Approach to examination of the neurological system

Dr Nortina Shahrizaila Consultant Neurologist University of Malaya Medical Centre

5 Possible Scenarios
Please examine this patients..
1. Eyes 2. Cranial nerves excluding the eyes 3. Speech 4. Upper or Lower Limb 5. Cerebellar system

Motor Nervous System

CEREBRAL HEMISPHERES BRAINSTEM/CEREBELLUM
N M J HEAD + NECK MUSCLES

CRANIAL NERVES

SPINAL
CORD
SPINAL NERVES

N M J

LIMB MUSCLES

UMN

LMN

Cranial Nerves and Speech

SCENARIO 1
Please examine this patients eyes

Examiners want to see if you can do a thorough eye examination.

System
Inspection
Optic nerve (II) Eye movements (III, IV, VI)

Inspection
Clues by bed
Eyepatch: diplopia Magnifying glass: poor acuities

Face
Ptosis Pupil size / symmetry

 TIP 1
Whenever you see asymmetrical pupils, look for ptosis

TIP 2
Whenever you see ptosis, look at pupil sizes

Pupil size and Ptosis : 4 Patterns

small pupil and ptosis
Horners (sympathetic lesion)

large pupil and ptosis

3rd nerve palsy (eye usually down&out aswell)

- unequal pupils BUT no ptosis - ptosis BUT equal pupils

Usuallly Holmes Adie pupil (parasympathetic lesion) large at onset shrinks with age Think Myasthenia Gravis (levator palpebrae)

II
Acuity Fields Fundoscopy Pupillary reflexes

Id like to formally examine vision with a Snellen chart

60

36 24 18 12 9 6 5

Visual Fields
L

ANTERIOR

Optic Nerve

2. Bitemporal hemianopia

Chiasm
3

3. C/l Homonymous hemianopia

3

Optic Tract Occipital Cortex

POSTERIOR

Visual Fields

Id like to assess the fundi

Normal

Optic Atrophy

Causes
1. MS

2. Chronic raised ICP

Papilloedema

Causes
1. Raised ICP 2. Hypertension

Pupil reflexes
Light (direct + consensual)
Normal pupil
constricts to light, dilates to dark

Failure to constrict or dilate

Implies severe optic nerve lesion

Relative failure to constrict in light (RAPD)

Implies moderate optic nerve lesion
Shine light on each eye in turn Consensual dilation to dark in an affected pupil overrides impaired direct constriction to light => affected pupil dilates despite light

Accommodation
Failure suggests Holmes Adie or 3rd N palsy

III, IV, VI
Eye movements
Range Diplopia Nystagmus

Eye Movements: Patients right eye

ABduction ADduction

3 6 3

Partial right-sided ptosis R pupil >> left

R eye looking down +/- out So this is a (partial) right-sided 3rd (oculomotor) nerve palsy

Summary
II
III,VI Ptosis

Horners (CxR); RAPD (MRI)

Recognise; DM (BM, BP, MRI) U/l: Horners (CXR) B/l: Myasthenia (Ach R ab, EMG), Myotonic dystrophy (gene test)

Scenario 2
Please examine the cranial nerves excluding the eyes

System
Inspection I V VII VIII IX-X XI XII

I
Have you noticed any change in your sense of smell?
If yes, may be due to frontal lesions (eg tumour), or neurodegenerative conditions (Alzheimers, Parkinsons)

V
Sensory Motor Reflex

Sensory supply of face

NB. V1 supplies tip of nose

NB. V3 does not supply angle of jaw

C2

 Test sensation in each division

Ideally with a pin

Clench teeth
Feel masseter & temporalis

Ask to open mouth

Watch for deviation (to weak side) Resist closure

I would like to examine the corneal reflexes

VII
Motor Distinguish between UMN & LMN

Inspection

VIII
Test with whispered numbers or finger rub Cover c/l ear
If u/l hearing loss, say I would like to perform Rinnes and Webers tests to distinguish between sensorineural and conductive deafness

Interpreting Rinnes
Normal
AC > BC

Sensorineural
AC > BC

Conductive
BC > AC
NB. Webers test just confirms conductive deafness

IX - X
IX
Sensory (gag)

X
Motor (uvula)

 I would like to test the gag reflex

Ask patient to say Aaah
Uvula pulled away from weak side Complete failure to elevate suggests b/l palatal weakness

XI
Trapezius
Shoulder shrug

Sternocleidomastoid
Turn your head against my hand Remember you are testing muscle on opposite side

XII
Inspection (in mouth) Deviation Strength Speed

Tongue deviates to left Strong (R) side pushes weaker (L) side past the midline So this is a left-sided 12th (hypoglossal) palsy

