neurological exam: still important after all these years eric kraus, md neurology
TRANSCRIPT
Neurological Exam: Still Important After All These
Years
Eric Kraus, MD
Neurology
Neurological “Levels”
Brain Brain stem Spinal cord Motor neuron Peripheral nerve Neuromuscular junction Muscle
Case 1
This is a 62 year-old male with chronic right leg weakness progressing over 6 months.
How do you use the motor exam to localize the problem to either a peripheral or central process?
Motor Exam
Strength Tone Bulk Fasciculations
MOTOR HOMUNCULUS
UPPER MOTOR NEURON
LOWER MOTOR NEURON
MUSCLE
Motor Exam
Central (UMN) Peripheral (LMN)
Strength Decreased Decreased
Tone Spasticity Normal or decreased
Bulk Normal Atrophy
Fasciculations No Yes (motor neuron dis., PN)
Case 1 Revisited
This is a 62 year-old male with chronic right leg weakness progressing over 6 months.
Does changing the history to acute right leg weakness over one day change your findings?
Central (UMN) Peripheral (LMN)
Strength Decreased Decreased
Tone Spasticity Normal or decreased
Bulk Normal Atrophy
Motor Exam
Grading» 5 = normal» 4 = weak with resistance» 3 = antigravity w/o resistance» 2 = less than antigravity» 1 = twitch» 0 = none
Grade only full effort Isolate each muscle
Functional testing Pronator drift Arm rolling test Hoover sign Spasticity in legs Bulk - symmetry and
experience
Case: Facial Weakness
Forehead has bilateral innervation Central weakness
» Pyramidal system» Forehead spared» Palpebral fissure normal
Peripheral weakness» 7th cranial nerve (Facial)» Forehead involved» Palpebral fissure large
– Not ptosis!
» Hyperacusis» Abnormal taste» Mastoid pain
III
CN7
CENTRAL
R
R
L
L
Case 2
This is a 62 year-old male with chronic bilateral leg weakness progressing over 6 months.
How do you use the reflex exam to localize the problem to either a peripheral or central process?
Reflex Exam
Central Peripheral
Reflexes Increased Decreased
Plantar stimulation Upgoing toe Downgoing toe
Upgoing toe = Babinski signUPPER MOTOR NEURON
LOWER MOTOR NEURON
MUSCLE
GOLGI RECEPTOR SENSORY NERVE
Reflexes Revisited
This is a 62 year-old male with chronic bilateral leg weakness progressing over 6 months.
Would changing the history to acute bilateral leg weakness over one day change your findings?
Central Peripheral
Reflexes Increased Decreased
Plantar stimulation Upgoing toe +/- Downgoing toe
Reflex Exam
Grading» 4 = Clonus» 3 = Hyperactive» 2 = Average» 1 = Hypoactive» 0 = none
Symmetry is critical Threshold testing Augmentation
0 3
1 3
0 2
2 2
2+ 2
Reflex Exam
Downgoing» “Mute” symmetrically is normal
Upgoing» Whole leg may flex» Reproducible
Withdrawal?» Movement at ankle, knee and hip» Variable movement» Decrease stimulation may help
Case 3
This is a 48 year-old woman with 2 years of numbness in her feet.
How do you use the sensory history and exam to localize the problem to either a peripheral or central process?
Sensory Exam
Posterior columns» Vibration» Proprioception» Light touch
Spinothalamic tract» Pain» Temperature
DORSAL ROOT GANGLION
POSTERIOR COLUMNSPINOTHALAMIC TRACT
SENSORY HOMUNCULUS
THALAMUS
Sensory Exam
Brain» Hemisensory
Brain stem» Hemisensory» Crossed face - body
Spinal cord» Sensory level» Separation of posterior column -
spinothalamic Peripheral nerve
» Symmetric - length dependent» Symmetric - proximal and distal» Focal or multifocal
DORSAL ROOT GANGLION
POSTERIOR COLUMNSPINOTHALAMIC TRACT
SENSORY HOMUNCULUS
THALAMUS
TRIGEMINAL NERVE
Sensory Exam Subjective Tuning fork Proprioception Sharp stick or pin Romberg Other “cortical” tests
Examples: Sensory
This is a 71 year-old woman with diabetes mellitus who noted onset of numb feet 6 months ago. On exam she can’t feel vibration until the ankle and light touch normalizes at the mid-shin.
