metastasize)

·       FMH: MI, stroke, high cholesterol

·       Social: Smoking, alcohol

·       ROS: weight loss, appetite, fever, night sweats, diplopia, blurred vision, headaches, seizures, N/V, bowel, bladder changes

Physical Exam

1.     Mental status

2.     Cranial nerves

3.     Motor exam

4.     Reflexes

5.     Coordination and gait

6.     Sensory exam

Parts of the General Physical Exam with Special Neurologic Significance:

1.     vital signs, including orthostatics

2.     Ophthalmoscopic exam

3.     Signs of cranial trauma

4.     Bruits

5.     Meningismus

6.     Straight-leg raising

7.     Rectal tone

Mini Mental Status Exam (MMSE)

·       Level of Consciousness

o   Ask: Year, season, day, date, month

o   What is tested?: Consciousness is impaired in damage to the brainstem reticular formation, bilateral thalami or cerebral hemispheres

·       Orientation.

o   Ask for patient’s full name, location and date

o   What is tested?: recent and long-term memory

·       Memory

o   Ask patient to recall three items for a delay of 3 to 5 minutes

o   What is tested?:

§  Medial temporal lobe and medial diencephalon

·       Damage leads to intact immediate recall, difficulty after delay

·       Anterograde and retrograde amnesia with sparing of earlier memories

§  loss of memory without these time characteristics may signify damage to other areas

·       Language

o   Ask patient to name pencil and watch. Read and obey the following “CLOSE YOUR EYES”

o   What is tested?: Broca’s and Wernicke’s area

·       Calculations, right-left confusion, finger agnosia, agraphia

o   Ask patient to complete serial 7’s, WORLD backwards

o   What is tested?: dominant parietal lobe

·       Apraxia

o   Ask patient to perform 3 stage command “take a paper in your hand, fold it in half and put it on the floor”

o   Inability to follow a motor command that is not due to a primary motor deficit or a language impairment but caused by a deficit in higher-order planning or conceptualization of the task

o   What is tested?:

§  localizing is difficult because many different regions may be involved

§  commonly present in lesions affecting the language areas and adjacent structures of the dominant hemisphere making it difficult to prove the deficit is apraxia rather than impaired language comprehension

§  Distinction can often be made by asking patient to perform a task, then if they fail, demonstrating several tasks and asking them to choose the correct one

·       Neglect and Constructions

o   What is tested?: right (nondominant) parietal lobe; much milder neglect may occur from lesions to left parietal lobe

·       Sequencing tasks and frontal release signs

o   What is tested?: frontal lobe

·       Mood

o   What is tested?: imbalances in neurotransmitter systems

Cranial Nerves:

·       CN I (Olfaction)

a.     Do not use noxious odors bc they stimulate pain fibers from CN V

b.    Not tested unless specific pathology (i.e. subfrontal brain tumor) suspected

c.     What is tested?: olfactory nerves in nasal mucosa, nerves as they cross the cribriform plate or intracranial lesions affecting the olfactory bulbs

·       CN II (Vision)

a.      Visual acuity, have patient look at nose and cover one eye. Hold up 1-3 fingers in 4 quadrants of visual field.

b.    Afferent pupillary defect

                                               i.     Decreased direct response caused by decreased vision in one eye

                                             ii.     Demonstrated with the swinging flashlight test

                                            iii.     When moving from the normal to the affected eye, the affected pupil dilates in response to light when it should normally remains constricted

c.     Hippus – brief oscillations of pupillary size; occurs normally in response to light

d.    Accommodation – pupils normally constrict while fixating on an object moved toward the eyes

e.     What is tested?:

                                               i.     Direct response: ipsilateral optic nerve, pretectal area, ipsilateral parasympathetics traveling in CN III, pupillary constrictor of the iris

                                             ii.     Consensual response: contralateral optic nerve (beyond optic chiasm), pretectal area, ipsilateral parasympathetics traveling in CN III, or the pupillary constrictor muscle

·       CN III, IV, VI (Extraocular Movements)

a.      Ask patient to follow fingers side to side and up/down.

b.     Causes of Ptosis:

                                               i.     CN III lesion à Paralysis of the levator palpebrae superioris

                                             ii.     Sympathetic chain lesion à Weakness of the tarsal muscle

·       CN V (Facial Sensation and Muscles of Mastication)

a.     Test facial sensation in all 3 trigeminal regions

b.    Corneal reflex – involves both CN V and CN VII

c.     Jaw jerk reflex – gently tapping on the jaw with the mouth slightly open

                                               i.     Both afferent and efferent limbs are mediated by CN V

                                              ii.     Sign of hyperreflexia – UMN projects to trigeminal motor nucleus

·       CN VII (Muscles of Facial Expression and Taste)

a.     Ask patient to close eyes tight, smile, puff out cheeks, etc.

b.    What is tested?:

                                               i.     UMNs

1.    begin in the contralateral motor cortex

2.    UMNs for the upper face project to both facial nuclei which innervate the upper face

3.    UMN lesions cause contralateral face weakness sparing the forehead

                                             ii.     LMNs

1.    begin in the ipsilateral facial nerve nucleus (CN VII)

