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Neurological

Examination

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Amr Hasan, MD,FEBN Associate Professor of Neurology -

Cairo University

I. A good clinical history holds the key

to diagnosis.

II. In some neurological disorders, it is

the ONLY avenue to diagnosis

(epilepsy, migraine)

III. Needs Skill & Experience

Make pt at ease: introduce yourself,

exchange social pleasantries, secure privacy.

Be friendly, attentive, courteous (Don’t haste,

interrogate or stereotype).

Analyze & inquire about significant symptoms,

minimize irrelevancies.

Modify your approach according to pt’s

personality, age, education, culture & sex.

Personal History.

Complaint.

Past History.

Family History.

Present History

Name

Age

Sex

Occupation

Marital Status (no.of children & age of youngest)

Residency

Habits

Handedness

NB: ♀ Menstrual history (?reg/duration/flow/pain)

Obstetric history

♂ stress on Special Habits+ Drug abuse.

Prenatal.

Natal .

Postnatal.

Feeding and lactation

Vaccinations

Milestones ( motor, psychic).

Patient’s own wordS.

O. C. D.

The most distressing complaint.

If more than one event…?

Diseases (chronic illness, allergies, admission to hospital(s)).

Operations (type & time, anesthesia, ?blood trasfision, post-

op complications).

Drugs (chronic drug intake/ preceding the onset).

Trauma (mechanism, site, witness/ associated with : altered

consc. convulsions, amnesia, personality changes, mfs of ↟ ICT,

bleeding/CSF leak)

Consanguinity

Similar condition (or risk factors) in the

family⇒ please establish “Pedigree Chart”

Motor

Sensory

Cranial nerves

Sphincters & Autonomic

Coordination

++(pain, abnormal movement , seizures)

Analysis of the complaint(s) :

O C D Onset: acute / subacute/ gradual.

Course: progressive, regressive, stationary, relapsing (duration of attack, frequency, timing (diurnal/nocturnal/seasonal, ⇧⇩fs).

Duration: since(date)….for (duration)

O C D

Distirbution: Uni/Bilateral.

Symm/Asymmetrical

Simultaneous/ Sequential

Distal/ Proximal

Flexor/Extensor

Discrimination: UMN/LMN (early wasting, fasciculation,

flail/stiff)

Degree of severity (ambulation)

Ambulant with out support.

Ambulant with minimum support

Ambulant with maximum support.

Wheel chair.

Bedridden.

Identify presence of weakness/paralysis: ف عضالتك؟/ف الحركة( ثقل)حاسس بضعف

Distibution:

Uni/bilat ....Rt/Lt.....UL/LL: من وال شمال؟ الذراع وال الساق وال االثنن؟/ ف أي ناحة

Symm/Asymm: ف ناحة أكثر من ناحة...نفس الدرجة

Simultaneous/Seaquential:

الضعف ابتدا ف الناحتن ف نفس الوقت وال واحدة سبقت الثانة

Proximal/Distal....

UL

او فتح الباب ...عصر لمونة /قفل برطمان أو زجاجة ماه/ ف صعوبة ف فتح

بالمفتاح؟

شل حاجة ثقلة؟/ربط االشارب / ف صعوبة ف تسرح الشعر

LL

لما تطلع السلم؟/الضعف أكثر لما تقوم من على الكرس من غر ما تسند

الشبشب فلت من رجلك؟

Dicrimination(UMNL/LMN):

الحظت ان عضالتك خست؟ فه رفة ف العضالت بتحس بها أو بتشوفها

حاسس ان جسمك ساب وال مخشب؟

Degree of severity (Ambulation):

تقدر تمش لوحدك وال حد الزم ساعدك وال مابتقدرش تقوم من السرر؟

The condition started 2w ago when the pt

experienced acute onset , regressive course of

weakness of RT UL and LL , such weakness was

D>P,the pt felt his limbs neither flail nor stiff ,

there were no fasiculations, no wasting, no

manifestations as regard the other limbs ,and at the

onset the pt was ambulant with maximum support

and now he is ambulant without support.

O C D

Distribution: Uni/Bilateral.

Symm/Asymmetrical

Simultaneous/ Sequential

Extent (glove&stock/ dermatomal sensory level/ hemi).

Descrimination:

Superficial :+ve⇒parathesia, hyperthesia,allodynia, pricking, burning,electrical

-ve⇒hypo/anasthesia.