Summary
I, IX,X,XI V VII very rare stroke; MS UMN: stroke LMN: Bells sensorineural: age, neuroma conductive: wax, otitis media stroke; MND

VIII

XII

Scenario 3
Please examine this patients speech

System
Easy question Free speech: Comprehension Naming Consonants Phrases (eg name, address) listen carefully! (increasing sophistication) (increasing sophistication) (p, t, k) (british constitution, baby hippopotamus, west register st)

Fluent
Comprehension intact
Normal Receptive dysphasia

Comprehension affected

Non-fluent
Naming problems
Expressive dysphasia Dysarthria

Articulation problems

Types of Dysarthria
Cerebellar
Explosive (poor control of volume) Staccatoed

Bulbar/Pseudobulbar
Nasal Strangled

Parkinsonian
Quiet Mumbled

Summary
Dysphasia
Dysarthria
Consonant Cerebellar
Bulbar/Pseudobulbar Parkinsonian

Stroke (CT)

VII, IX-X, XII (MRI) MS (MRI), tumour (CT), genetic (gene test) MND (EMG), Strokes (MRI) Myasthenia (Ach R ab, EMG) Parkinsons! (clinical)

Limbs & Cerebellum

Scenario 4
Please examine this patients upper / lower limbs

Upper or Lower Limb

Aims a) localise the lesion
R or L Motor or sensory (or both) If motor, UMN or LMN (or both)

b) give a reasonable differential based on that lesion site (s)

 So you need an anatomical / structural overview of the nervous system And a list of 3-4 differentials for each site

Structure of (motor) nervous system

Brain Spinal cord Anterior horn cell Nerve root / plexus Peripheral nerve Neuromuscular junction Muscle

Structure

Main differentials per part

Brain and cord

MRI

Vascular (stroke) Tumour Central demyelination (multiple sclerosis) Infection (herpes encephalitis, zoster myelitis) Degenerative disease (Parkinsons, Alzheimers)

Anterior horn cell

MND Infection (polio)

NCS/EMG

(NCS / EMG = Nerve conduction studies / Electromyography)

Structure

Nerve root / plexus

Intervertebral disc Tumour Demyelination (Guillain-Barre) Infection (Lyme)

NCS/EMG

Peripheral nerve
Diabetes Alcohol/drugs Genetic (Charcot-Marie-Tooth) Peripheral demyelination (Guillain-Barre) Infection (syphilis)

NCS/EMG

 Neuromuscular junction (NMJ)

Antibody (myasthenia, LEMS) Infection (botulism, diphtheria) AChR Ab Culture

Muscle
Genetic Muscular dystrophy Myotonic dystrophy Mitochondrial myopathy Myositis Gene test Gene test Muscle biopsy CK, ENA

Conventional system of Examination

Inspection Tone Power Reflexes Coordination Sensation

Inspection

 Bedside
Walking aids

Patient
Wasting & Fasciculations (LMN) Spotters
Parkinsons Myasthenia gravis Myotonic dystrophy

LMN
Wasting

Fasciculations

Parkinsons
Reduced facial expression
Rest tremor Bradykinesia ( if undertreated) Dyskinesia ( from treatment)

Myasthenia gravis
Ptosis (u/l or b/l) Difficulty rising from chair with arms folded

Myotonic dystrophy
Bilateral ptosis Grip myotonia Tent-shaped mouth

Tips 1 and 2
Best ways to start a limb examination
For UL exam
First test arms outstretched

For LL exam
First test gait

UL exam

Outstretched arms - 4 signs:

Hemiparesis
Pronator drift
Palms up

Gross weakness
Subtle UMN weakness Cerebellar sign

Rebound

Pseudoathetosis
Proprioceptive loss

LL exam

Funny walks
Ataxic

Broad base

Shuffling
Waddling

Parkinsonian
Myopathic

Stamping
High stepping Circumduction Antalgic

Neuropathic
Foot drop UMN Non-neurological / functional

Tone
Upper Limbs
Elbow: flexion / extension, feel Wrist: flexion / extension & rotation, feel

Lower Limbs
Knee: Knee: Ankle: Ankle: flex hip quickly, observe for heel lift from bed flexion / extension, feel roll thigh, observe movement rapidly flex knee and ankle, observe for clonus

Tone

Abnormal tone
Reduced (Flaccid)
Difficult unless clear asymmetry

Increased
Clasp knife (Spastic) Lead Pipe / Cogwheel (Rigid)

Tone

Clasp Knife vs Lead Pipe

Pyramidal
Sudden give/catch

Extrapyramidal
Even resistance

Power
Start proximally, work distally Compare R with L Isolate the joint when testing
UL SAB
EF/EE WE FAB Thumb abduction

LL
HF/HE KF/KE DF/PF

Power

MRC Grading
0 1 2 3 4 5 no muscle or joint movement muscle contraction only joint movement (gravity removed/aided) joint movement (despite gravity) joint movement (despite resistance) full power

Power

Tip 3
Interpreting power findings
Look for patterns of weakness

Patterns of Weakness
Focal v Diffuse

Nerve or nerve root

Proximal v Distal?

