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

The Neurologic ExamThe Neurologic Exam

Andy Jagoda, MDAndy Jagoda, MD

Department of Emergency MedicineDepartment of Emergency MedicineMount Sinai School of MedicineMount Sinai School of Medicine

New York, New YorkNew York, New York

Andy Jagoda, MD

OverviewOverview

• Neuroanatomy

• History

• Physical

• Clinical Scenarios

Andy Jagoda, MD

IntroductionIntroduction

• Facilitates communication

• Provides baseline

• Directs testing

• Identifies need for life-saving therapies

• Risk management

Andy Jagoda, MD

Risk Management: Case #1Risk 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

Andy Jagoda, MD

Risk Management: Case #2Risk 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.

Andy Jagoda, MD

Cauda Equina SyndromCauda 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

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

NeuroanatomyNeuroanatomy• Central versus peripheral

– symmetrical vs asymmetrical

• If central, what is the level:– Cerebrum

– Midbrain

– Spinal cord

• If peripheral, is it– Nerve

– Muscle

– NMJ

Andy Jagoda, MD

Andy Jagoda, MD

Anatomy of the Spinal CordAnatomy 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

Andy Jagoda, MD

Cross-sectionCross-section

Andy Jagoda, MD

Brown-SequardBrown-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

Andy Jagoda, MD

UMN vs LMNUMN vs LMN

• UMN increased DTR (after SS)

LMN decreased DTR

• UMN muscle tone increased

LMN tone decreased, atrophy

• UMN no fasciculations

LMN fasciculations

Andy Jagoda, MD

The Neuro Exam: HistoryThe 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

Andy Jagoda, MD

The Neuro Exam: HistoryThe 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

Andy Jagoda, MD

Andy Jagoda, MD

The Neuro Exam: Initial ApproachThe Neuro Exam: Initial Approach

• Posture

–Decorticate

–Decerebrate

–Facial or body assymetry

•Hemiparesis results in external rotation of the foot to the affected sides

Andy Jagoda, MD

The Neuro Exam: PhysicalThe Neuro Exam: Physical

• Vital Signs

• Head: Evidence of Trauma

• Neck: Bruits, Rigidity

• Heart: Murmurs

• Abdomen: Masses / Distention

• Skin / Scalp: Lesions / Tenderness

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

The Neuro Exam: Physical The Neuro Exam: Physical

• Mental Status

• Cranial Nerves

• Motor

• Sensory

• Coordination

• Reflexes

Andy Jagoda, MD

Mental Status Exam 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

– < 20 = cognitive impairment

Andy Jagoda, MD

Cranial Nerve Exam Cranial Nerve Exam

• Focus exam on II - VIII

• Symmetrical vs assymetrical

Andy Jagoda, MD

Cranial Nerve II Cranial Nerve II

• Visual acuity

• Visual fields

• Fundoscopy

• Swinging flashlight test

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Cranial Nerve V 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

Andy Jagoda, MD

Cranial Nerve VII Cranial Nerve VII

• Motor– Smile

– Bury eyelashes

– Nasolabial fold

– Forehead has bihemispheric innervation centrally

• Taste anterior 2/3

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Cranial Nerve VIII – XII Cranial Nerve VIII – XII

• VIII – vestibular function / hearing

• IX – taste / sensation posterior pharynx

• X – SCM; chin to the opposite side

• XII - tongue

Andy Jagoda, MD

Motor Exam 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

Andy Jagoda, MD

Andy Jagoda, MD

Andy Jagoda, MD

Motor Exam 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

Andy Jagoda, MD

Sensory Exam 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

Andy Jagoda, MD

Sensory Exam 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

Andy Jagoda, MD

Andy Jagoda, MD

Sensory Exam Sensory Exam

• Distribution– Right vs left vs bilateral

– Dermatomal

– Distal versus proximal

• Stocking glove

• Cape like

• Pinprick versus light touch

Andy Jagoda, MD

Sensory Exam 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.

Andy Jagoda, MD

Coordination 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

Andy Jagoda, MD

Reflexes 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

Andy Jagoda, MD

Pitfalls in the Neurologic Exam 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

Andy Jagoda, MD

Pearls 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