2.    LMN lesions such as a facial nerve injury cause weakness involving the whole ipsilateral face

·       CN VIII (Hearing and Vestibular Sense)

a.     After hearing pathways enter the brainstem, they cross at multiple levels and ascend bilaterally to the thalamus and auditory cortex

b.    Therefore, clinically significant unilateral hearing loss is invariably caused by peripheral neural or mechanical lesions

·       CN IX, X (Palate Elevation and Gag Reflex)

a.      Ask patient to open mouth and say “ahh”, determine if palate rises symmetrically

b.     Gag reflex in unconscious patients

·       Sternocleidomastoid and Trapezius Muscles (CN XI)

a.      Shoulder shrug and head turning to resistance

·       CN XII (Tongue Muscles)

a.     Ask patient to stick out tongue and move side to side

b.    Unilateral tongue weakness causes deviation toward the weak side

·       Articulation

a.      Dysarthria is an abnormal pronunciation of speech; different than aphasia

b.     Dysarthria can arise from damage to peripheral or central portions of CN V, VII, IX, X, XII, motor cortex, cerebellum, basal ganglia or descending pathways to the brainstem

c.      

Muscle Strength

0/5: no contraction

1/5: muscle twitch, but no movement

2/5: movement possible, but not against gravity

3/5: movement possible against gravity, but not against resistance

4/5: movement possible against some resistance

5/5: normal strength

Cervical Spine Motor Exam
Muscles	Nerves	Nerve Roots
Biceps	Musculocutaneous	C5, C6
Triceps	Radial nerve	C7, C8
Wrist extensors	Radial nerve	C5, C6
Wrist flexors	Median/Ulnar	C6-T1
Interosseous	Ulnar nerve	C8, T1
Grip

Pronator Drift

·       Must be done on every patient with cranial pathology

·       Sign of contralateral UMN pathology

Lumbar Spine Motor Exam
Action	Muscles	Nerves	Segment
Hip flexion	Iliopsoas	Femoral nerve	L2, L3
Knee extensors	Quadriceps	Femoral nerve	L3, L4
Ankle dorsiflexion	Tibialis anterior	Deep peroneal	L4, L5
Knee flexion	Hamstrings	Sciatic	L5, S1
Toe dorsiflexion	Extensor hallicus longus	Deep peroneal	L5, S1
Ankle plantar flexion	Gastrocnemius, soleus	Tibial nerve	S1, S2

Deep Tendon Reflexes

0: absent reflex

1⁺: trace

2⁺: normal

3⁺: brisk

4⁺: nonsustained clonus

Reflex Biceps	Spinal Nerve C5, C6
Brachioradialis	C5, C6
Triceps	C7, C8
Patellar	L3, L4
Achilles	S1, S2

5⁺: sustained clonus

Normal DTRs:

·       1⁺, 2⁺, or 3⁺

Abnormal DTR’s:

·       0, 4⁺, or 5⁺

·       asymmetricality

·       dramatic difference between arms and legs

·       signs of hyperreflexis: clonus, Hoffman’s sign, Babinski’s sign, spread of reflexes to other muscles not directly being tested

Reflexes of Special Situations	Spinal Nerve	About
Masseter reflex		Only reflex above the C spine
Abdominal cutaneous reflexes
Above umbilicus	T8-T10
Below umbilicus	T10-T12
Cremasteric reflex	L1-L2	scrape inner thigh à testicle ascends
Bulbocavernosus reflex	S2-S4	Compress glans penis and rectal sphincter contracts
Anal wink	S2-S4	sharp stimulus in the perianal area causes rectal sphincter to contract

Cerebellar Exam

·       Appendicular ataxia – lesions of the cerebellar hemispheres

o   Dysdiadochokinesia  - difficulty with rapid alternating movements (RAM)

o   Finger-nose-finger test

o   Modified finger-nose-finger test – have patient to this while supine to incorporate gravity into the exam; more sensitive that standing

o   Heel-shin test

·       Truncal ataxia – midline damage to the cerebellar vermis

o   Tend to have wide-based, unsteady gait

o   Difficulty with tandem gait

·       Romberg

o   3 sensory systems provide cerebellar input to maintain truncal stability: vision, proprioception and vestibular sense

o   mild lesions in the vestibular or proprioceptive systems lead to instability when the patient closes their eyes

o   Severe proprioceptive or vestibular lesions, or midline cerebellar lesions lead to instability in patients even with eyes open

·       Horizontal Jerk Nystagmus

o   Quick phase is taken to indicate the direction of the nystagmus

o   Produced by lesions in the vestibular system which may occur peripherally in the labyrinth, centrally at the nuclei, in the brainstem or in the cerebellum

o   Eyes slowly drift to the side of the lesion and jerk (quick phase) back to center

·       Vertical nystagmus

o   due to intrinsic brainstem lesions such as multiple sclerosis, brainstem tumors, phenytoin toxicity, or PCP (phencyclidine)

o   Chiari syndrome