Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Neuroanaesthesia PPT 10 Cns Neurological Examination Part 2 Lecture Notes
NEUROLOGICAL EXAMINATION-2
MOTOR SYSTEM EXAMINATION
COMPONENTS :
BULK
TONE
POWER
REFLEXES
Look at the position of the patient overall
Look especially for a hemiplegic positioning, flexion of elbow and wrist with extension of
knee and ankle.
Look for wasting
Look for fasciculation
Test for tone
Test muscle groups in a systematic way for power
Test reflexes
General observation and Bulk
Muscle groups being examined to be
exposed completely.
Inspect on a whole for any assymetry
between sides
Then palpate individually, which gives insight
about bulk, regarding any inflammation or
tenderness.
Both the sides being examined need to be
exposed .
TONE
Ensure the patient is relaxed, or at least distracted by
conversation.
Repeat each movement at different speeds.
Arms
Take the hand as if to shake it and hold the forearm. First
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.
Legs
Tone at the knee
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
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:
myopathies, 'spinal shock' (e.g. early after a stroke), chorea.
Spasticity: upper motor lesion.
Rigidity and cogwheel rigidity: extrapyramidal syndromes ? common causes: Parkinson's disease,
phenothiazines.
Myotonia (rare) ? cause: myotonic dystrophy (associated with frontal balding, ptosis, cataracts
and cardiac conduction defects) and myotonica congenita. Percussion myotonia may be found in both
conditions.
POWER
Test the following muscle groups and movements:
shoulder abductors and adductors
elbow flexors and extensors
wrist extensors and flexors
hip flexors
knee flexors and extensors
ankle dorsiflexors, and plantar flexors
Muscle strength is graded on a 0 to 5 scale?
Ask the patient to move actively against your
opposing Resistance; assign Grade 5 if the
patient overcomes the opposing movement.
If the patient can only move against gravity,
assign Grade 3
Testing shoulder
abduction
Testing elbow
flexion
Testing elbow
extension
Testing strength of
brachioradialis
Testing hip flexion
Testing hip extension
Testing knee extension
Testing knee flexion
Testing dorsiflexion of the foot
Testing plantarflexion of the foot
Deep Tendon reflexes
Reflex arc made has afferent (sensory) & efferent (motor) component.
Synapse happens in spinal cord, which recieves input from upper motor
neuron
Disruption of any part of path alters reflexes: e.g.
UMN lesion reflexes more brisk (hyper-reflexia)
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
single stimulus)
Reflexes are generally assessed at 5 places - 3 in the upperlimb (biceps, triceps,
brachioradialis);
2 in the lower limb (patellar & achilles)
Basic Technique for assessing a reflex:
?Clearly identify tendon of muscle to be tested
?Position limb so that the muscle is at rest.
?Strike tendon briskly
Observe for muscle contractions & limb movements.
Biceps jerk (C 5, 6)
Identify biceps tendon
Have the patient flex elbow against
resistance while you palpate the
antecubital fossa.
Place the arm on yours so it's bent at
an angle of 90 degrees
Place one of your fingers on tendon
and strike it birskly
Muscle should be contracting and
flexion at the forearm.
Triceps jerk (C 7, 8)
Identify triceps tendon.
Have the patient extend elbow against
resistance while you palpate above it
Allow the arm to hang down ninety
degrees or have hands on hips
Strike tendon directly or place finger on
the tendon & strike it
Triceps muscle contracts & arm extends.
Brachioradialis or supinator jerk (C5, 6)
Tendon for brachioradialis is ~ 10 cm
proximal to wrist ,its difficult to see or
feel it
Place the arm resting on patient's
thigh, bent @ elbow
Strike firmly
Muscle will contract & arm will flex
elbow & supinate
Patellar reflex (L2,L3, 4)
Patellar tendon extends below THE
knee cap.
it's thick & usually visible & palpable ? if
not, palpate while patient extends
lower leg.
Strike firmly over the tendon.
Muscle will contract & leg extend at
the knee
Achilles tendon jerk (S1, S2)
Achilles tendon is a thick structure
connecting calf muscles with heel.
In case of a trouble palpating, palpate
as patient pushes their foot into your
other hand
Hold foot at 90 degrees
Strike tendon firmly
Muscles will contract & foot plantar-
flex (move downward)
Interpreting the DTRs
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
Absent reflexes isolated ? indicates either a peripheral nerve or, more commonly, a root
lesion.
