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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

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Demystifying the neurology examination

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

  • 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


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


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)


Pupil

Retina

Optic nerve

III

Optic chiasm

Lateral geniculate bodies

Ciliary ganglion

Edinger-Westfahl nucleus

Pretectal nucleus


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


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


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



Reflexes spinal levels
Reflexes – spinal levels

  • Supinator C 5-6

  • Biceps C 5-6

  • Triceps C 7-8

  • Knee L 3-4

  • Ankle S 1-2

Plantar reflex


Reflexes spinal levels1
Reflexes – spinal levels

  • Supinator C 5-6

  • Biceps C 5-6

  • Triceps C 7-8

  • Knee L 3-4

  • Ankle S 1-2

Plantar reflex


Reflexes spinal levels2
Reflexes – spinal levels

  • Supinator C 5-6

  • Biceps C 5-6

  • Triceps C 7-8

  • Knee L 3-4

  • Ankle S 1-2

Plantar reflex


Reflexes spinal levels3
Reflexes – spinal levels

  • Supinator C 5-6

  • Biceps C 5-6

  • Triceps C 7-8

  • Knee L 3-4

  • Ankle S 1-2

Plantar reflex


Reflexes spinal levels4
Reflexes – spinal levels

  • Supinator C 5-6

  • Biceps C 5-6

  • Triceps C 7-8

  • Knee L 3-4

  • Ankle S 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)



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


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


6th nucleus

7th nucleus

Pons

GG

Nerve to stapedius

Medulla

Facial muscles

Spinal cord

Stylomastoid foramen


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


 ‘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


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


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