Demystifying the neurology examination
This presentation is the property of its rightful owner.
Sponsored Links
1 / 58

Demystifying the neurology examination PowerPoint PPT Presentation


  • 47 Views
  • Uploaded on
  • Presentation posted in: General

Demystifying the neurology examination. Dr BSF Stacey, Consultant Physician. Aims. Introduce the principles underpinning a structured neurological examination Revise some neuroanatomy Show some pathologies Not creating instant experts Not the only neurology talk you’ll ever need to attend

Download Presentation

Demystifying the neurology examination

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Demystifying the neurology examination

Demystifying the neurology examination

Dr BSF Stacey, Consultant Physician


Demystifying the neurology examination

Aims

  • Introduce the principles underpinning a structured neurological examination

  • Revise some neuroanatomy

  • Show some pathologies

  • Not creating instant experts

  • Not the only neurology talk you’ll ever need to attend

  • Not a substitute for practice


Format

Format

  • Cranial nerves

    • Names and function

    • Some anatomy

  • Motor system

  • Reflexes

  • Sensory system

  • Some practicalities of examination

    • Cranial nerves and more anatomy

    • Limbs

  • Images

    • Normality and pathology


Demystifying the neurology examination

Cranial nerves

Arms

Torso

Legs

Higher mental function

Observation

Tone

Power

Co-ordination

Reflexes

Sensation

Light touch

Proprioception

Vibration sense

Pin prick

Temperature

I - XII


Demystifying the neurology examination

Cranial nerves

Arms

Torso

Legs

Higher mental function

Observation Ex/Pyr

Tone C/Sp

Power C/Sp

Co-ordination Cblr

Reflexes

Sensation

Light touch

Proprioception D/Col

Vibration sense

Pin prick S/Thal

Temperature

Gait


Cranial nerves

1

2

3

4

6

Smell

Vision

Eye movements

Cranial nerves


Cranial nerves1

5

7

8

9

10

12

11

Face –motor and sensory

Face –motor (+ taste)

Hearing and balance

Palatal movement and gag reflex

Tongue movement

Head/shoulder movements

Cranial nerves


Cranial nerves 1

Cranial nerves – 1

Olfactory

  • Sense of smell

    • Rarely formally tested

    • Ask directly

    • Bedside foodstuffs


Cranial nerves 2

Cranial nerves – 2

Optic

  • Visual acuity

    • Snellen chart, newspaper

  • Visual fields

  • Direct light reflex

  • (Consensual light reflex)


Demystifying the neurology examination

Pupil

Retina

Optic nerve

III

Optic chiasm

Lateral geniculate bodies

Ciliary ganglion

Edinger-Westfahl nucleus

Pretectal nucleus


Demystifying the neurology examination

L

R

Visual fields

Retina

Optic nerve

Optic chiasm

P

Bitemporal hemianopia

Optic radiation

RIGHT homonymous hemianopia


Cranial nerves 3 4 and 6

Cranial nerves – 3, 4 and 6

Occulomotor, Trochlear and Abducens

  • Eye movements, pupil dilatation

    • SO4, LR6

      • Double vision? Nystagmus? INO?

  • Ptosis


Cranial nerves 5

Cranial nerves – 5

Trigeminal

  • Motor

    • Masseter, temporalis

  • Sensory

    • Va, Vb, Vc

    • Corneal reflex (unpleasant)


Cranial nerves 7

Cranial nerves – 7

Facial

  • Motor

    • Frontalis (UMN v LMN)

    • Other facial muscles

    • Stapedius

  • Sensory

    • Taste from anterior 2/3 of tongue via chordi tympani


Cranial nerves 8

Cranial nerves – 8

Vestibulocochlear

  • Hearing

    • Crude bedside testing

  • Balance

  • Rinne

    • Normal is positive

  • Weber

    • Towards a conductive defect


Cranial nerves 9 and 10

Cranial nerves – 9 and 10

Glossopharyngeal and vagus

  • Palatal movement with “aaaah”

  • Gag reflex – bilateral

  • IX: taste from posterior 1/3 of tongue


Cranial nerves 12

Cranial nerves – 12

Hypoglossal

  • Tongue movement (NB: fasciculation)

    • Deviates towards the lesion


Cranial nerves 11

Cranial nerves – 11

Accessory

  • Shoulder and head movements

    • Sternocleidomastoid and trapezius muscles


Cranial nerves epilogue

Cranial nerves – ‘epilogue’

Fundoscopy!

