Neurological examination

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Neurological examination

• Dr. D. Barry

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Many Parts in Full Neuro Exam

• Inspection alertness/GCS
• Dysmorphia (syndrome?)
• Cranial Nerves
• Peripheral Nerves
• Upper limb
• Lower limb
• 4) Co-ordination, Gait, Cerebellar signs
• Developmental
• Higher functioning
• Cognitive Behavioural

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• 1) Neonate
• 2) Infant/toddler
• Child with Neuro-disability
• Older Child (age ability - appropriate tests)
  thats the childs ability, not the
  examiners!

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• Examination texts/technique should be
  age-appropriate
• CN II XII gt 5 years
• ?? with co-operation, sociability etc.

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1) Neonate

• Alertness
• Expose observe
• Dysmorphism facies
• OFC plot on centile chart
• Skeleton, spine, hands feet (deformities)
• Skin, genitalia, eyes
• Position, Posture Movement (Muscle bulk etc.)
• OFC, shape, sutures fontanelle (? VP shunt?)
• Comment (eyes open/movements? feeding/sucking)
• Tone position, fisting, head control, floppy?
  etc.
• Spinal Reflexes knee jerk, clonus etc.
• Spine / Natal cleft
• Primitive Reflexes ( moro at end its upsetting)

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Reflex How to elicit Disappears at
Stepping hold baby vertically walk with feet touching ground gt feet move in stepping motion 2/12
Rooting stroke cheek gt mouth moving to that side 4/12
ATNR rotate infants head to side x 15 secs gt extension of limbs on side turned to with flexion of limbs on side turned away from 4/12
Palmar grasp place index finger in palm of infant gt flexion of fingers/makes fist 4/12
Moro startle response 4-6/12
Galant child held prone, stroke along side of spine on one side gt flexion of trunk on that side 4-8/12
Plantar extensor until 1 yr old
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Primitive Reflexes

• Brainstem-mediated
• Most have fuctional role
• Disappear with Cortical Inhibition
• Many books vary on exactly when these reflexes
  are lost, so it can be confusing, therefore at
  least have general rule
• most gone by 6/12 (with motor dev. voluntary
  movement takes over),
• All gone by 1 year (roughly)
• in general, they are lost in a Cephaol-caudal
  direction

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2) Infant

• Alertness
• Dysmorphism (as before)
• Position, Posture Movement
• CN Eyes - ? Fixing following
• Face smiling, crying? Symmetrical?
• Bulbar feeding making sounds
• Primitive Reactions Postural Reactions
• Peripheral Tone, Reflexes
• Developmental Milestones gross motor, fine motor
  (co-ord) what are they doing watch them
  playing with toys etc.

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Postural Reactions

• As opposed to primitive reflexes which neonate is
  born with, these evolve early in infancy
• Many doctors include them together with primitive
  reflexes, but they have very different underlying
  significance
• Head-righting reflexes
• Horizontal suspension (extension of head, spine
  legs) 3-6/12
• Vertical to horizontal position (? Knees flex
  head corrects) 6/12
• Parachute reflex support childs trunk lower
  him/her suddenly down towards bed/surface. Child
  will throw out arms to protect him/her-self
  appears 9/12, and persists!

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3) Child with NeuroDisability

• Alertness
• Examination tests depend on level of disability
• Speak to these children directly, introduce
  yourself
• do they respond / react?
• Dysmorphic features (nb OFC)
• Position, Posture
• Movements Muscle Bulk
• External Supports nb. (?Catheter/urine bag/
  splints/ etc.)
• if in a wheelchair / sitting out ideally Id
  like to examine them in the bed esp for spinal
  lower limb exam expose
• Peripheral Nerves
• tone, reflexes /- power
• CN relative to understanding etc. (as described
  before)

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4) Older child

• At gt 5 yrs can comply with most of formal
  neurological exam
• Need to improvise with younger children engage
  the exam as a game
• If co-operation vital but difficult (eg. CN)
  - attempt, but if not possible, say so move on

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May be asked

• Examine this childs lower limbs
• Examine this childs gait
• Examine this patients visual fields / eye
  movements / for squint
• Demonstrate this childs reflexes
• Examine this child for signs of cerebellar
  dysfunction
• Any individual / isolated part of neuro exam

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General Neuro Inspection

• Dysmorphic features
• Facies
• OFC (eg. Macrocephaly, microcephaly), shape
• Skeleton, spine (eg. scoliosis, spina bifida),
  hands feet
• Skin (eg. Neurocutaneous syndromes), genitalia
  eyes
• Posture
• Movement
• Muscle bulk /- fasciculations
• Supports eg glasses / hearing aids / wheelchair
  etc. etc. etc.