Deep: +Rhomberg, Lhermitt symptom, walk on sponge, hesitancy.

Cortical (less common)

Identify presence of sensory affection?

الحظت بتغر ف االحساس

Hypothesia:

احساسك قل؟..

بتحس بالسخن و الساقع وال ضعف؟

Hyperthesia:

فه احساس زائد باأللم؟

Parathesia:

احساس بشكشكة أو حرقان او كهرباء من غر اي سبب؟

Distribution: Uni/Bilat:

فن؟ الناحتن؟ Symm/Asymmetrical

زي بعض ؟ Simmultaneous/sequential

فه ناحة قبل الثانة وال مع بعض؟ Extent

التأثر ده واصل لفن ؟ محزمك ؟ واخد نصف الجسم؟ Deep sensory affection:

لما تغسل و شك الصبح؟/ تتطوح لمل تغمض عنك / ممكن تقع االرض تحت رجلك صلبة وال زي كأنك ماش على رمل أو اسفنج؟ بتحس بكهرباء تسرح ف ظهرك لمل تثن رقبتك فجأة؟

Cortical sensation: جبك؟/ بتقدر تتعرف علع المفتاح جوة الشنطة

The condition was also associated with

diminution of sensation( tingling and

numbness) involving the RT side of the body.

The pt loses his balance on closing his eyes or

on entering a dark room.

The pt is feeling the ground underneath as if

spongy

I : ⇩/ altered smell, olfactory hallucinations.

II : -ve: ⇩vision(blindness), scotomas, field defect.

+ve: scintillations , flashes, unformed/formed hallucinations.

III, IV & VI: ptosis, diplopia, osillopsia

V : ⇩/ altered sesation/pain in face, weak mastication.

VII : ⇩mov facial ms:eye closure/

VIII : ⇩hearing, tinnitus/ vertigo , unstaediness.

IX,X, XI, XII: dysphagia /dysarthria/ dysphonia.

Olfactory nerve:

Diminished olfaction

Altered smell:

بتشم روائح غربة؟ Olfactory hallucinations:

لفترة قد اه؟......ماحدش غرك شممها؟....بتشم روائح وحشة؟

Visual acquity:

ضعف؟/حست نظرك قل

Field of vision:

ممكن بتخبط ف الحاجات و انت ماش؟

Retinal affection:

تغر ف حجم األشاء ؟/انوار/ممكن تشوف خطوط

Colored vision:

الحظت ان رؤتك للوان مختلفة عن االخرن؟

O C D

Distribution: Uni/Bilateral.

Symm/Asymmetrical

Simultaneous/ Sequential

Severity

Painful or not.

Limitation of ocular motility( double vision)

Ptosis

Local eye manifestations: (photophobia, lacrimation, exophthalmos, red eye)

Diplopia بتشوف الحاجة اثنين؟/ فيه ازدواجية في الرؤية

برضه بتشوف صورتين؟, لما تغمض عين واحدة

الصورتين جنب بعض وال فوق بعض ؟

ازدواجية الرؤية بتزيد لما تبص في ناحية معينة

أو تتحسن في وضع معين؟

O C D Monocular or binocular. Corrected with closure of one eye or not. 2 images ( next to each other, above each

other). False and true image. Painful or not. Diminution of vision. Ptosis. Local eye manifestations: (photophobia,

lacrimation, exophthalmos, red eye).

Pupillary affection

عنك بتزغلل ف الشمس؟

Oscilopsia

ممكن تحس الصورة بتهتز امامك؟

Ptosis:

الحظت ان جفنك سقط ؟

O C D

Distribution: Uni/Bilateral.

Symm/Asymmetrical

Simultaneous/ Sequential

Partial / complete

Painful or not.

Limitation of ocular motility( double vision)

Diminution of vision.