Diabetic, length-dependent, peripheral neuropathy.
Examples: Sensory
This is a healthy 31 year-old construction worker who noted onset of numb hands 3 months ago. On exam he has decreased light touch in the thumb, index and middle fingers.
Carpal tunnel syndrome.
Examples: Sensory
This is a healthy 25 year-old woman with subacute onset of numbness from the abdomen down, weak legs, and urinary retention starting 2 days ago. On exam she has a T10 sensory level to pinprick.
T10 transverse myelitis.
Examples: Sensory
This is a healthy 25 year-old woman with subacute onset of numbness from the abdomen down, and weak right leg starting 2 days ago. On exam she has a T10 sensory level to pinprick on the left, and loss of vibration in the right leg.
T8 multiple sclerosis plaque on the right.
Examples: Sensory
This is a 80 year-old man with diabetes mellitus, HTN and hyperlipidemia who noted acute onset of left face/arm/leg numbness 2 hours ago. On exam he has decreased light touch on the left.
Right thalamic stroke.
Case 4
This is a 22 year-old female who feels clumsy.
How can you tell if poor coordination localizes to the cerebellum?
Cerebellar Exam
Very difficult exam» Finger-nose-finger» Heel-knee-shin» Rapid alternating movements » Tandem gait
Interfering issues» Weakness» Sensory loss» Vertigo» Normal imperfection» Side-to-side differences
Case 5
This is a 65 year-old male who keeps bumping into furniture on the left and crashed his car when turning left.
Can bedside visual field testing pick up a defect?
Visual Field Exam
Monocular blindness
Bitemporal hemianopia
Left homonymous hemianopia
Left superior quadrantanopia
Left homonymous hemianopia with central sparing
Visual Field Exam
Methods:» Static» Kinetic
Good (+)LR = 4.2-6.8 Poor (-)LR: Absence of
a defect does not rule one out
Arcuate defect
Case 6
This is a 63 year-old male with trouble walking.
How do you use the gait exam to localize the problem to either a peripheral or central process?
Gait Exam
Peripheral» Nerve
– Peripheral neuropathy
» Muscle– Muscular dystrophy
» Vision– Macular degeneration
» Vestibular– Meniere’s disease
» Joint– Hip arthritis
Central» Pyramidal
– Stroke
» Extrapyramidal– Parkinson disease
» Frontal lobes– Normal pressure hydrocephalus
» Cerebellar– Multiple sclerosis
» Psychiatric– Conversion disorder
Gait Exam
Walk down the hall
Motor Reflexes Sensory Cerebellar Vision
Gait Exam
Peripheral» Nerve
– Foot drop or steppage gait
» Muscle– Trendelenburg or
waddle gait
» Vision» Vestibular» Joint
– Antalgic gait
Gluteus medius
Gait Exam
Central» Pyramidal
– Hemiparetic or circumduction gait
» Extrapyramidal– Shuffling gait
» Frontal lobes» Cerebellar
– Ataxic gait
» Psychiatric
Case: Writing Trouble
Patient 1» Progressive for 2 months» Slow hand movements» No sensory loss
Patient 2» Progressive for 2 months» Slow hand movements» No sensory loss
Writing Trouble
Patient 1» Progressive for 2 months» Slow hand movements» No sensory loss» Right arm 4/5 + drift» Increased reflexes right arm» Action tremor
Patient 2» Progressive for 2 months» Slow hand movements» No sensory loss» No weakness or drift» Normal reflexes» Tone increased (cogwheel)» Rest tremor
Writing Trouble
Patient 1» Progressive for 2 months» Slow hand movements» No sensory loss» Right arm 4/5 + drift» Increased reflexes right arm» Action tremor
Patient 2» Progressive for 2 months» Slow hand movements» No sensory loss» No weakness or drift» Normal reflexes» Tone increased (cogwheel)» Rest tremor
Pyramidal: Brain tumor Extrapyramidal: Parkinson disease
Summary
The neurological exam is not any one part, but rather, the addition of multiple parts to localize the lesion.
Brain Brain stem Spinal cord Motor neuron Peripheral nerve Neuromuscular junction Muscle
CENTRAL
PERIPHERAL
END