Download MBBS Neuroanaesthesia PPT 10 Cns Neurological Examination Part 2 Lecture Notes

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COMPONENTS :

BULK
TONE
POWER

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REFLEXES
Look at the position of the patient overall

Look especially for a hemiplegic positioning, flexion of elbow and wrist with extension of

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knee and ankle.

Look for wasting

Look for fasciculation

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Test for tone

Test muscle groups in a systematic way for power

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Test reflexes

General observation and Bulk

Muscle groups being examined to be

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exposed completely.

Inspect on a whole for any assymetry

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between sides

Then palpate individually, which gives insight

about bulk, regarding any inflammation or

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tenderness.

Both the sides being examined need to be

exposed .

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TONE

Ensure the patient is relaxed, or at least distracted by
conversation.

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Repeat each movement at different speeds.

Arms

Take the hand as if to shake it and hold the forearm. First

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pronate and supinate the forearm. Then roll the hand round at
the wrist.

Hold the forearm and the elbow and move the arm through
the full range of flexion and extension at the elbow.

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Legs

Tone at the knee

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Put your hand behind the knee and lift it rapidly.
Watch the heel. Hold the knee and ankle. Flex
and extend the knee.

Tone at the ankle

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Hold the ankle and flex and dorsiflex the foot.
ABNORMAL TONE

Flaccidity or reduced tone ? common causes: lower motor nurone or cerebellar lesion; rare causes:

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myopathies, 'spinal shock' (e.g. early after a stroke), chorea.

Spasticity: upper motor lesion.

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Rigidity and cogwheel rigidity: extrapyramidal syndromes ? common causes: Parkinson's disease,

phenothiazines.

Myotonia (rare) ? cause: myotonic dystrophy (associated with frontal balding, ptosis, cataracts

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and cardiac conduction defects) and myotonica congenita. Percussion myotonia may be found in both
conditions.

POWER

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Test the following muscle groups and movements:

shoulder abductors and adductors

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elbow flexors and extensors

wrist extensors and flexors

hip flexors

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knee flexors and extensors

ankle dorsiflexors, and plantar flexors
Muscle strength is graded on a 0 to 5 scale?

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Ask the patient to move actively against your
opposing Resistance; assign Grade 5 if the
patient overcomes the opposing movement.

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If the patient can only move against gravity,
assign Grade 3

Testing shoulder
abduction

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Testing elbow
flexion
Testing elbow
extension

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Testing strength of
brachioradialis

Testing hip flexion

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Testing hip extension
Testing knee extension

Testing knee flexion

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Testing dorsiflexion of the foot

Testing plantarflexion of the foot
Deep Tendon reflexes

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Reflex arc made has afferent (sensory) & efferent (motor) component.

Synapse happens in spinal cord, which recieves input from upper motor

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neuron

Disruption of any part of path alters reflexes: e.g.

UMN lesion reflexes more brisk (hyper-reflexia)

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LMN lesions opposite effect (hypo-reflexia)

Reflexes are graded as 0-4+ scale: 0 = no reflex, 1+ = hyporeflexia,

2+ = normal, 3+ = hyper-reflexia, 4+ = clonus (multiple movements after a

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single stimulus)

Reflexes are generally assessed at 5 places - 3 in the upperlimb (biceps, triceps,

brachioradialis);

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2 in the lower limb (patellar & achilles)

Basic Technique for assessing a reflex:

?Clearly identify tendon of muscle to be tested

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?Position limb so that the muscle is at rest.
?Strike tendon briskly

Observe for muscle contractions & limb movements.
Biceps jerk (C 5, 6)

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Identify biceps tendon

Have the patient flex elbow against

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resistance while you palpate the
antecubital fossa.

Place the arm on yours so it's bent at

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an angle of 90 degrees

Place one of your fingers on tendon

and strike it birskly

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Muscle should be contracting and

flexion at the forearm.

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Triceps jerk (C 7, 8)

Identify triceps tendon.

Have the patient extend elbow against

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resistance while you palpate above it

Allow the arm to hang down ninety

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degrees or have hands on hips

Strike tendon directly or place finger on

the tendon & strike it

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Triceps muscle contracts & arm extends.
Brachioradialis or supinator jerk (C5, 6)

Tendon for brachioradialis is ~ 10 cm

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proximal to wrist ,its difficult to see or
feel it

Place the arm resting on patient's

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thigh, bent @ elbow

Strike firmly

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Muscle will contract & arm will flex

elbow & supinate
Patellar reflex (L2,L3, 4)

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Patellar tendon extends below THE

knee cap.

it's thick & usually visible & palpable ? if

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not, palpate while patient extends
lower leg.

