The Neurologic Exam Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York

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The Neurologic Exam Andy Jagoda,
MDDepartment of Emergency MedicineMount Sinai
School of MedicineNew York, New York
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Overview

• Neuroanatomy
• History
• Physical
• Clinical Scenarios

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Introduction

• Facilitates communication
• Provides baseline
• Directs testing
• Identifies need for life-saving therapies
• Risk management

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Risk Management Case 1

• A 46-year-old female with a long history of
  migraine headaches presented c/o a severe
  occipital HA that was different from her past
  headaches in location and intensity. Neuro exam
  WNL. Patient was treated with Compazine, 10 mg
  IV, with resolution of headache and discharged
  home to follow-up With PMD.
• 18 hours later, patient was brought in by EMS
  comatose

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Risk Management Case 2

• A 64-year-old male presented with lower back pain
  which had become progressively worse over the
  past 2 weeks. The pain was primarily in the lower
  back without radiation, with nonspecific numbness
  in the legs. PMH presently being treated for
  prostatitis. Exam mild paralumbar tenderness,
  SLR -, Motor / Sensory Intact, Knee DTR 2.
  Patient was prescribed Motrin and told to
  follow-up with his PMD.
• Patient developed irreversible renal damage.

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Cauda Equina Syndrom

• Injury to lumbosacral roots
• Variable sensorimotor deficits and bowel and
  bladder function
• Conus medullaris s3-5 saddle anesthesia,
  sphincter loss, intact LE motor/sensory

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Neuroanatomy
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Michelangelo
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Michelangelo
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Neuroanatomy

• Central versus peripheral
• symmetrical vs asymmetrical
• If central, what is the level
• Cerebrum
• Midbrain
• Spinal cord
• If peripheral, is it
• Nerve
• Muscle
• NMJ

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Anatomy of the Spinal Cord

• Corticospinal Tracts motor from cerebral cortex
  cross in the lower medulla
• Spinothalamic Tracts pain and temperature cross
  1 or 2 levels above entry
• Posterior Column proprioception and vibration

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Cross-section
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Brown-Sequard

• Usually after penetrating trauma
• Ipsilateral motor paralysis
• Ipsilateral loss of light touch and
  proprioception (anesthesia) below the level of
  the lesion
• Ipsilateral hyperaesthesia
• Contralateral loss of pain and temperature
  (analgesia) found one or two segments below the
  lesion

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UMN vs LMN

• UMN increased DTR (after SS)
• LMN decreased DTR
• UMN muscle tone increased
• LMN tone decreased, atrophy
• UMN no fasciculations
• LMN fasciculations

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The Neuro Exam History

• Neuro complaints may be primary or secondary to
  other system disease
• Infection
• Overdose
• Metabolic disorder
• History often provides the key since the neuro
  exam may be normal
• Subarachnoid hemorrhage
• Carbon monoxide poisoning
• Subdural hematoma
• Nonconvulsive seizures

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The Neuro Exam History

• Time of Onset
• Type of Onset
• Progression
• Trauma
• Associated Symptoms
• Factors that make it better/worse
• Past Symptoms / Events
• Past Medical History
• Occupational / Environ Exposures

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The Neuro Exam Initial Approach

• Posture
• Decorticate
• Decerebrate
• Facial or body assymetry
• Hemiparesis results in external rotation of the
  foot to the affected sides

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The Neuro Exam Physical

• Vital Signs
• Head Evidence of Trauma
• Neck Bruits, Rigidity
• Heart Murmurs
• Abdomen Masses / Distention
• Skin / Scalp Lesions / Tenderness

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The Neuro Exam Physical

• Mental Status
• Cranial Nerves
• Motor
• Sensory
• Coordination
• Reflexes

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Mental Status Exam

• AVPU
• GCS
• Orientation
• Speech (dysarthria vs aphasia)
• Comprehension
• Confusion assessment method (CAM)
• Acute onset / fluctuating course
• Inattention
• Disorganized thinking
• Altered level of consciousness
• Mini-mental status exam
• Score affected by education and age
• lt 20 cognitive impairment

