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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

slide2
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
slide4
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

slide5
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)
slide11
Pupil

Retina

Optic nerve

III

Optic chiasm

Lateral geniculate bodies

Ciliary ganglion

Edinger-Westfahl nucleus

Pretectal nucleus

slide12
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
slide23
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
slide25
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
slide49
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
slide51
6th nucleus

7th nucleus

Pons

GG

Nerve to stapedius

Medulla

Facial muscles

Spinal cord

Stylomastoid foramen

slide52
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

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
slide58
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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