NEUROLOGICAL EXAMINATION

The ultimate goal:

To find out WHERE is the lesion? A. Level the lesion along the neuraxis B. Lateralize the lesion C. Localize the lesion To figure out the pathophysiology of the lesion disturbance in function To discover the pathology WHAT is the lesion?

COMPONENTS OF THE NEUROLOGICAL EXAMINATION

Cerebral Examination / Mental Status Examination Speech, Level of consciousness, Attention and Orientation, Memory processing, Calculation, Abstract thinking, Fund of information Cranial Nerve Examination CN I to XII Motor System Examination, including Cerebellar tests Inspection of body position, Involuntary movements, muscle bulk, Muscle Tone, Manual Motor Testing, Coordination and Gait

COMPONENTS OF THE NEUROLOGICAL EXAMINATION

Sensory System Examination Light touch, pain and temperature, position and vibration senses, Discrimination modalities

Muscle Stretch Reflexes Deep tendon reflexes Other Significant Findings Signs of meningeal irritation, primitive reflexes, superficial reflexes

Equipment needed for neurological examination

Whats missing?

Mental Status Examination

1. Speech Phonation Articulation Language Production 2. Level of consciousness 3. Attention and Orientation 4. Memory processing Immediate recall Recent Memory Remote Memory 5. Calculation 6. Abstract thinking 7. Fund of information

Speech
PHONATION - is the production of sounds as the air passes through the vocal cords Disorder: dysphonia ARTICULATION - is the manipulation of sounds as it passes through the upper airways by the palate, tongue, and the lips to produce phonemes Disorder: dysarthria

LANGUAGE PRODUCTION - the organization of phonemes into words and sentences, and is controlled by the speech centers in the dominant hemisphere Disorder: dysphasia or aphasia

Level of Consciousness
Alert Lethargic Obtunded Stuporous Coma = awake, fully aware and responsive; normal waking consciousness = responds when spoken to, may drift to sleep if no stimulation = may awaken to voice but is minimally responsive when doing so = difficult to rouse, may groan or become restless to brief pain = pt is unresponsive or may show abnormal response to voice or pain

GLASGOW COMA SCALE

Eye Opening Score

spontaneously to verbal stimuli

to pain never Best Verbal Response oriented and converses disoriented and converses inappropriate words incomprehensible sounds

4 3
2 1 Score 5 4 3 2

no response

GLASGOW COMA SCALE

Best Motor Response obeys commands localises pain flexion withdrawal abnormal flexion (decorticate rigidity) extension (decerebrate rigidity) no response

Score 6 5 4 3 2 1

ORIENTATION
DEFINITION: capacity to identify and recall one's identity and place in time and space ASSESSMENT: directed questions

TIME PLACE

Do you know what date it is? "Can you tell me where you are right now?" PERSON Who is that man standing beside you? Who am I?

CRANIAL NERVE EXAMINATION

1st CN 2nd CN 3rd CN 4th CN 5th CN 6th CN 7th CN 8th CN 9th CN 10th CN 11th CN 12th CN Olfactory Optic nerve Occulomotor Trochlear Trigeminal Abducens Facial Vestibulolocochlear Glossopharygeal Vagus Spinal accessory Hypoglossal

CRANIAL NERVE I (OLFACTORY NERVE)

The olfactory nerve is a special afferent cranial nerve composed of sensory fibers only. Its sole function is to discern smells. Olfaction depends on the integrity of the olfactory neurons in the roof of the nasal cavity and their connections through the olfactory bulb, tract, and stria to the olfactory cortex of the medial frontal and temporal lobes.

To test olfaction: 1.An odorant, such as concentrated vanilla, perfume or coffee, is presented to each nostril in turn. 2.The patient is asked to sniff (with eyes closed) and identify each smell.
Avoid using irritating substances (ammonia, alcohol) for these substances could stimulate the trigeminal nerve endings, even in anosmic patients! Olfaction is frequently not tested because of unreliable patient responses and lack of objective signs.

CRANIAL NERVE 2 (OPTIC NERVE)

The optic nerve contains special sensory afferent fibers that convey visual information from the retina to the occipital lobe via the visual pathway. Evaluation gives important information about the nerves, optic chiasm, tracts, thalamus, optic radiations, and visual cortex.

 The optic nerve is tested in the office by visual acuity measurement, color vision testing, pupil evaluation, visual field testing, and optic nerve evaluation via ophthalmoscopy and/or stereo biomicroscopy.