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Cranial Nerve Exam

• Focus exam on II - VIII
• Symmetrical vs assymetrical

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Cranial Nerve II

• Visual acuity
• Visual fields
• Fundoscopy
• Swinging flashlight test

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Cranial Nerve V

• Sensory corneal reflexes
• Motor jaw strength and muscle bulk
• Corneal reflex may be abnormal in
  cerebellopontine angle lesions test in patients
  with hearing deficits or vertigo

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Cranial Nerve VII

• Motor
• Smile
• Bury eyelashes
• Nasolabial fold
• Forehead has bihemispheric innervation centrally
• Taste anterior 2/3

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Cranial Nerve VIII XII

• VIII vestibular function / hearing
• IX taste / sensation posterior pharynx
• X SCM chin to the opposite side
• XII - tongue

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Motor Exam

• Strength
• Primary concern can patient breathe
• Key test drift of extremity
• Tone
• Hypertonia subacute or chronic corticospinal
  lesion
• Hypotonia LMN lesion or acute UMN
• Rigidity basal ganglia disease
• Bulk
• Wasting correlates with LMN
• Fasciculation
• Anterior horn cell lesion
• Tenderness
• Metabolic/inflammatory muscle disease

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Motor Exam

• 0 no movement
• 1 flicker but no movement
• 2 movement but cannot resist gravity
• 3 movement against gravity but cannot resist
  examiner
• 4 resists examiner but weak
• 5 normal

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Sensory Exam

• Pain/Temp cross at entrance, ascend in spinal
  thalamic tract
• Light touch ascend in posterior column, cross
  in the brain stem
• Vibration posterior column, cross in the brain
  stem

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Sensory Exam

• Dermatomal deficit accompanied with pain suggests
  peripheral lesion
• Central deficits are not dermatomal and usually
  result in loss of sensation and pain
• Thalamic pain syndrome

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Sensory Exam

• Distribution
• Right vs left vs bilateral
• Dermatomal
• Distal versus proximal
• Stocking glove
• Cape like
• Pinprick versus light touch

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Sensory Exam

• Double simultaneous testing
• Establish sharp / dull
• Check cheek, dorsum of hands, dorsum of feet
• Test both sides simultaneously with pain
• Lateralized pain, significant sensory deficit
• Initially no lateralization but on repeat 15 sec
  later, lateralization suggest subtle deficit.

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Coordination

• Requires integration of cerebellar, motor, and
  sensory functions
• Balance requires (2 of 3)
• Vision
• Vestibular sense
• Proprioception
• Falling with eyes open or closed cerebellar
• Falling only with eyes closed posterior column
  or vestibular

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Reflexes

• Symmetry / upper vs lower
• 0 absent
• 1 hyporeflexia
• 2 normal
• 3 hyperreflexia
• 4 clonus (usually indicates organic disease)
• Superficial reflexes (corneal, pharyngeal,
  abdominal, anal, cremasteric, bulbocavernosus)
• Pathologic reflexes babinski

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Pitfalls in the Neurologic Exam

• Not getting a complete history utilizing family
  or observers
• Not performing a systematic exam
• Jumping to conclusions before gathering all the
  data
• Misinterpreting old lesions for new
• Misinterpreting limitations from pain as
  neurologic deficits

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Pearls

• Lesions of the cerebral cortex result in sensory
  and motor defects confined to the contralateral
  side of the body
• Brain stem and spinal cord lesions result in
  ipsilateral as well as contralateral defects due
  to varying patterns of crossover
• Unilateral pain syndromes without motor deficits
  suggest possible thalamic pathology
• A careful exam of CN II, III, IV and V is
  indicated in patients with headache or suspected
  processes that cause increased ICP
• Testing for pronator drift is the best screen for
  muscle weakness of central origin