Neurological examination

Neurological Examination

Adam Zeman

Professor of Cognitive and Behavioural Neurology

University of Exeter Medical School

Neurological examination

• History rules!


• History rules!

– and you are very good at it


• History rules!


• History yields hypotheses


• History rules!



– Where?


• History rules!



– Where?

– What?

Neurological history taking

• Diagnostic hypothesis – where, then what?

– Where?

• Muscle

• NMJ

• Peripheral nerve

• Spinal cord

• Brain

– Brain stem

– Cerebellum

– Thalamus

– basal ganglia

– Lobe or network


Some common symptom patterns:

• NMJ – Fatiguable weakness

• LMN – Distal weakness and numbness

– Dysarthria, dysphagia

• UMN – Dexterity, dragging foot, exertional worsening, clonus, spasms and

sphincter disturbance

• Extrapyramidal – Aching, slowing up, shuffling, dexterity, handwriting

• Cerebellar – Slurring of speech, clumsiness, unsteadiness


• Diagnostic hypothesis – where, then what?

– What?

eg spinal cord syndrome:

• Compression

– Disc

– tumour

• Demyelination

• Stroke…


• ‘Whats’ – Inherited vs acquired

– Vascular

– Inflammatory

– Neoplastic

– Traumatic

– Allergic

– Metabolic

– Endocrine

– Drugs

– Iatrogenic

– Psychiatric

– Mechanical/Structural

– Degenerative

– Deficiency

– Sleep-related

– Physiological


• Examination tests the hypotheses framed

from the history

• It rarely surprises

• So why do it?


• It’s expected


• It’s expected

• Helps to build a relationship


• It’s expected


• Allows some more history taking


• It’s expected



• Buys time for thought


• It’s expected




• Allows you to recognise ‘normal’


• It’s expected





• May provide confirmatory signs


• It’s expected






• Occasionally springs a surprise


• It’s expected






• Occasionally springs a surprise

• Therapeutic ritual


• Neurologists have two advantages –



– Calibration by many normal examinations




– Knowledge of neurological disorders:




– Knowledge of neurological disorders:

‘the eye will not see what the mind does not

know’


• Focus on aspects that are

– Most robust


• Focus on aspects that are

– Most robust

– Most revealing – especially in neuropsychiatry

Useful patterns of signs

• Neuromuscular junction

– fatiguable weakness (eg ptosis)


• Neuromuscular junction

– fatiguable weakness (eg ptosis)

• Lower motor neuron

– Wasting, fasciculation

– Decreased tone

– Weakness

– Reduced or absent reflexes

– +/- accompanying sensory loss, often distal

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&docid=k2Bfpe3OqemJ4M&tbnid=qE2ttOZhYH2C5M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.studyblue.com%2Fnotes%2Fnote%2Fn%2Flecture-7-motor-contro-lower-motor-neurons-upper-motor-neurons%2Fdeck%2F4770257&ei=0kSkU-3PJ7KX0AWM04CABg&bvm=bv.69411363,d.d2k&psig=AFQjCNGXVtmtKnWhIU-GPMamL4fFeB89yA&ust=1403359915668241

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&docid=k2Bfpe3OqemJ4M&tbnid=qE2ttOZhYH2C5M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.studyblue.com%2Fnotes%2Fnote%2Fn%2Flecture-7-motor-contro-lower-motor-neurons-upper-motor-neurons%2Fdeck%2F4770257&ei=0kSkU-3PJ7KX0AWM04CABg&bvm=bv.69411363,d.d2k&psig=AFQjCNGXVtmtKnWhIU-GPMamL4fFeB89yA&ust=1403359915668241


• Upper motor neuron

– Spastic posture

– Clasp-knife increase in tone

– ‘Pyramidal pattern’of weakness

– Excessively brisk reflexes

– Extensor plantars

– +/- accompanying sensory loss

• sensory level

• hemisensory loss

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=U5CbBkWDtQQ5EM&tbnid=M7m8bZWZiW6SIM:&ved=0CAUQjRw&url=http%3A%2F%2Fmedchrome.com%2Fbasic-science%2Fanatomy%2Flesions-of-upper-motor-neurons-and-lower-motor-neurons%2F&ei=_EGkU53-C4n30gW-oIBI&bvm=bv.69411363,d.d2k&psig=AFQjCNGXVtmtKnWhIU-GPMamL4fFeB89yA&ust=1403359915668241


• Extrapyramidal (pathology in basal ganglia)

– Reduced spontaneous movement if akinetic

rigid syndrome (eg Parkinson’s)

– chorea if hyperkinetic (eg Huntington’s)

– Rigid increase in tone if akinetic

– Power near normal once mobilised

– Reflexes normal

– Decrementing bradykinesia in Parkinson’s

disease

Cortico-striatal loops


• Cerebellar

– DANISH

• Dysdiadochokinesia

• Ataxic gait

• Nystagmus

• Intention tremor

• Slurred speech

• Hypotonia


• Functional weakness (‘hysterical’)

– Hoover’s sign (voluntary hip extension weak,

automatic hip extension on flexion of opposite

leg normal)

• - Fluctuating or ‘collapsing’ weakness

• ‘acrobatic’ gait


• Informal observation

– Muscle bulk

– Posture

• Spastic

• Dystonic

– Involuntary movements

• Tics, choreoathetosis, tremor, myoclonus

– Paucity of movement


• Informal observation

– Gait

• Stiff

• Ataxic

• Bradykinetic

• Lurching


• Gait

– Ordinary

– Heel-toe

– Romberg’s

– Heel, toe walking

– Rise from squat

– Hopping on one leg at a time


• I eg head injury

• II

– Acuity eg optic neuropathy

– Fields eg tumour

– Fundi…postpone

• III, IV, VI eg PSP, MS

– Pursuit

– Saccadic

– Convergence

…Fundi eg papilloedema, atrophy

…pupillary responses eg Syphilis


• V eg Sjogren’s syndrome

– Motor

– Sensory

• VII eg Lyme disease

• VIII eg mitochondrial cytopathy

• IX/X eg MND

• XI

• XII eg cerebellar, spastic, extrapyramidal


• Limbs

– Observation

– Tone

– Power

– Reflexes

– Sensation • Temperature or pin-prick

• Vibration or joint position

– Coordination

…hunting for the patterns….


• History rules

• Yields hypotheses –

– Where?

– What?

• Examination tests these

• Much of this is informal

• LMN, UMN, cerebellar, extrapyramidal patterns

are (relatively) robust

• Some signs are especially revealing

• Calibration and knowledge are keys


• ps

– Ask your neurologist to perform a mental state

examination


• An example

Health & Medicine

Neurological examination