Examine Optic Fundi

Test Visual Acuity

1. Allow the patient to use their glasses if available. You are interested in the patient's best corrected vision. 2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance). 3. Have the patient cover one eye at a time with a card. 4. Ask the patient to read progressively smaller letters until they can go no further. 5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) Repeat with the other eye.

Screen Visual Fields by Confrontation

1. Stand two feet in front of the patient and have them look into your eyes. 2. Hold your hands about one foot away from the patient's ears, and wiggle a finger on one hand. 3. Ask the patient to indicate which side they see the finger move. 4. Repeat two or three times to test both temporal fields. 5. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card.

Test Pupillary Reactions to Light

1. 2. 3. 4. Dim the room lights as necessary. Ask the patient to look into the distance. Shine a bright light obliquely into each pupil in turn. Look for both the direct (same eye) and consensual (other eye) reactions. 5. Record pupil size in mm and any asymmetry or irregularity. o If abnormal, proceed with the test for accommodation.

CN 3: OCULOMOTOR NERVE CN 4: TROCHLEAR CN 6: ABDUCENS S O 4 L R 6 All The Rest 3 may help remind you which CN does what
Superior Oblique CN 4 Lateral Rectus CN 6 All The Rest of the muscles innervated by CN 3

Test Extraocular Movements

1. Stand or sit 3 to 6 feet in front of the patient. 2. Ask the patient to follow your finger with their eyes without moving their head. 3. Check gaze in the six cardinal directions using a cross or "H" pattern. 4. Pause during upward and lateral gaze to check for nystagmus. 5. Check convergence by moving your finger toward the bridge of the patient's nose.

CRANIAL NERVE 5 (TRIGEMINAL)

This nerve has both motor and sensory components. The sensory limb has 3 major branches, each covering roughly 1/3 of the face. 1. Ophthalmic 2. Maxillary 3. Mandibular

Assessment of CN 5 Sensory Function:

Use a sharp implement (e.g. broken wooden handle of a cotton tipped applicator). Ask the patient to close their eyes so that they receive no visual cues. Touch the sharp tip of the stick to the right and left side of the forehead, assessing the Ophthalmic branch. Touch the tip to the right and left side of the cheek area, assessing the Maxillary branch. Touch the tip to the right and left side of the jaw area, assessing the Mandibular branch. The patient should be able to clearly identify when the sharp end touches their face. Of course, make sure that you do not push too hard as the face is normally quite sensitive.

CRANIAL NERVE 5 (TRIGEMINAL)

The Ophthalmic branch of CN 5 also receives sensory input from the surface of the eye. To assess this component: 1. Pull out a wisp of cotton. 2. While the patient is looking straight ahead, gently brush the wisp against the lateral aspect of the sclera (outer white area of the eye ball). 3. This should cause the patient to blink. Blinking also requires that CN 7 function normally, as it controls eye lid closure.

CRANIAL NERVE 5 (TRIGEMINAL)

The motor limb of CN 5 innervates the Temporalis and Masseter muscles, both important for closing the jaw. Assessment of CN 5 Motor Function: Place your hand on both Temporalis muscles, located on the lateral aspects of the forehead. Ask the patient to tightly close their jaw, causing the muscles beneath your fingers to become taught. Then place your hands on both Masseter muscles, located just in front of the Temporo-Mandibular joints (point where lower jaw articulates with skull). Ask the patient to tightly close their jaw, which should again cause the muscles beneath your fingers to become taught. Then ask them to move their jaw from side to side, another function of the Masseter.

CRANIAL NERVE 7 (FACIAL)

Assessment is performed as follows: First look at the patients face. It should appear symmetric. There should be the same amount of wrinkles apparent on either side of the forehead The nasolabial folds should be equal The corners of the mouth should be at the same height If there is any question as to whether an apparent asymmetry if new or old, ask the patient for a picture for comparison.

Ask patient to wrinkle their eyebrows and then close their eyes tightly. You should not be able to open the patients eyelids with the application of gentle upwards pressure. CN 7 controls the muscles that close the eye lids (as opposed to CN 3, which controls the muscles which open the lid). Ask the patient to smile. The corners of the mouth should rise to the same height and equal amounts of teeth should be visible on either side. Ask the patient to puff out their cheeks. Both sides should puff equally and air should not leak from the mouth.