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1) Cranial Nerves

• I - olfactory
• Eyes vision movements
• II optic visual acuity, fields, fundoscopy,
• III - oculomotor
• IV trochlear
• VI abducens (false localising)
• Face (motor sensory)
• V facial muscles of facial expression
• VII trigeminal sensory to face ( tongue)
• VIII vestibule-cochlear hearing
• Bulbar (speech swallow)
• IX glossopharyngeal
• X vagal
• XI accessory
• XII hypoglossus

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• Examine relative to childs understanding
• May need to improvise
• Remember what your testing
• Eyes (vision, movement, pupils)
• Face
• Hearing
• Speech (making sounds) Swallow

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Eyes CN II, III, IV, VI

• Pupils round, regular, reactive, equal?
• Visual Acuity ? Any books around / Snellen chart
• Visual Fields confrontation perimetry
• For younger child distraction test with 2
  examiners or engage the childs gaze, shine a
  light / toy at periphery move it around until it
  catches their attention
• If abnormal, do formal testing
• Red-pin test (scotoma) seldom necessary
• Fundoscopy do at end, dim lights/pull curtains
• Get child to fix on something interesting
• Eye Movements ptosis ? Nystagmus ? squint
• Hold childs head still
• follow my finger
• ? Ask re double vision if old enough

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Squint (Strabismus)

• Remove glasses
• Observe position of eyes
• Corneal reflections (of a light 30 cm away)
• Cover test (manifest vs. latent)
• Cover/uncover manifest squint
• Alternate cover test latent squint
• Eye Movments (paralytic vs. concomitant)
• Offer to do visual acuity (each eye separately)

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Squint may be

• Paralytic or Concomitant
• Divergent or Convergent
• Horizontal or Vertical
• Hypertropic or Hypotropic
• Permanent or Intermittent
• Pseudo-squint (epicanthic folds etc.)

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Squint (Strabismus)

• Paralytic
• ??deviation with direction of gaze
• Divergent (CN III)
• Convergent (CN IV, VI)
• ie. Muscle / nerve dx
• CN VI palsy is assn with ? ICP esp if squint
  recent!

• Concomitant (non-paralytic)
• Angle of deviation constant in all directions of
  gaze
• ie. Eye disease /
• refractive errors /
• ? binocular vision

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Cover/Uncover test

• If Normal, (ie. no squint normal binocular
  vision), both eyes maintain steady fixation on
  distant object
• gt no deviation when either eye covered
• focus on distant object
• Cover uncover each eye in turn
• Watch eye movements
• If deviation of one eye when one/other is covered
  gt squint!
• But which eye?

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Practice on each other!!!Think it out!

• Manifest Squint
• Squinting eye turns in, normal eye maintains
  fixation distant object
• Which is which?
• Cover one eye, if the uncovered eye moves to take
  up fixation it has the manifest squint!
• (see diagram)

• Latent Squint
• Both eyes fix at object
• Cover one eye, if it deviates it has latent
  squint
• ie. Deviates when you cover it! Resumes fixation
  when you uncover it!

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Face (CN V, VI)

• Trigeminal (CN V)
• Sensory 3 divisions ophthalmic / maxillary /
  mandibular
• Close eyse, when you feel something, point to
  side you feel it on
• Compare sides
• Motor Muscles of mastication
• ? Bite wooden spatula resist you removing it
• Reflexes corneal jaw jerk (seldom done)
• Facial (CN VII) facial expression
• Do these with the child, so they can see it!
• raise your eyebrows
• shut them tight dont let me open
• smile, show me your teeth

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Vestibulo-cochlear (VIII)

• Hearing
• Examine external auditory meatus
• ? Speech normal ?
• Conductive or Sensorineural?
• Rinne Weber
• Balance
• (often tested with cerebellar signs/gait)