  • Optic disc - only part of the brain that you can see

  • Retina, vessels

  • Cataracts


The motor system

The Motor System

  • Corticospinal system = pyramidal

    - Cortex  anterior horn cells

    - skilled, strong, organized movement

  • Extra-pyramidal = basal ganglia

    - facilitates fast fluid movements

  • Cerebellum

    - coordination

  • Lower motor neurones


1 corticospinal tracts

1. Corticospinal tracts

  • Main nerve fibres meet in internal capsule

  • Cross in medulla

  • Lesions  UMN signs

    = contralateral hemiparesis, spasticity

    NB: upper limb drift

    (UL: flexors; LL extensors predominate)

  • Causes:

    • Most common = CVA

    • SOL

    • MS


Demystifying the neurology examination

Leg

Cerebral cortex

Arm

Head and neck

Internal capsule


2 extra pyramidal system

2. Extra-pyramidal system

  • Reduction in speed with muscle rigidity

  • Involuntary movements

  • Most common disorder = Parkinson’s


Demystifying the neurology examination

Cranial nerve nuclei

Cerebral cortex

Caudate nucleus

Corpus striatum

Globus pallidus

Putamen

Thalamus

Substantia nigra

Subthalamic nuclei

Cerebellum

Reticular formation

Spinal cord


3 cerebellum

3. Cerebellum

  • Coordination (rather than speed)

  • Lateral lobes coordinate ipsilateral limb

  • Vermis – axial posture and balance

    Signs: intention tremor, ataxia, nystagmus, dysarthria (bilateral)


4 lower motor neurones

4. Lower motor neurones

  • Motor pathway from anterior horn cell (or cranial nerve nucleus) via peripheral nerve to end plate

  • Weakness, hypotonia, wasting, loss of reflexes

  • Causes:

    • Bell’s, MND, polio

    • Spinal root compression

    • Peripheral nerve trauma, entrapment, mononeuritis multiplex


Umn v lmn

UMN v LMN

Cortex

UMN

LMN

Muscle

Spasticity

Flaccidity


Reflexes the spinal reflex arc

Reflexes – the spinal reflex arc

  • Activation of stretch receptors = first order sensory neurones

  • Synapse directly with motor efferent fibres at local spinal level

  • Activate LMNs  contraction

    REINFORCEMENT


Demystifying the neurology examination

Myotomes


Reflexes spinal levels

Reflexes – spinal levels

  • SupinatorC 5-6

  • BicepsC 5-6

  • TricepsC 7-8

  • KneeL 3-4

  • AnkleS 1-2

Plantar reflex


Reflexes spinal levels1

Reflexes – spinal levels

  • SupinatorC 5-6

  • BicepsC 5-6

  • TricepsC 7-8

  • KneeL 3-4

  • AnkleS 1-2

Plantar reflex


Reflexes spinal levels2

Reflexes – spinal levels

  • SupinatorC 5-6

  • BicepsC 5-6

  • TricepsC 7-8

  • KneeL 3-4

  • AnkleS 1-2

Plantar reflex


Reflexes spinal levels3

Reflexes – spinal levels

  • SupinatorC 5-6

  • BicepsC 5-6

  • TricepsC 7-8

  • KneeL 3-4

  • AnkleS 1-2

Plantar reflex


Reflexes spinal levels4

Reflexes – spinal levels

  • SupinatorC 5-6

  • BicepsC 5-6

  • TricepsC 7-8

  • KneeL 3-4

  • AnkleS 1-2

Plantar reflex


Plantar reflex babinski s sign

Plantar reflex – Babinski’s sign

  • Normal = downgoing (flexor)

  • Extensor in UMN lesions

  • Most receptive – posterior 1/3 of the lateral aspect of the sole

  • Dorsiflexion and fanning of other toes


Abdominal reflex

Abdominal reflex

  • Contraction of oblique muscles in response to sensory stimulus

  • Ipsilateral loss in UMN lesions


Sensory pathways

Sensory pathways

  • Posterior columns

  • Spinothalamic tracts


Posterior columns

Posterior columns

  • Travel ipsilaterally to brainstem, then cross to form medial lemniscus and pass to the thalamus

  • Carry:

    • light touch (and 2-point discrimination)

    • vibration sense

    • proprioception (joint position sense)


Spinothalamic tracts

Spinothalamic tracts

  • Axons synapse in the dorsal horn and cross within two levels

  • Then pass to the thalamus and reticular formation

  • Carry:

    • pain

    • temperature


Sensory symptoms

Sensory symptoms

  • Paraesthesia

  • Numbness

  • Pain

  • Quality and distribution suggest site of lesion


Spinal root and cord lesions

Spinal root and cord lesions

  • Root pain

    • Worse with stretch

  • Posterior column lesions

    • Lhermitte’s phenomenon

  • Spinothalamic lesions

    • Dissociated sensory loss

  • Cord compression

    • External (tumour, abcess) or internal (syrinx)