Testing the facial nerve. The patient wrinkles her forehead while the two sides are compared. Patient tightly shuts eyelids while examiner attempts to pry open. The two sides are compared. Patient smiles and shows her teeth while the examiner compares the nasolabial folds on either side.

 CN 7 is also responsible for carrying taste sensations from the anterior 2/3 of the tongue. To test the sensory fibers of the facial nerve, apply sugar, salt, or lemon juice on a cotton swab to the lateral aspect of each side of the tongue and have the patient identify the taste. Taste is often tested only when specific pathology of the facial nerve is suspected.

CRANIAL NERVE 8 (VESTIBULOCOCHLER)

Assessment is performed as follows: Stand behind the patient and ask them to close their eyes. Whisper a few words from just behind one ear. The patient should be able to repeat these back accurately. Then perform the same test for the other ear. Alternatively, place your fingers approximately 5 cm from one ear and rub them together. The patient should be able to hear the sound generated. Repeat for the other ear.

Weber Test
1. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm, generating a continuous tone. Alternatively you can get the fork to vibrate by "snapping" the ends between your thumb and index finger. 2. Hold the stem against the patients skull, along an imaginary line that is equidistant from either ear. 3. The bones of the skull will carry the sound equally to both the right and left CN 8. Both CN 8s, in turn, will transmit the impulse to the brain. 4. The patient should report whether the sound was heard equally in both ears or better on one side then the other (referred to as lateralizing to a side).

Rinne Test
1. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm, generating a continuous tone. 2. Place the stem of the tuning fork on the mastoid bone, the bony prominence located immediately behind the lower part of the ear. The vibrations travel via the bones of the skull to CN 8, allowing the patient to hear the sound. 3. Ask the patient to inform you when they can no longer appreciate the sound. When this occurs, move the tuning fork such that the tines are placed right next to (but not touching) the opening of the ear. At this point, the patient should be able to again hear the sound. This is because air is a better conducting medium then bone.

Interpretation: In the setting of conductive hearing loss, bone conduction (BC) will be better then air conduction (AC) when assessed by the Rinne Test. If there is a blockage in the passageway (e.g. wax) that carries sound from the outside to CN 8, then sound will be better heard when it travels via the bones of the skull. Thus, the patient will note BC to be better then or equal to AC in the ear with the subjective decline in hearing.
In the setting of a sensorineural hearing loss, air conduction will still be better then bone conduction (i.e. the normal pattern will be retained). This is because the problem is at the level of CN 8. Thus, regardless of the means (bone or air) by which the impulse gets to CN 8, there will still be a marked hearing decrement in the affected ear. As AC is normally better then BC, this will still be the case.

CRANIAL NERVE 9 (GLOSSOPHARYNGEAL) CRANIAL NERVE 10 (VAGUS)

These nerves are responsible for raising the soft palate of the mouth and the gag reflex, a protective mechanism which prevents food or liquid from traveling into the lungs. As both CNs contribute to these functions, they are tested together. Testing Elevation of the soft palate: Ask the patient to open their mouth and say, ahhhh, causing the soft palate to rise upward. Look at the uvula, a midline structure hanging down from the palate. If the tongue obscures your view, take a tongue depressor and gently push it down and out of the way. The Uvula should rise up straight and in the midline

Testing the Gag Reflex:

Ask the patient to widely open their mouth. If you are unable to see the posterior pharynx (i.e. the back of their throat), gently push down with a tongue depressor. In some patients, the tongue depressor alone will elicit a gag. In most others, additional stimulation is required. Take a cotton tipped applicator and gently brush it against the posterior pharynx or uvula. This should generate a gag in most patients. A small but measurable percent of the normal population has either a minimal or non-existent gag reflex. Presumably, they make use of other mechanisms to prevent aspiration

CN 9 is also responsible for taste originating on the posterior 1/3 of the tongue. CN 10 also provides parasympathetic innervation to the heart, though this cannot be easily tested on physical examination.

CRANIAL NERVE 11 SPINAL ACCESSORY

CN 11 innervates the muscles which permit shrugging of the shoulders (Trapezius) and turning the head laterally (Sternocleidomastoid). Assessment is performed as follows: Place your hands on top of either shoulder and ask the patient to shrug while you provide resistance. Dysfunction will cause weakness/absence of movement on the affected side. Place your open left hand against the patients right cheek and ask them to turn into your hand while you provide resistance. Then repeat on the other side. The right Sternocleidomastoid muscle causes the head to turn to the left, and vice versa.