Local eye manifestations: (photophobia, lacrimation, exophthalmos, red eye)

حاسس ان وشك منمل؟ فه ناحة فارقة عن التانة؟

بتعرف تمضغ االكل كوس ؟

لسانك كمان حاسس انه منمل؟ فن؟

بتعرف تقفل عنك كوس؟ حد الحظ ان عنك مش بتقفل كوس و انت

نام على غر العادة؟

الحظت ان نص وشك مش بتحرك زي النص اآلخر؟

حست ان سمعك قل؟

طنن ف احدى األذنن؟/ زن /بتحس فه وش

؟(انت أو الل حوالك)هل فه احساس بالدوار

هل ف احساس بعدم االتزان؟

Dysathria (nasal tonation):

حست ان صوتك اتغر؟ فه خنفان؟

Dysphagia to liquids:

(اي سا ئل)تشرق لما تشرب الماه

Nasal regurgitation:

من منخرك؟( ترجع)الماه ممكن ترد

UL ⇒ intention tremors↟on reaching target

(keys to locker, spoon to mouth), difficult

buttoning.

LL ⇒clumsiness, staggering, wide base gait.

Dysathria ⇒ Staccato

UL ataxia

أو الباب ف المفتاح تحط تج لما مثال بتزد أدن أو اد ف رعشة فه

بالمعلقة؟ شمورب تشرب

Dysarthria(staccato)

اتغرت؟ كالمك طرقة ان الحظوا االخرن أو الحظت

LL ataxia

ناحتن؟ أو لناحة تتطوح بتمش

UMNL: acute ⇒retention, gradual ⇒precipitancy

Post col.: hesitancy

Autonomic manifestations:

1. Altered taste/ satiety/vomiting

2. CVS: postural hypotension/palpations

3. Skin: altered sweating, flushing, trophic changes

4. GIT: delayed emptying, diarrhea/constipation

5. Genitalia: erectile dysfunction, ⇩libido & orgasm

حصل ان البول اتحبس فك؟ لمدة قد اه؟ كان فه ألم؟

عندك احساس بالبول لكن ما تقدرش تفضه؟

هل البول بسب منك على فترات على مدى الوم؟

هل البوا مغرقك على طول؟

البراز فلت منك ؟ كله؟ ماتقدرش تحكم نفسك؟/ممكن البول

ممكن تتحال على البول علشان نزل؟

عندك احساس انك محتاج تروح الحمام باستمرار .

Pain/Headache:

1. OCD.

2. Character, site, radiation.

3. ⇧, ⇩, assosciation

4. Relation (sleep/stress: mental, physical & psychological/ posture).

5. Severity (interrupt sleep/interfere with DLA)

Abnormal mov

(slow/fast, regular/irregular, postural/twisting/pseudopuposeful/ ? coordinated& stereotyped, hyper/hypotonic )

History is the most important part of Neurological evaluation, that guides to establish:

• Focal

• Systemic

• Dissiminated

Anatomical

diagnosis

• Heredofamilial

• Symtomatic

• Idiopathic

Aetiological

diagnosis

Anatomical diagnosis

Focal Systemic Dissiminated

Dissimination in time

Dissimination in place

Dissimination in time

and place

12/24/2016 42

1. The anterior (ventral) horn cell (MND)

2. The radicle (root). 3. The peripheral nerve. 4. The neuromuscular junction. 5. The muscle.

5

4

2

1

2

2

3

Where is the lesion

•Cortical

•Sub-cortical

•Cerebellar

•Brainstem

•Spinalcord

•AHC

•Roots

•PN

•Neuromascular Junstion

•Muscle

Cortical: loss of consc/ convulsions/

aphasia/cognition and behavioral dis/

incomplete motor/ cortical sensory loss.

Subcortical: complete motor/ all 1ry

sensations/ visual field defect

Cerebellar: staccato speech/ intension

tremors/ wide base gait.

Brainstem: ipsilat. Cranial nv

lowemotor+contralat. Hemiparesis(hypothesia)

Spinal cord: sensory level , below UMN,

sphinchteric troubles

AHC: fasiculations, weakness of LMN nature ( +/-

UMNL)

Roots: radicular pain, Asymm , dermatomal motor

& sensory loss, ↟ with stretch.

PN: usually symm, motor (LMN), sensory(glove &

stock).

N-M junction: motor only, fatigability, diurnal

Muscle: motr only (>px) mild ⇩ tone and atrophy.

Hereditary

Symptomatic Vascular

Infection

Trauma

Toxin/Drugs

Autoimmune

Metabolic

Endocrinal Nutritional

Neoplastic-paraneoplastic

Congenital

Idiopathic

SCAN

FILTER

ARRANGE

STAMPS

Old classification :

Based on:

Degree of disturbance of consciousness.

Response to external stimuli.