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
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
note. It is associated with hypothyroidism
Superficial reflexes
This group of reflexes includes
The plantar response
The superficial abdominal reflex
Cremasteric reflex.
These are polysynaptic reflexes, which are evoked by cutaneous stimulation.
Babinski's reflex
Gently stroke bottom of foot, starting
Babinski
laterally & near heel ? moving up &
across the feet (metatarsal heads)
If no response, increase your pressure
Normal = great toe moving downward
and other toes curling in with a flexor
plantar response
In UMN lesion (or in newborns), great
toe will extend and other toes fan out-
called positive babinski's response or
Babinski Response ? UMN lesion
babinski's sign positive
Other superficial reflexes
Test the abdominal reflexes by lightly but briskly stroking
each side of the abdomen, above (T8, T9, T10) and
below (T10, T1l, T12) the umbilicus, in the directions
illustrated.
Use a key,wooden end of a cotton-tipped applicator,
or a tongue blade twisted and split longitudinally.
Note the contraction of the abdominal muscles and
deviation of the umbilicus toward the stimulus.
Feel with your retracting finger for the muscular
contraction.
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
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
anal opening is scratched. This is often abolished in total spinal cord damage (along
with other superficial reflexes).
Cerebellar system.
Signs of cerebellar disease, from head to foot.
1. Scanning speech ? Causes enunciation of individual
syllables
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
them to touch their nose then fully extend to touch your
finger.
You increase the difficulty of this test by adding resistance
to the patient's movements or move your finger to different
locations. Abnormality of this is called dysmetria.
Rapid alternating movements
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
as possible)
if abnormal, this is called
dysdiadochokinesia.
Rebound phenomenon (of Stewart &
Holmes)
Have the patient pull on your hand and when they
do, slip your hand out of their grasp. Normally the
antagonists muscles will contract and stop their arm
from moving in the desired direction.
A positive sign is seen in a spastic limb where the
exaggerated "rebound" occurs with movement in the
opposite direction.
However in cerebellar disease this response is
completely absent causing to limb to continue moving
in the desired direction. (Be careful that you protect
the patient from the unarrested movement causing
them to strike themselves.)
Heel to shin test
Have patient run their heel down the
contralateral shin (this is equivalent the
finger to nose test).
Abnormal exam occurs when they are
unable to keep their foot on the shin.
Hypotonia
"Pendular" knee jerk, leg keeps
swinging after knee jerk more than 4
times (4 or less is normal).
Gait
Always examine patient's gait.
It is a co-ordinated action requiring integration of sensory and
motor functions.
The gait may be the only abnormality on examination.
The most commonly seen are: hemiplegic, parkinsonian, marche
a' petits pas, ataxic and unsteady gaits.
Approach to a gait examination
Ask the patient to walk
Ensure you are able to see the arms and legs adeguately
Is the gait symmetrical?
Gait can usually be divided into symmetrical and asymmetrical.
If symmetrical:
- Look at the size of paces
- Small or normal
If small paces
- 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,
If normal paces:
A.Look at the lateral distance between the feet
1.normal
2.widely separated - broad based
3.Legs unco-ordinated ? cerebellar gait.
4.Crossing over, toes dragged ? scissoring- may be seen in : spastic paraparesis ? common causes: cerebral
palsy, multiple scelrosis, cord compression.
B. look at knees
1. normal
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
sclerosis ,Syphilis, Guillain?Barr? syndrome , Spinal disc herniation , Anterior Compartment Muscle Atrophy, Deep fibular nerve Injury , Spondylolisthesi
:
Look at the pelvis and shoulders
1.normal
2. marked rotation of pelvis and shoulder ?waddling gait ? indicates a weak or an ineffective
proximal muscles ? commonly associated
with proximal myopathies, bilateral cogenital dislocation of the hip.
Look at the whole movement
1. normal
2. disjointed as if forgotten how to walk? apraxic gait -indicates the cortical integration of the
movement is abnormal, usually with frontal
lobe pathology ? common causes: normal pressure hydrocephalus, cerebrovascular disease.
bizarre, elaborate and inconsistent ? functional cause.
If asymmetrical
Is the patient in pain?
yes ? painful or antalgic gait- arthritis, trauma ? usually obvious
Look for a bony deformity
orthopaedic gait- common causes: shortened limb, previous hip surgery, trauma.
