1 Presented by Tracey Anderson, MSN, CNRN, FNP-BC, ACNP-BC Neurosurgery Nurse Practitioner UCHealth Medical Group – Brain & Spine Complete advanced assessment of patients with neurologic complaint Identify appropriate diagnostic tests based on presenting symptoms Identify those presentations requiring emergent referral Review NPH & Back Pain as seen in Primary Care
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Neuro Assessment Diagnostic Work Up for Advanced ... · Identify appropriate diagnostic tests based ... High volume LP can be diagnostic (pre/post LP eval by physical ... Neuro Assessment
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� The biceps muscle is innervated by the C5 and C6 nerve roots via the musculocutaneous nerve.
The Precise Neurologic Exam retrieved from http://informatics.med.nyu.edu/modules/pub/neurosurgery/motor.html on
2/10/2017
� The triceps muscle
is innervated by the C6 and C7 nerve roots via the radial
nerve.
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� The deltoid muscle
is innervated by the C5 nerve root via the axillary nerve.
� Indicates an upper motor neuron lesion
� May be first indicator of pending change
� The wrist extensors are innervated by C6 and C7 nerve roots via the radial nerve.
� The radial nerve is the "great extensor" of the arm: it innervates all the extensor muscles in the upper and lower arm.
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� Finger flexion is
innervated by the C8 nerve root via the median nerve.
� Tests forearm flexors and the
intrinsic hand muscles.
� Finger abduction or
"fanning" is innervated by the T1 nerve root via
the ulnar nerve.
� Thumb opposition
is innervated by the C8 and T1 nerve roots via the
median nerve.
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� Hip flexion is innervated by the L2 and L3 nerve roots via the femoral nerve.
� Tests iliopsoas muscles.
� Adduction of the hip is mediated by the L2, L3 and L4 nerve roots.
� Tests adductors of medial thigh.
� Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.
� Tests gluteus maximus and gluteus minimus.
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� Abduction of the hip is mediated by the L4, L5 and S1 nerve roots.
� Tests gluteus maximus when they press down on hand placed under thigh.
� Knee extension by the quadriceps muscle is innervated by the L3 and L4 nerve roots via the femoral nerve.
� The hamstrings are innervated by the L5 and S1 nerve roots via the sciatic nerve.
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� Ankle dorsiflexion is innervated by the L4 and L5 nerve roots via the peroneal nerve.
� Tests anterior compartment of lower leg.
� Ankle plantar flexion is innervated by the S1 and S2 nerve roots via the tibial nerve.
� Tests posterior compartment of lower leg.
� Move large toe towards head.
� This tests the extensor halucis longus (EHL) muscle.
� The EHL is almost completely innervated by the L5 nerve root.
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� 5/5 = normal against gravity & resistance
� 4/5 = full ROM against moderate resistance and gravity
� 3/5 = full ROM against gravity only
� 2/5 = extremity moves but not against gravity
� 1/5 = muscle contracts, extremity doesn’t move
� 0/5 = no visible/palpable contraction/movement
� Stereognosis – size & shape
� Graphesthesia - feel� Discrimination – right vs. left
� Calculation
� Serial 7’s: Subtract 7 from 100 serially
� What is 6 x 7
� How many quarters in $1.75
� Rapid Alternating Movements
� Finger to Nose� Heel-Shin
� Balance
� Romberg
� Gait
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� Motor� Dermatome distribution C4-S1
� Sensory� Dermatomes
� Light touch
� Superficial pain
� Temperature/Deep pain
� Vibration� Reflexes
� Hoffman sign
� Clonus
� Anal Wink
� Radiculopathy – dysfunction of a nerve root due to
isolated points of pressure w/ signs and symptoms including: pain, sensory disturbance, weakness, hypoactive reflexes
� Myelopathy – gradual loss of nerve function caused by
disorders of the spine
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� Patient supine
� Lift each leg (one at a time) to approx 70 degrees� Positive result
� Sciatic pain
� Radicular pain that goes below knee
▪ Worsened by ankle dorsiflexion
▪ Improved with ankle plantar flexion or lowering leg
� Reproducing back pain or pain in the hamstring area is NOT a positive result
� Level of
Consciousness� Glasgow Coma Score
▪ Motor
▪ Verbal
▪ Eyes
� CNS� II/III pupils (midbrain)
� V/VII corneals (pons)
� IX/X cough/gag (medulla)
� Developmental Progression / Delays
� Reaction to Strangers / Pain� Sick vs. Not Sick
� Emergence of migraines in very young
� Input of parents
� Great website: http://library.med.utah.edu/pedineurologicexam/html/introduction.html
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� Environment
� Opioids� Fluid & Electrolyte Balance
� Infection
� Fatigue� Pain
Neurologic Assessment of the Older Adult, AANN Clinical Practice Guideline Series 2014
� Wet, Wacky, & Wobbly!