Strike firmly over the tendon.

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Muscle will contract & leg extend at

the knee

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Achilles tendon jerk (S1, S2)

Achilles tendon is a thick structure

connecting calf muscles with heel.

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In case of a trouble palpating, palpate

as patient pushes their foot into your
other hand

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Hold foot at 90 degrees

Strike tendon firmly

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Muscles will contract & foot plantar-

flex (move downward)
Interpreting the DTRs

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Increased reflex or clonus ? this indicates upper motor neuron lesion above the root at

that level. Often associated with hypertonia.

Absent reflexes - generalized ? indicates peripheral neuropathy

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Absent reflexes isolated ? indicates either a peripheral nerve or, more commonly, a root

lesion.

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Reduced reflexes (more difficult to judge) ? occurs in a peripheral neuropathy, muscle

disease and cerebellar syndrome.

Pendular reflex ? this is usually best seen in the knee jerk where the reflex continues to

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swing for several beats. This is associated with cerebellar disease.

Slow relaxing reflex ? this is especially seen at the ankle reflex and may be difficult to

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note. It is associated with hypothyroidism
Superficial reflexes

This group of reflexes includes

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The plantar response

The superficial abdominal reflex

Cremasteric reflex.

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These are polysynaptic reflexes, which are evoked by cutaneous stimulation.

Babinski's reflex

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Gently stroke bottom of foot, starting

Babinski

laterally & near heel ? moving up &

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across the feet (metatarsal heads)

If no response, increase your pressure

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Normal = great toe moving downward

and other toes curling in with a flexor

plantar response

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In UMN lesion (or in newborns), great

toe will extend and other toes fan out-

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called positive babinski's response or

Babinski Response ? UMN lesion

babinski's sign positive

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Other superficial reflexes

Test the abdominal reflexes by lightly but briskly stroking

each side of the abdomen, above (T8, T9, T10) and

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below (T10, T1l, T12) the umbilicus, in the directions
illustrated.

Use a key,wooden end of a cotton-tipped applicator,

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or a tongue blade twisted and split longitudinally.

Note the contraction of the abdominal muscles and

deviation of the umbilicus toward the stimulus.

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Feel with your retracting finger for the muscular

contraction.

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Abdominal reflexes may be absent in both central and

peripheral nervous system disorders
The cremaster reflex is produced by scratching the skin of the medial thigh, which

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should produce a brisk and brief elevation of the testis on that side.
Both the cremaster reflex and the abdominal reflex can be affected by surgical
procedures (in the inguinal region and the abdomen, respectively)

The "anal wink" is a contraction of the external anal sphincter when the skin near the

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anal opening is scratched. This is often abolished in total spinal cord damage (along
with other superficial reflexes).

Cerebellar system.

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Signs of cerebellar disease, from head to foot.

1. Scanning speech ? Causes enunciation of individual
syllables

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eg.British parliament becomes "Brit-tish Par-la-ment"
2. Nystagmus ? fast phase towards the side of the lesion.
3. Finger to nose & finger to finger test ?
Ask patient to fully extend arm then touch nose or ask

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them to touch their nose then fully extend to touch your

finger.
You increase the difficulty of this test by adding resistance

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to the patient's movements or move your finger to different

locations. Abnormality of this is called dysmetria.
Rapid alternating movements

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Ask patient to place one hand over
the next and have them flip one hand
back and forth as fast as possible
(alternatively you can ask the patient to
quickly tap their foot on the floor as fast

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as possible)

if abnormal, this is called
dysdiadochokinesia.

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Rebound phenomenon (of Stewart &
Holmes)

Have the patient pull on your hand and when they

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do, slip your hand out of their grasp. Normally the

antagonists muscles will contract and stop their arm

from moving in the desired direction.

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A positive sign is seen in a spastic limb where the

exaggerated "rebound" occurs with movement in the

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opposite direction.

However in cerebellar disease this response is

completely absent causing to limb to continue moving

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in the desired direction. (Be careful that you protect

the patient from the unarrested movement causing

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them to strike themselves.)
Heel to shin test
Have patient run their heel down the

contralateral shin (this is equivalent the

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finger to nose test).
Abnormal exam occurs when they are

unable to keep their foot on the shin.

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Hypotonia
"Pendular" knee jerk, leg keeps
swinging after knee jerk more than 4
times (4 or less is normal).

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Gait

Always examine patient's gait.

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It is a co-ordinated action requiring integration of sensory and

motor functions.

The gait may be the only abnormality on examination.