Does one leg swing out to the side?
yes ? hemiplegic gait-unilateral upper motor neurone lesion ? common
causes: stroke, multiple sclerosis
Myopathic gait
High stepping gait
Hypokinetic gait
Hemiparetic gait
Ataxic gait
Sensory system examination
2 main pathways
Spinothalamic tracts
?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
?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)
Special stand points
Subjective " examination
Requires good cooperation on the patient`s side.
Allows accurate localisation of the pathology.
Preliminary diagnosis is needed. Examine according to the expected damage
only !
Most often we compare different parts of the body.
Do not tell the patient what should be felt !
The patient should not see the examined part of the body !
Nerves and Their Distributions
Specific dermatomes not usually
memorzied ? reference charts are
helpful to pin down deficits
?Distributions (& spinal root
contributions) for specific peripheral
nerves are looked up in appropriate
setting
Spinothalamics ? Pain, Temperature & Crude Touch
Pin pricks or tooth picks may be used.
Ask patient to close eyes
Do not alllow any visual clues.
Start top of foot.
Orient patient by first touching w/sharp
implement, then non-sharp object (e.g. the
soft end of a q-tip)
This clarifies the patient what you're defining
as sharp & dull
2 sec. b/t each stimulus to avoid summation
(frequent consecutive stimuli percieved as
one strong stimulus)
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
sec between stimuli as mentioned above
Remember to cross dermatomes
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 !"
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
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,
like across dermatomes , well timed stimulii etc.
Dorsal Columns - Proprioception
Allows body to "know" where it is in space
Important for balance, walking
Ask patient to close eyes?With one hand, grasp either
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:
Flex the toe (pull it upwards) while telling patient what
you're doing.
Extend toe (pull it downwards) while informing them of
which direction you're moving it.
Dorsal Columns ? Proprioception ( continued)
Alternately deflect toe up or down without out telling patient in which direction you
are moving.
Patient should be able to correctly identify movement & direction.
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.
Upper extremities assessed in same fashion,deflecting fingers up & down
Romberg's test
-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.
NOTE: THE ROMBERG TEST IS NOT A SIGN OF CEREBELLAR
DISEASE.
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
problems.
if they are swaying even with open eyes ? indicates cerebellar
pathology .
Dorsal Columns ? Vibratory Sensation
Ask patient to close eyes and don't
give any visual cues.
Place the stem of a vibrating 128 Hz
tuning fork on top of interphalangeal
joint of great toe.
Place fingers of your other hand on
bottom-side of joint
Ask patient if they can feel vibration.
You should be able to feel same
sensation w/fingers on bottom side of
joint.
Patient determines when vibration stops.
Correlate this with when you can't feel it transmitted through the joint yourself.
Test for both the feet.
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
Two point discrimination:
The ability to discriminate between two blunt points when applied simultaneously. (3-5 mm on
the finger, 4-7
cm on the trunk)
Sensory inattention (perceptual rivalry)
The ability to detect sensory stimuli applied simultaneously on both limbs.
Subdominant parietal lobe, associative areas
Stereoaesthesia
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 )
Astereognosis.
Inability to identify an object by palpation
The primary sense data being intact
Lesion of the opposite hemisphere, postcentral gyrus
Tactile agnosia
The patient is unable to recognize an object by touch in both the hands.
Disorder of perception of symbols.
Lesion of the dominant parietal lobe, associative areas.
Graphaesthesia
The ability to recognize numbers or letters traced out on the palm.
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
Wash Hands
Cranial Nerves:
CN1 (Olfactory) Smell
CN2 (Optic) Visual acuity; Visual fields
CNs 2&3 (Optic, Occulomotor) Pupilary Response to light
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)
CN 7 (Facial) Facial expression
CN 8 (Auditory) Hearing
CN 9, 10 (Glosopharyngeal, Vagus) Raise palate ("ahh"), gag
CN 11 (Spinal Accessory) Turn head against resistance, shrug
shoulders
CN 12 (Hypoglossal) Tongue CONTINUED ---- >>>>
Time Target: < 15 minutes
SUMMARY OF NEUROLOGICAL examination( CONTINUED)
Motor testing:
? muscle bulk
? tone
? strength of major groups
Sensory testing ?
? in distal lower & upper extremities:
? pain/crude touch
? proprioception
? vibration
Reflexes
? Achilles
? patellar
? brachioradialis
? biceps
? triceps
? Coordination (finger nose, heel shin, etc.)
? Gait, Romberg
? Wash Hands
Time Target: < 15 minutes
Videos uploaded after sorting permission from "The University of Utah "
neurology center.
This post was last modified on 07 April 2022