The practicalities

The Practicalities


Clinical examination

Clinical examination

  • Introduction

    • Shake hands (myotonia)

  • General observation

    • Tremor, chorea

    • Obvious wasting

    • Asymmetry

  • ‘Clues’

    • Diabetic accessories

    • ‘White stick’


Cranial nerves2

Cranial nerves

  • Face the patient

  • Observe for:

    • ptosis (NB: myasthenia), asymmetry, scars

  • Go through in logical order

    • (1) 2 ‘3 4 6’ 5(+r) 7 8 ‘9 10 12’ 11

  • Equipment required:

    • Snellen chart, pen-torch, red hatpin, cotton wool, needle, orange stick, tuning fork, opthalmoscope


Clinical abnormalities

Clinical abnormalities

  • Horner’s syndrome

    • Unilateral pupillary constriction, partial ptosis, enopthalmos

  • Causes:

    • Brain stem – pontine glioma, LMS

    • Cervical cord – syringomyelia, tumour

    • T1 root lesions – bronchial apical tumour, cervical rib

    • Sympathetic chain in the neck – neoplastic infiltration, post-surgery, carotid artery occlusion

    • Others - congenital


Occular and pupillary abnormalities

Occular and pupillary abnormalities

  • Argyll Robertson pupil

    • neurosyphilis

  • Holmes-Adie pupil (myotonic pupil)

  • Internuclear opthalmoplegia

    • MS (lesion in MLF)

  • Diplopia

  • Strabismus (squint)

    • Paralytic, non-paralytic


Demystifying the neurology examination

Pontine nucleus of 5

6th nucleus

Pons

7th nucleus

Va

VG

SUPERIOR ORBITAL FISSURE

Medulla

Vb

FORAMEN ROTUNDUM

Spinal cord

FORAMEN

OVALE

Vc

Spinal nucleus of 5


Facial nerve palsies

Facial nerve palsies

  • Part of facial nucleus supplying frontalis receives supranuclear fibres from each hemisphere

  • UMN

    • Upper part of face spared

  • LMN

    • Whole face affected

  • Ramsay Hunt syndrome

  • Hyperacusis


Demystifying the neurology examination

6th nucleus

7th nucleus

Pons

GG

Nerve to stapedius

Medulla

Facial muscles

Spinal cord

Stylomastoid foramen


Demystifying the neurology examination

Relationship between V and VII

5

Pons

6

Va

7

VG

SUPERIOR ORBITAL FISSURE

Medulla

GG

Vb

FORAMEN ROTUNDUM

N to S

FORAMEN OVALE

Spinal cord

CHORDA TYMPANI

Vc

5

Tongue

Facial muscles


Demystifying the neurology examination

 ‘Aldermanic’ nerve

9

10

11


Upper limbs

Upper limbs

  • Visual inspection

    • Wasting, fasciculation, tremor, chorea, burns

  • Test tone

    • ‘cogwheel’, ‘clasp knife’, lead pipe’

  • Power – main myotomes / muscle groups

    • Grade 1–5 out of 5

  • Coordination (need power)

    • “finger-nose”, dysdiadochokinesis

  • Reflexes

    • Supinator, biceps, triceps

  • Sensation

    • L/T, joint position, vibration, pin-prick, temperature


Lower limbs

Lower limbs

  • Visual inspection

    • Wasting, fasciculation, tremor, burns, trophic changes

  • Test tone, clonus

  • Power – main myotomes / muscle groups

    • Grade 0–5 out of 5

  • Coordination (need power)

    • “heel-shin”, “tapping foot”

  • Reflexes

    • Abdominal, knee, ankle, plantar

  • Sensation

    • Include testing for sensory level over abdomen/chest

    • (Perianal sensation, anal tone)

    • Romberg’s test: proprioception NOT cerebellum

  • Gait


Other neurology to test

“Other neurology to test”

  • Higher mental function

    • Speech, memory, recognition, numeracy, emotion

  • Sympathetics and parasympathetics

  • Disorders of micturition

  • Urinary and faecal continence

  • Disorders of sexual function


Demystifying the neurology examination

Cranial nerves

Arms

Legs

Higher mental function

Observation Ex/Pyr

Tone C/Sp

Power C/Sp

Co-ordination Cblr

Reflexes

Sensation

Light touch

Proprioception D/Col

Vibration sense

Pin prick S/Thal

Temperature

Gait


  • Login