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Bulbar

• Glossopharyngeal (IX) Vagus (X)
• Dysarthria, nasal speech, difficulty swallowing
  ?drooling
• Say ahhh ? Palate elevates (IX X)
• ? Uvula deviation (deviates away from affected
  side)
• Gag reflex (do not elicit in conscious child)
• Accessory (XI)
• Shrug shoulders
• Turn chin over to. (against your resistance)
• Hypoglossal (XII)
• Tongue ? fasciculations?
• Stick out tongue (deviates to affected side)

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Cranial Nerves Summary

• Comment on pupils, eye position reactivity
• Visual fields
• Eye movements
• Im going to leave acuity, fundoscopy to the
  end if thats ok
• Comment on facial symmetry
• raise eye brows
• shut your eyes, dont let me open them
• smile show me your teeth
• Do you feel this? (cotton ball etc), ok, now
  close your eyes point with your hand to which
  side you feel this on
• blow out your cheeks like this / bite down on
  this spatula
• Im also going to come back to hearing
  assessment when Ive completed other cranial
  nerves
• Comment on speech swallow / drooling etc.
• open your mouth, say ahh comment on palate,
  uvula,
• tongue rest . .stick out your tongue
• Shrug up shoulders (against resistance) turn
  chin against resistance
• Pupil reactivity, Fundoscopy - offer to do
  acuity hearing

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2) Peripheral Nerve Examination

• Tone
• Power
• Reflexes
• Co-ordination
• Sensation

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Tone

• Resistance to Passive Movement
• Child should be relaxed (ie distract them with
  chat)
• Note difference hypotonia vs. joint flexiblity
• Clonus rhythmic series of involuntary muscle
  contraction evoked by stretching the muscle

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? Tone

• Spasticity
• rapid build-up of
• resistance during first
• few degrees of passive
• movement,
• then resistance lessens
• Much more common in paeds!
• UMN eg. CP

• Rigidity
• sustained resistance
• passive movement
• Extrapyramidal / Basal ganglia

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Power

• Know grades
• Compare side to side
• Muscle groups

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Power

• 0 no contraction
• 1 flicker of contraction
• 2 active movement (gravity eliminated)
• 3 anti-gravity movement
• 4 movement against resistance (but weaker)
• 5 Normal power

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Reflexes

• Know how to elicit reflexes!!!!!
• Child must be still relaxed
• Therefore use distraction (conversation)
• Absent (?or not elicited)
• Normal
• Increased/Brisk

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Tendon Reflexes

• Triceps C7, 8
• Biceps C5, 6
• Supinator C5, 6
• Knee L3, 4
• Ankle S1, 2

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please examine this childs upper limbs
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Upper Limbs Inspect

• Ideally undress child to waist
• Stand with arms outstretched, fingers wide
• Wasting
• Fasciculations
• Spontaneous purposeful movements
• Involuntary movements
• Asymmetry
• ? handedness

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Upper limbs Tone

• is there any pain, is it ok if I move your arm
  well do it together, ok?
• Wrist, elbow, /- shoulder passively move

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Upper Limbs Power

• Shoulders abduction C5 adduction C6,7
• Elbows flexion C5,6 extension C7,8
• Wrist Flexion/extension C6,7,8
• Fingers abduction/adduction T1
• Isolate muscle groups
• Compare side to side

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Upper Limb Reflexes

• Distract child with conversation
• Lie arm semi-flexed over body
• Biceps C5,6
• Triceps C7,8
• Supinator C5,6

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Finger jerk (C7,8, T1)

• If ? Brisk reflexes
• Childs hand relaxed, palm down
• Place your fingers (facing up) under childs
  fingers
• Tap (with hammer) your fingers
• Childs fingers flex briskly!