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The most commonly seen are: hemiplegic, parkinsonian, marche

a' petits pas, ataxic and unsteady gaits.
Approach to a gait examination

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Ask the patient to walk

Ensure you are able to see the arms and legs adeguately

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Is the gait symmetrical?

Gait can usually be divided into symmetrical and asymmetrical.

If symmetrical:

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- Look at the size of paces
- Small or normal

If small paces

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- Look at the posture and arm swing
- Stooped with reduced armswing ? parkinsonian (may be difficult to start and stop ? festinant gait ).
- Upright with marked armswing ? marche a' petits pas ? often in Bilateral diffuse cortical dysfunction, diffuse
lacunar infarcts , Multiple sclerosis,

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If normal paces:

A.Look at the lateral distance between the feet

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1.normal

2.widely separated - broad based

3.Legs unco-ordinated ? cerebellar gait.

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4.Crossing over, toes dragged ? scissoring- may be seen in : spastic paraparesis ? common causes: cerebral

palsy, multiple scelrosis, cord compression.

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B. look at knees

1. normal

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1.

2. knees lifted high ? high-stepping gait/neuropathic gait - seen with foot drop due to loss of dorsiflexion, Charcot?Marie?Tooth disease, Polio, Multiple

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sclerosis ,Syphilis, Guillain?Barr? syndrome , Spinal disc herniation , Anterior Compartment Muscle Atrophy, Deep fibular nerve Injury , Spondylolisthesi

:

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Look at the pelvis and shoulders

1.normal

2. marked rotation of pelvis and shoulder ?waddling gait ? indicates a weak or an ineffective

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proximal muscles ? commonly associated

with proximal myopathies, bilateral cogenital dislocation of the hip.

Look at the whole movement

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1. normal

2. disjointed as if forgotten how to walk? apraxic gait -indicates the cortical integration of the
movement is abnormal, usually with frontal

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lobe pathology ? common causes: normal pressure hydrocephalus, cerebrovascular disease.

bizarre, elaborate and inconsistent ? functional cause.

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If asymmetrical

Is the patient in pain?

yes ? painful or antalgic gait- arthritis, trauma ? usually obvious

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Look for a bony deformity

orthopaedic gait- common causes: shortened limb, previous hip surgery, trauma.

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Does one leg swing out to the side?

yes ? hemiplegic gait-unilateral upper motor neurone lesion ? common

causes: stroke, multiple sclerosis

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Myopathic gait

High stepping gait
Hypokinetic gait

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Hemiparetic gait
Ataxic gait

Sensory system examination

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2 main pathways

Spinothalamic tracts

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?Pain, temperature, crude touch
?Impulses enter from periphery cross to other side of cord within ~ 2 vertebral
levels travel up that side to brain

Dorsal Columns

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?Vibration, position, fine touch
?Impulses from periphery enter cord travel up that side cross to opposite
at the base of brain then travel to their terminus( dorsal column medial leminiscal
pathway)

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Special stand points

Subjective " examination

Requires good cooperation on the patient`s side.

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Allows accurate localisation of the pathology.

Preliminary diagnosis is needed. Examine according to the expected damage

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only !

Most often we compare different parts of the body.

Do not tell the patient what should be felt !

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The patient should not see the examined part of the body !

Nerves and Their Distributions

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Specific dermatomes not usually

memorzied ? reference charts are
helpful to pin down deficits

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?Distributions (& spinal root

contributions) for specific peripheral
nerves are looked up in appropriate
setting

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Spinothalamics ? Pain, Temperature & Crude Touch

Pin pricks or tooth picks may be used.

Ask patient to close eyes

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Do not alllow any visual clues.

Start top of foot.

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Orient patient by first touching w/sharp

implement, then non-sharp object (e.g. the

soft end of a q-tip)

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This clarifies the patient what you're defining

as sharp & dull

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2 sec. b/t each stimulus to avoid summation

(frequent consecutive stimuli percieved as
one strong stimulus)

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Spinothalamics ? continued

Touch lateral aspect of foot w/either sharp or blunt .

Move medially across top of foot, noting their response to touch , with a gap of 2

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sec between stimuli as mentioned above

Remember to cross dermatomes

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Temperature tested by using a tuning fork (run under cold or warm water)

Instructions to patients : 1. Tell me if you feel the stimulus !

2.Name the area stimulated !"

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3."Is it equal on both sides?
4. ("Tell me if the sensation changes" ( As you map out the extent of
abnormality by moving from the abnormal to the normal area.
Spinothalamics ? continued

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Light touch assessed by gently brushing your finger against the extremity

and asking the patient (eyes closed) to note when they feel it

Upper extremities checked in same fashion as mentioned for lower limb,

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like across dermatomes , well timed stimulii etc.

