Title: Neurological examination
1Neurological examination
2Many 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
3- 1) Neonate
- 2) Infant/toddler
- Child with Neuro-disability
- Older Child (age ability - appropriate tests)
thats the childs ability, not the
examiners!
4- Examination texts/technique should be
age-appropriate - CN II XII gt 5 years
- ?? with co-operation, sociability etc.
51) 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)
6Reflex 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
7Primitive 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
82) 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.
9Postural 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!
103) 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)
114) 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
12May 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
13General 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.
141) 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
15- Examine relative to childs understanding
- May need to improvise
- Remember what your testing
- Eyes (vision, movement, pupils)
- Face
- Hearing
- Speech (making sounds) Swallow
16Eyes 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
17Squint (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)
18Squint may be
- Paralytic or Concomitant
- Divergent or Convergent
- Horizontal or Vertical
- Hypertropic or Hypotropic
- Permanent or Intermittent
- Pseudo-squint (epicanthic folds etc.)
19Squint (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
20Cover/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?
21Practice 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!
22Face (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
23Vestibulo-cochlear (VIII)
- Hearing
- Examine external auditory meatus
- ? Speech normal ?
- Conductive or Sensorineural?
- Rinne Weber
- Balance
- (often tested with cerebellar signs/gait)
24Bulbar
- 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)
25Cranial 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
262) Peripheral Nerve Examination
- Tone
- Power
- Reflexes
- Co-ordination
- Sensation
27Tone
- 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
28? 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
29Power
- Know grades
- Compare side to side
- Muscle groups
30Power
- 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
31Reflexes
- Know how to elicit reflexes!!!!!
- Child must be still relaxed
- Therefore use distraction (conversation)
- Absent (?or not elicited)
- Normal
- Increased/Brisk
32Tendon Reflexes
- Triceps C7, 8
- Biceps C5, 6
- Supinator C5, 6
- Knee L3, 4
- Ankle S1, 2
33please examine this childs upper limbs
34Upper Limbs Inspect
- Ideally undress child to waist
- Stand with arms outstretched, fingers wide
- Wasting
- Fasciculations
- Spontaneous purposeful movements
- Involuntary movements
- Asymmetry
- ? handedness
35Upper limbs Tone
- is there any pain, is it ok if I move your arm
well do it together, ok? - Wrist, elbow, /- shoulder passively move
36Upper 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
37Upper Limb Reflexes
- Distract child with conversation
- Lie arm semi-flexed over body
- Biceps C5,6
- Triceps C7,8
- Supinator C5,6
38Finger 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!
39Hoffmans sign
- If ? Brisk reflexes
- Stabilise childs middle phalanx (with your thumb
index finger) - Flick DIP
- Thumb flexes test (hyper-reflexia)
40Upper Limbs Co-ordination
- Composite function motor, sensory cerebellar
systems - Ask handedness!
- Finger-nose test
- Dysdiadochokinesis
- Writing
- Drawing
41Upper 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)
42Dermatomes
43dermatomes
44please examine this childs lower limbs
45Lower Limbs Inspection
- Ideally undress child from waist down, but expose
leg is accepted - Comment on
- Wasting
- Fasciculations
- Spontaneous purposeful movements
- Involuntary movements
- Asymmetry
46Lower 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)
47Lower Limb Power
- Infants movements? Against pressure?
- Toddler pre-school Gait
- School-going individual muscle groups
- (next slide)
48Lower 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 ?)
49Lower 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
50Lower Limb Co-ordination
- Gait
- /- stairs, running, hopping
- Heel form opposite knee to ankle
51Lower Limb Sensation
- Modalities Dermatomes (as per upper limb
assessment)
52please examine this childs cerebellar function
/ gait / co-ordination
53Cerebellar signs
- S speech
- P past-pointing
- I intention tremor
- N nystagmus
- D dysdiadochokinesis
- A ataxic gait
- R Rombergs sign
54Gait!
- 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)
55Gait 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
56Spinal 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)
57Upon 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
58Neuro Tutorial
- Ill ask you to assess
- 1) Upper limb/Lower limb
- Cranial Nerves
- Cerebellar / Co-ordination
- Neuro exam of neonate
- Infant/toddler exam