Response to Increased verbal stimuli

impaired Lethargy or drwsiness

Response to Vigorous and continuous verbal stimuli

Impaired Stupor

No response to verbal stimuli only reflex to painful stimuli

Lost Semi coma

No response to verbal or painful stimuli

lost coma

GLASGOW COMA SCALE:

Motor response Verbal response Eye opening

Obeys orders 5

Oriented 5

Spontaneous 4

Localise to pain 4

Confused 4

In response to speech 3

Flex to pain 3

Words no sentences 3

In response to pain 2

Extend to pain 2

Sounds no words 2

None 1

None 1

None 1

Watch the patient while taking history.

Q1:Are there signs of self neglect?

Dirty ,unkempt (depression, dementia, drug abuse)

Q2:Does the patient appear anxious?

Restlessness

Q3:Does the patient behave appropriately?

Overfamiliarity ,disinhibited (frontal lobe)

Unresponsive ,little emotional response (depression)

Mood: inner feeling. (history taking)

Affect: outword expression. (examination)

Q:How are your spirits at the moment?

Q:How can u describe your mood?

Abnormalities :

Depression.

Euphoria.

Emotional labilty.

Apathy or indifference.

Orientation: For time ,place and person . Q1:What date,day,month,season,year,time of

the day? Q2:What place,town? Q3:What your name,ask about

persons(familiar and nonfamiliar) Attension: Passive: external stimulus

Active: digit span.

A:immediate memory: ◦ “I will tell u 3 word and u repeat them”

◦ Name and adress test.

◦ Digit span.

B: short term(recent) memory. ◦ 5 minutes later ,ask about the 3 words or name and

adress.

◦ Events in last 24 hrs “what did u have for breakfast”.

C: remote memory: ◦ Old events e.g. who was the first president of Egypt

Abnormalities: AMNESIA ◦ Anterograde : loss of immediate and recent events.

◦ Retrograde :loss of remote events

◦ Transient global amnesia:

Causes : ◦ Dementias: Alzheimer’s disease ,vascular dementia.

◦ Tempora lobe lesions,

◦ Post concussion.

◦ korsakow’s syndrome with chronic alcoholism.

Serial seven test :

Ask the patient to take 7 fro 100 thentake 7 from what remains.

Q1: Ask patient to explain well known proveb.

Abnormality:

Concrete thinking.

Causes:

Frontal lobe lesions

Dementias.

Ask the patient about Illusions and Hallucinations

Illusion: misinterpretation of external stimuli

Hallucinations: perception without external stimuli (olfactory,visual,auditory,gustatory,somatic)

Test for AGNOSIA e.g.

Facial recognition “prosopagnosia”

Body perception “asomatagnosia, finger agnosia,lt/rt agnosia”

Thought flow:

refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought.

Thought content:

content would describe a patient's delusion, overvalued ideas, obsessions, phobias and preoccupations.

The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options.

insight can be said to have three components: ◦ recognition that one has a mental illness,

◦ Compliance with treatment, and

◦ the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological

Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions.

Ask the patient "what would you do if you found a stamped, addressed envelope lying in the street?"

The patient is fully conscious, well oriented for time place

and person, with normal memory and

mood, he is cooperative and avarege

intelligence.

How to examine? ◦ Familiar substance

◦ Non irritant

◦ Each nostril alone

• Anosmia • Unilateral :

• traumatic, • Inflammatory

• neoplastic: Foster-Kennedy syndrome

• Bilateral : •ENT, •Hereditary, •Hysterical

• Parasomia

•Olfactory hallucination is due to central olfactory dysfunction

Visual acuity

Colour vision

Visual field

Fundus examination

Snellen chart

Counting fingers 6 meters to 30 cm.

Hand movement. Perception of light.

Ishihara colour plates

NORMAL FUNDUS

Normal

Confrontation method

Automated perimetry Bjerrum screen.

Monocular blindness

Bitemporal hemianopia

Contralateral homonymous hemianopia

Loss of vision with optic atrophy

Bitemporal hemianopia

Contralateral homonymous hemianopia Hemianopic pupillary reaction

Contralateral homonymous hemianopia with Macular sparing

Contralateral homonymous hemianopia preserved pupillary reaction

How to examine

◦ Ocular movements

Individual

Gaze

Ptosis

◦ Pupils

External ophthalmoplegia Internal ophthalmoplegia NB: compression: early mydriasis

and lost light reflex infarction: pupillary reflex

intact

Abducent nerve palsy Trochlear nerve palsy

Partial Complete

Block the action of frontalis to differentiate between partial and

complete ptosis.