� Triad of Symptoms
� Gait disturbance
� Cognitive deficit
� Urinary incontinence
� More prevalent as population ages
� Rule out other causes� High volume LP can be diagnostic (pre/post
LP eval by physical therapy)
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� Differentials
� Decision on imaging and other work up� Consult with a peer
� Decision to refer to specialist
� Biggest risk is missing a diagnosis that is time
sensitive – never hesitate to refer to ED!
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� Loss of Consciousness / Unresponsiveness
� Acute Vision Loss
� Prolonged Seizure (Status Epilepticus)
� Acute loss of extremity function (paralysis)
� Loss of Bowel/Bladder control
� Chronic Back Pain without neurologic deficit
� Chronic headaches that have been evaluated for cranial lesions
� Non-hemorrhagic metastatic lesions that are asymptomatic
� Numbness
� Tingling
� Stable deficits that have been present for weeks/months
� Fevers, chills, recent urinary or skin infections� Significant trauma� Unrelenting night pain or pain at rest� Progressive motor or sensory deficit� Saddle anesthesia� Urinary or bowel dysfunction or incontinence� Unexplained weight loss� History of cancer or strong suspicion of cancer� Severe osteoporosis� Immunosuppression� Chronic oral steroid use� Intravenous drug use� Substance abuse
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� 70% of back pain is musculoskeletal in nature
� One of the most common complaints that
drive people to seek medical care (ED/PCP)
� Almost all MRIs will have some kind of
finding, the majority of which is not surgical
� The natural history is generally favorable
� 30-60% of patients recover within 1 week
� 60-90% of patients recover within 6 weeks
� 95% of patient recover in 12 weeks ( 3 months)
� Relapses and recurrences are common and occur in approximately 40% of patients within a 6 month period
� L3-4 disk herniation:� Affects the L4 nerve root
� Sensory loss in the MEDIAL FOOT
� Motor loss in the KNEE EXTENSION
� Reflex loss in the PATELLA
� L4-5 disk herniation:� Affects the L5 nerve root
� Sensory loss in the DORSAL FOOT (large toe)
� Motor loss in the DORSIFLEXION (anterior tibialis & extensor hallicus longus)
� NO reflex loss
� L5-S1 disk herniation:� Affects the S1 nerve root
� Sensory loss in the LATERAL FOOT (small toe)
� Motor loss in the PLANTAR FLEXION
� Reflex loss in the ACHILLES
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� In the absence of red flag findings, 4 to 6 weeks of conservative therapy is safe and appropriate and imaging is not indicated
� Plain radiographs have a fairly low yield and if the clinical suspicion is sufficiently high then it is generally necessary to proceed directly to MR imaging
� MR imaging in asymptomatic patients has a very high rate of abnormal findings:
� 40% of patients will have herniated disks
� 50% of patients will have a degenerative disk
� 40% of patients will have an annular tear
� X-Rays
� CT / CTA
� MRI / MRA
� Lumbar Puncture
� Angiography
� Mostly a cursory screening
� Helps assess alignment� Dynamic xrays (flexion/extension) can help in
some settings
� Not indicated in acute low back pain unless Red Flag present
� Can be used to monitor fractures
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� Non contrast – if looking for blood� Contrast if looking for infection or tumor� Looks best at:
� Blood
� Bone
� “Quick Look” – this is often your 1st test (STAT!)� Poor quality for:
� Brain tumors
� Brainstem lesions� Can also do CT Perfusion & CT Angio
� Non contrast – if looking at brain structure� Contrast if looking for infection, enhancement of
high grade tumor� Looks best at:
� Pathologic brain lesions� Early changes in brain tissue� Brainstem lesions
� Poor quality for:� Blood� Bone
� Can also do MRA, DWI, PWI� May be done on urgent basis – rarely first test
done
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� Indicated for � AMS with no clues from imaging / labs� Assessment of CNS infections (all types)� For help in diagnosis of SAH