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Hoffmans sign

• If ? Brisk reflexes
• Stabilise childs middle phalanx (with your thumb
  index finger)
• Flick DIP
• Thumb flexes test (hyper-reflexia)

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Upper Limbs Co-ordination

• Composite function motor, sensory cerebellar
  systems
• Ask handedness!
• Finger-nose test
• Dysdiadochokinesis
• Writing
• Drawing

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Upper Limb Sensation

• Light touch cotton wool
• Superficial Pain pin prick
• Deep Pain tendon reflexes
• Temperature warm-cold
• Proprioception joint position
• Vibration tuning fork
• 2 point discrimination (seldom done)

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Dermatomes
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dermatomes
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please examine this childs lower limbs
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Lower Limbs Inspection

• Ideally undress child from waist down, but expose
  leg is accepted
• Comment on
• Wasting
• Fasciculations
• Spontaneous purposeful movements
• Involuntary movements
• Asymmetry

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Lower Limbs Tone

• is there any pain in your legs?
• Distract child (conversation)
• Lightly lift leg passive movement of hips,
  knees feet
• /- flex knee abduct hip (with pelvis
  stabilised) ? ? tone (if ankle raises also)
• Compare sides ? Asymmetry
• Clonus on dorsiflexion of ankle
• (gt3 sustained contractions)

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Lower Limb Power

• Infants movements? Against pressure?
• Toddler pre-school Gait
• School-going individual muscle groups
• (next slide)

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Lower Limbs Power

• Hip flexion (L1,2) Extension (L5, S1)
• abduction adduction
• Knee extension (L3,4) Flexion (S1)
• Plantar flexion (L4,5) Extension (S1,2)
• Foot inversion (L4,5) Eversion (L5, S1)
• Hallux flexion (L5)
• Pelvic Gridle power
• stand up from kneeling position with arms folded
• stand up from lying position (? Gowers sign ?)

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Lower Limb Reflexes

• Head in central position
• Distraction (Jendrassiks maneouvre)
• Knee jerk (L3,4)
• Dangle over bed or your arm
• Ankle jerk (S1,2)
• Flex ankle over opposite shin
• Babinski stroke along lat aspect of sole
• Withdrawal unequivocal
• ie hallux dorsiflexion splaying of toes
  (UMN)
• - (normal) ie down-going plantars

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Lower Limb Co-ordination

• Gait
• /- stairs, running, hopping
• Heel form opposite knee to ankle

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Lower Limb Sensation

• Modalities Dermatomes (as per upper limb
  assessment)

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please examine this childs cerebellar function
/ gait / co-ordination
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Cerebellar signs

• S speech
• P past-pointing
• I intention tremor
• N nystagmus
• D dysdiadochokinesis
• A ataxic gait
• R Rombergs sign

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Gait!

• Observe walking firstly
• Qs Walk on heels
• Tip-toes
• Run
• Stand on one leg (x 5 secs) 3 yrs
• Hop 4 yrs
• Walk straight line x 20 steps 5 yrs
• Tandem (heel-toe) walking 7 yrs
• Crouch down (distal muscles)
• stand up (proximal muscles)

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Gait abnormalities

• Broad-based
• appropriate when learning to walk
• Hypotonia of legs / pelvic girdle
• Cerebellar dysfunction
• Hip joint problems
• Narrow gait (?scissoring)
• Adductor spasm (mild diplegia)
• Hemiplegic gait (wide swing)
• Waddling gait
• poximal muscle weakness
• High-stepping gait
• Sensory neuropathy
• Distal weakness eg. foot-drop

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Spinal Cord

• Adult to L1 (lower border)
• Infant to L3
• Vertebral column growth gt spinal cord
• Exaimine spine ? Spina bifida?
• Bowel Bladder
• Pelvic girlde / posture
• Lower limbs (as before)

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Upon completing your neuro examination, try to
elicit a pattern

• Which cranial nerves (if any)?
• Which peripheral modalities (tone/weakness/parasth
  esia etc)?
• Unilateral (which side) vs. symmetrical?
• Upper or lower limbs or all 4?
• UMN vs LMN etc. etc.
• Composite/integrated functioning
  co-ordination/gait etc.
• Ultimately can you piece together your clinical
  findings
• locate the lesion!
• Make comment on any difficulties/obstacles to
  completeness of your examination
• Any further testing you think appropriate
• Eg. Formal visual or hearing assessment
• Eg. Developmental / cognitive / psychiatric
  assessments

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Neuro Tutorial

• Ill ask you to assess
• 1) Upper limb/Lower limb
• Cranial Nerves
• Cerebellar / Co-ordination
• Neuro exam of neonate
• Infant/toddler exam