CRANIAL NERVE 12 (HYPOGLOSSAL)

CN 12 is responsible for tongue movement. Each CN 12 innervates one-half of the tongue. Assessment is performed as follows: Ask the patient to stick their tongue straight out of their mouth. If there is any suggestion of deviation to one side/weakness, direct them to push the tip of their tongue into either cheek while you provide counter pressure from the outside.

Cranial Nerve Olfactory Optic

Number I II

Innervation(s) Sensory Sensory

Primary Function(s) Smell Vision Upper lid elevation, extraocular eye movement, pupil constriction, accommodation Superior oblique muscle Muscles of mastication

Test(s) Identify odors Visual acuity, fields, color, nerve head Physiologic "H" and near point response

Oculomotor

III

Motor

Trochlear Trigeminal

IV V

Motor Motor

Physiologic "H" Corneal reflex Clench jaw/palpate, light touch comparison

Trigeminal

Sensory

Scalp, conjunctiva, teeth

Abducens

VI

Motor

Lateral rectus muscle

Abduction, physiologic "H"

Facial

VII

Motor

Muscles of facial expression

Smile, puff cheeks, wrinkle forehead, pry open closed lids

Facial Vestibulocochlear Glossopharyngeal Glossopharyngeal

VII VIII IX IX

Sensory Sensory Motor Sensory

Taste-anterior two thirds of tongue

Hearing and balance Tongue and pharynx Taste-posterior one third of tongue Rinne test for hearing, Weber test for balance Gag reflex

Vagus
Vagus Accessory Hypoglossal

X
X XI XII

Motor
Sensory Motor Motor

Pharynx, tongue, larynx, thoracic and abdominal viscera

Larynx, trachea, esophagus Sternomastoid and trapezius muscles Muscles of tongue

Gag reflex

Shrug, head turn against resistance Tongue deviation

Evaluation of Motor Function

 Evaluation of the motor system is divided into the following components. 1. Observation 2. Inspection 3. Palpitation 4. Muscle tone testing 5. Functional testing 6. Strength testing of individual muscle groups

Evaluation of Motor Function

MUSCLE STRENGTH 41 groups of muscles on each side 1. Bulbar 2. Neck 3. Upper limb 4. Abdomen 5. Lower limb 6. Anal Sphincter

Manual Motor Testing

Test the following:
Flexion at the elbow (C5, C6, biceps) Extension at the elbow (C6, C7, C8, triceps) Extension at the wrist (C6, C7, C8, radial nerve) Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) Finger abduction (C8, T1, ulnar nerve) Oppostion of the thumb (C8, T1, median nerve) Flexion at the hip (L2, L3, L4, iliopsoas) Adduction at the hips (L2, L3, L4, adductors) Abduction at the hips (L4, L5, S1, gluteus medius and minimus) Extension at the hips (S1, gluteus maximus) Extension at the knee (L2, L3, L4, quadriceps) Flexion at the knee (L4, L5, S1, S2, hamstrings) Dorsiflexion at the ankle (L4, L5) Plantar flexion (S1)

Grading Motor Strength

Grade 0/5 1/5 2/5 3/5 4/5 5/5 Description No muscle movement Visible muscle movement, but no movement at the joint Movement at the joint, but not against gravity Movement against gravity, but not against added resistance Movement against resistance, but less than normal Normal strength

SENSATION
Vibration Joint Position Sense Light Touch Pinprick Two-point Discrimination Stereognosis Double simultaneous stimulation Temperature Deep Pain - comatose

Reflexes
Evaluation of deep tendon reflexes. With the lower leg hanging freely off the end of the chair, the "knee-jerk" reflex is tested by striking the patellar tendon directly with the reflex hammer.

Tendon Reflex Grading Scale

Grade

Description

0
1+ or + 2+ or ++ 3+ or +++ 4+ or ++++

Absent
Hypoactive "Normal" Hyperactive without clonus Hyperactive with clonus

Cerebellar Testing

Evaluation of cerebellar function. While the examiner holds his finger at arm's length from the patient, the patient touches her nose and then touches the examiner's finger. After several sequences, the patient is asked to repeat the exercise with her eyes shut. A patient with a cerebellar disorder tends to overshoot the target.

Evaluation of Coordination and Gait

The Romberg test. Have the patient stand still with heels and toes together. Ask the patient to close her eyes and balance herself. If the patient loses her balance, the test is positive.