Dorsal Columns - Proprioception

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Allows body to "know" where it is in space

Important for balance, walking

Ask patient to close eyes?With one hand, grasp either

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side of great toe at the interphalangeal (IP) joint.
Place your other hand on the lateral and medial aspects
of the great toe distal to the IP.
Orient patient as to up and down:

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Flex the toe (pull it upwards) while telling patient what

you're doing.

Extend toe (pull it downwards) while informing them of

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which direction you're moving it.
Dorsal Columns ? Proprioception ( continued)

Alternately deflect toe up or down without out telling patient in which direction you

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are moving.

Patient should be able to correctly identify movement & direction.

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Both feet to be tested.

If position sense is impaired, move proximally to the next joint

If position sense intact distally , then it is OK proximally as well.

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Upper extremities assessed in same fashion,deflecting fingers up & down

Romberg's test

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-This is a simple test primarily of joint position sense.

-make patient Stand upright, place feet together, then close eyes

- if patient loses balance- indicates a positive Romberg test.

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NOTE: THE ROMBERG TEST IS NOT A SIGN OF CEREBELLAR

DISEASE.

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It is a sign of a disturbance of proprioception, either from neuropathy

or posterior column disease. The patient does not know where their joint is in

space and so uses their eyes. In the dark or with eyes closed they have

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problems.

if they are swaying even with open eyes ? indicates cerebellar

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pathology .
Dorsal Columns ? Vibratory Sensation

Ask patient to close eyes and don't

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give any visual cues.

Place the stem of a vibrating 128 Hz

tuning fork on top of interphalangeal

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joint of great toe.

Place fingers of your other hand on

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bottom-side of joint

Ask patient if they can feel vibration.

You should be able to feel same

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sensation w/fingers on bottom side of

joint.
Patient determines when vibration stops.

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Correlate this with when you can't feel it transmitted through the joint yourself.

Test for both the feet.

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Check more proximal joints (e.g. ankle) if sensation impaired.

Upper extremities assessed similarly, with the tuning fork placed on distal finger joint.

Special Sensory Testing

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Two point discrimination:

The ability to discriminate between two blunt points when applied simultaneously. (3-5 mm on

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the finger, 4-7
cm on the trunk)

Sensory inattention (perceptual rivalry)

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The ability to detect sensory stimuli applied simultaneously on both limbs.
Subdominant parietal lobe, associative areas

Stereoaesthesia

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An object is placed in the patient's hand.
Ask patient to describe its size, shape, surface, material !
Stereoanaesthesia indictaes disturbance of the sensory afferent tracts.
Special Sensory Testing ( continued )

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Astereognosis.

Inability to identify an object by palpation
The primary sense data being intact
Lesion of the opposite hemisphere, postcentral gyrus

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Tactile agnosia

The patient is unable to recognize an object by touch in both the hands.
Disorder of perception of symbols.

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Lesion of the dominant parietal lobe, associative areas.

Graphaesthesia

The ability to recognize numbers or letters traced out on the palm.

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Loss of graphesthesia indicates either parietal lobe damage on the side opposite the hand
tested or damage to the dorsal column pathway at any point between the tested point and the
contralateral parietal lobe.

Summary of NEUROLOGICAL examination

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Wash Hands

Cranial Nerves:

CN1 (Olfactory) Smell

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CN2 (Optic) Visual acuity; Visual fields

CNs 2&3 (Optic, Occulomotor) Pupilary Response to light

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CNs 3, 4 & 6 (Occulomotor, Trochlear, Abduscens) Extra-Occular
Movements

CN 5 (Trigeminal) Facial sensation; Muscles Mastication (clench
jaw, chew); Corneal reflex (w/CN 7)

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CN 7 (Facial) Facial expression

CN 8 (Auditory) Hearing

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CN 9, 10 (Glosopharyngeal, Vagus) Raise palate ("ahh"), gag

CN 11 (Spinal Accessory) Turn head against resistance, shrug
shoulders

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CN 12 (Hypoglossal) Tongue CONTINUED ---- >>>>
Time Target: < 15 minutes
SUMMARY OF NEUROLOGICAL examination( CONTINUED)
Motor testing:
? muscle bulk

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? tone
? strength of major groups

Sensory testing ?
? in distal lower & upper extremities:

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? pain/crude touch
? proprioception
? vibration

Reflexes

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? Achilles
? patellar
? brachioradialis
? biceps
? triceps

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? Coordination (finger nose, heel shin, etc.)
? Gait, Romberg
? Wash Hands
Time Target: < 15 minutes

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