Ask the patient to look at you finger placed: laterally, upwards and downwards.

Comment on: ◦ Is it sponteneous or fixational

◦ If it has slow and rapid phases

◦ Direction

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Size, shape, symmetry

Response to direct and indirect light reflex.

Accomodation reaction.

Cilio-spinal reflex

Miosis Mydriasis

Horner syndrome ◦ Congenital

◦ acquired

Pontine lesion

Opiate toxicity

Argyl-Robinson pupil

Diminution of vision. Drugs Hemianopic pupillary

defect Compression of 3rd

nerve. Adie pupil

Argyl-Robinson pupil Adie pupil

Motor part Sensory part

Temporalis

Masseters

Pterygoids

Pain -------touch Both sides of the face Ophthalmic, maxillary,

mandibular branches. The inner----- outer

part of the face

Pons

Spinal cord

medulla

Sensory supply of the face

Motor

Sensory D reflex

S reflex

Jaw reflex Corneal and conjunctival reflexes

Exaggerated jaw reflex

Blinking of both eyes

Absence of blinking on one side

Absence of blinking on both sides

Corneal

reflex

St.

Aff

C )MSN→MFN(

Eff

R •Corneo-mandibular

(jaw winking)

•Corneo oculogyric

Reflexes

Jaw deviation Herpes zoster ophthalmicus

How to examine ◦ Muscle power

Frontalis…..orbicularis oculi

Orbicularis oris, buccinator, retractor anguli

◦ Reflexes

Glabellar reflex

Corneal reflex

◦ Taste sensation

Stylohyoid

Post. Belly of

diagastric

Stapidus

Site of the lesion: Nuclear Cerebellopontine Facial canal Extracranial facial lesion

Paralysis of the muscles of the upper and lower parts of the face Affecting voluntary, emotional and associated movements.

It is not known which pathways mediate mimetic (involuntary) innervation of facial muscles.

virus reactivation.

Sympathetic vasospasm

Marcus Gunn jaw

winking

Cochlear part

Vestibular part

Vestibular dysfunction Caloric test

Vertigo

Central

Brain stem

VBI

PICA

MS

encephalitis

Cerebral

TLE

VASCULAR

Peripheral

Labryinthine

PHYSIOLOGICAL

Labrynthitis,

Meniere

Peripheral nerve

CPA LESIONS

VESTIBULAR

NEURITIS

Deviation of the palate

Palatal reflex

Pharyngeal reflex

Swallowing water

Examination of trapezius.

Examination of sternomastoid.

Inspect the tongue for: Deviation.

Wasting.

Fasiculations.

Abnormal movement

Evidence of systemic disease

Test for the power

The motor system evaluation is divided into the following:

Inspection:

◦ Body positioning,

◦ Muscle state [ wasting or hypertrophy],

◦ Involuntary movements, fasciculations.

◦ Skeletal deformities

◦ Trophic changes

Muscle tone.

Muscle strength.

Inspection

hemiplegic posture Parkinson disease

Distribution ◦ Focal in one area

◦ Generalized Proximal

Distal

Unilateral or bilateral

Symmetrical or not

.

Look for skeletal deformities e.g. pes cavus,scoliosis .

Distribution

Rest , postural, action .

Frequency.

Amplitude.

Rhythmic or not

What increase or decrease them

..\..\p\all\PATIENTS\CLIPS\ex\static tremors.mp4

Tone

A: upper limbs: ◦ Shoulder: Gower’s method

◦ Elbow: passive flexion and extension.

◦ Wrist: shaking ,passive flexion and extension.

B:lower limbs: ◦ Hip: rolling

◦ Knee: hooking, passive flexion and extension.

◦ Ankle :shaking , passive flexion and extension.