Muscle

Neuropathy

Neither

Pyramidal (UMN)

Non-specific

Patterns of Weakness

Focal weakness
Wrist drop
Radial nerve palsy C7 radiculopathy

Foot drop
Common peroneal nerve palsy L5 radiculopathy

Patterns of Weakness

Proximal v Distal
Proximal
Muscle / Neuromuscular junction EXCEPTION: Myotonic dystrophy

Distal
Peripheral Neuropathy AND Myotonic dystrophy

Patterns of Weakness

UMN
Posture
Flexed, Pronated arm

Anti-Gravity Muscles> Antagonistic muscles

Extended, Adducted leg

Reflexes
Hold Tendon hammer loosely
Compare sides Practice reinforcement Babinski
Scratch outside of foot and round below toes Observe the first movement of the big toe only

Reflexes

Root levels
(1 2 3 4 5 6 7)
Ankle Knee Biceps Supinator Triceps S1 L2,3,4 C5,6 C5,6 C7

Reflexes

Interpretation
Absent (after reinforcement)
LMN lesion Very helpful sign But remember acute UMN areflexia

Brisk
Normal: Young, anxious Abnormal: UMN
Especially if asymmetrical

Coordination (see later)

Upper Limb
Finger-nose Dysdiadochokinesia (DDCK)

Lower Limbs:
Heel-shin Tandem gait

Sensation
Difficult! This will be taken into account. Learn the dermatomes & practice them

Ensure you test

Pin Prick Proprioception (including Rombergs test) Id like to test vibration sense using a tuning fork Id like to test temperature sense using hot and cold water in suitable containers

Sensation

Tip 4
Once again, look for patterns!

Sensation

1. Glove and stocking

peripheral neuropathy

2. Dermatomal
root lesion cord lesion (sensory level)
T4 (nipples) T10 (umbilicus)

3. Romberg
Implies proprioceptive or vestibular failure, NOT cerebellar disease

Scenario 5
Please examine this patients cerebellar system

Cerebellum

System
Speech Eyes Arms Legs Gait

Cerebellum

Speech
How did you get here today Repetition
British Constitution West Register Street Baby hippopotamus

Usually a mix of non-fluent, staccato, variable volume, monotone pitch

Cerebellum

Eyes
Nystagmus
Increases towards side of cerebellar lesion

Eye movements
Pursuit (slow tracking movements) Follow my finger
Broken, jerky

Saccades (rapid finding movements) Look left, right, up, down

Overshoots

Cerebellum

Arms
Fingernose
Tip of nose to tip of finger as quickly and accurately as possible
Observe past-pointing, intention tremor (NB,. If tremor seen, check rest & postural components)

DDCK
Tap your hand like so (demonstrate) as fast as possible
Observe errors

Legs
Heel-shin
Place your heel onto your knee Then run it down your shin As quickly and accurately as possible Observe: overshooting

Cerebellum

Gait
First test truncal ataxia on bed
Ability to sit upright unsupported

Then stand them, observe base Then ask to walk normally, observe base Assess balance, especially on turns Ask to walk heel to toe (tandem), unless too unsteady

Observe: broad base, unsteady turns & tandem

Cerebellum

Causes?
Same as for rest of brain: Stroke MS Tumour Infection Degenerative (genetic)

SUMMARY

 Limited number of clinical scenarios

Eyes Cranial nerves except the eyes Speech Limbs Cerebellum Spotters (ptosis, mask-like face & gait)

Summary

Tip 5
Dont be too specific with the diagnosis
Identify the site of the lesion from the findings Then reel off your pre-prepared differential

Motor summary
UMN (Corticospinal) Inspection UL flexed LL extended Spasticity Pyramidal weakness Brisk Babinksi+ Ataxic Circumducts Festinant Reduced armswing Bradykinesia Soft voice Broad based Waddling Basal ganglia Cerebellar Anterior horn, root, nerve Wasting Fascics Reduced Distal weakness Absent Proximal weakness Proximal weakness Absent Neuromuscular junction Ptosis Muscle Rest tremor Mask-like face Lead pipe/ cogwheeling Titubation Ptosis Wasting

Tone Power Reflexes Coordination Gait

Additional Features

Pronator Drift

Dysarthria Nystagmus

Fatigueable

Be polite Be confident Be complete Be accurate Be sensible Be succint

(with patient) (with examiner) (with examination) (with findings) (with diagnosis & DD) (with investigations)