Hypotonia Hypertonia ◦ Spasticity [ clasp knife] ◦ Rigidity Cogwheel

Lead pipe

Dystonia Myotonia Catatonia Stiffness [ meningeal irritation, stiff person

syndrome]

REFLEXES

Upper limb Lower limb

Biceps reflex

Brachioradialis reflex

Triceps reflex

Supraspinatous reflex

Finger reflex

Knee reflex Ankle reflex Patellar reflex Adductor reflex

Reinforcement

Clonus

Ankle Patellar wrist

Organic ===hysterical

Planter reflex ◦ Babiniski method

◦ Chaddok method

◦ Baradah method

◦ Oppenhime method

◦ Gordon method

◦ Schaefer method

Abdominal reflexes

Cremastric reflex

Gluteal reflex

Anal reflex

Rate the reflex with the following scale:

5+ Sustained clonus

4+ Very brisk, hyperreflexive, with clonus

3+ Brisker or more reflexive than normally.

2+ Normal

1+ Low normal, diminished

0.5+ A reflex that is only elicited with reinforcement

0 No response

0 : No muscle contraction is detected 1 : A trace contraction is noted in the muscle by palpating the muscle while the patient attempts to contract it. 2 : The patient is able to actively move the muscle when gravity is eliminated. 3 :The patient may move the muscle against gravity but not against resistance from the examiner.

4 :The patient may move the muscle group against some resistance from the examiner.

5 :The patient moves the muscle group and overcomes the resistance of the examiner. This is normal muscle strength.

Power

Examination Technique: •power or strength is tested by comparing the patient’s strength against your own.

•compare one side to the other.

•grade strength using the Medical Research Council (MRC) scale.

MRC Scale

Grade Description

0 no contraction

1 flicker or trace of contraction

2 active movement with gravity eliminated

3 active movement against gravity

4* active movement against gravity and resistance

5 normal power

Shoulder ◦ Adduction

◦ Abduction

◦ Flexion

◦ Extension

◦ Lateral rotators

◦ Medial rotators

◦ Serratus anterior

Elbow ◦ Flexion

◦ Extension

Wrist ◦ Flexion

◦ Extension

Hand ◦ Thumb

◦ Intreossei

◦ Lumbricals

Hip ◦ Flexion

◦ Extention

◦ Adduction

◦ Abduction

Knee ◦ Flexion

◦ Extention

Ankle ◦ Dorsiflexion

◦ Planterflexion

◦ Inversion

◦ Eversion

COORDINATION

In the upper limb Lower limb

Finger to nose, to finger, to doctor finger. Assess decomposition,intention tremors and dysmetria.

Dysdiadokokinesia

Rebound phenomena

Buttoning and unbuttoning

Heel to knee test Walking straight Romberg test

For pain use pin prick, for touch use a cotton piece

Comapre ◦ Both sides……….if you are suspecting for hemihypthesia ◦ Lower limbs trunk upper limbs…….if you are suspecting

a level or jacket sensory loss ◦ Distal to proximal if you are suspecting socks and glove

distribution. ◦ Each radicle ( dermatomal suply) if you are suspecting

radiculopathy. ◦ Sensory area of each nerve if your are suspecting nerve

injury ◦ Do not forget examining the saddle rea

Deep senstion Cortical sensation

Vibration sense

Joint sense

Muscle sense

Nerve sense

Romberg test

Tactile localization Two points

discrimination Stereognosis Graphosthesia Perceptual rivalry

Root Action Muscles

L2 Flexor of the hip Ileopsoas.

L3 Extensor of the knee Quadriceps

L4 Dorsiflexion of the ankle Anterior tibial group

L5 Dorsiflexion of the toes Anterior tibial group & glutei

S1 Plantar flexion of the ankle and toes Calf muscles & glutei

S2 Flexor of the knee Hamstrings

S3, 4, 5 Anal contraction Anal and perianal muscles

Root Sensory

L1 Upper third of the front of the thigh.

L2 Middle third of the front of the thigh

L3 Lower third of the front of the thigh.

L4 Antero-lateral aspect of the thigh, Front of the knee, of the knee , Antero - Medial

aspect of the leg, medial aspect of the dorsum of the foot and the foot and big toe.

L5 Lateral aspect of the thigh and leg, Middle third of the dorsum of the foot and

Middle three toes.

S1 Postero-lateral aspect of the thigh and leg, Lateral third and little toe .

S2 Posterior aspect of the thigh and leg and sole of the foot.

S 3,4, 5 Anal, perianal and gluteal region (saddle-shaped area).

Meningeal Irritation tests

Circumduction

Scissor

High steppage

Waddling

Stamping

Wide base

Deviation or zigzag

Short steppage

Dancing

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