Neurological examination
Dr. D. Barry
Many Parts in Full Neuro Exam
1) Inspection – alertness/GCS
Dysmorphia (syndrome?)
2) Cranial Nerves
3) Peripheral Nerves
Upper limb
Lower limb
4) Co-ordination, Gait, Cerebellar signs
5) Developmental
6) Higher functioning
Cognitive & Behavioural
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Neonate
Infant/toddler
Child with Neuro-disability
Older Child (age & ability - appropriate
tests) [* that’s the child’s ability, not the examiners!*]
• Examination texts/technique should be
age-appropriate
• CN II – XII > 5 years
• ↑↓ with co-operation, sociability etc.
1) Neonate
• Alertness
• Expose & observe
• Dysmorphism; facies
– OFC & plot on centile chart
– Skeleton, spine, hands & feet (deformities)
– Skin, genitalia, eyes
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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; it’s upsetting)
Reflex
How to elicit…
Disappears at
Stepping;
hold baby vertically & ‘walk’ with feet
touching ground
=> feet move in stepping motion
2/12
Rooting;
stroke cheek
=> mouth moving to that side
4/12
ATNR;
rotate infants head to side x 15 secs
=> extension of limbs on side turned to with
flexion of limbs on side turned away from
4/12
Palmar
grasp;
Moro;
place index finger in palm of infant
=> flexion of fingers/makes fist
4/12
startle response;
4-6/12
Galant;
child held prone, stroke along side of spine
on one side
=> flexion of trunk on that side
4-8/12
Plantar
extensor
until 1 yr old
Primitive 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 *
2) Infant
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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.
Postural 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 child’s trunk & lower him/her
suddenly down towards bed/surface. Child will throw out arms to
protect him/her-self appears ~
9/12, and persists!
3) Child with NeuroDisability
• Alertness
• Examination tests depend on level of disability
• Speak to these children directly, introduce yourself
– do they respond / react?
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Dysmorphic features (nb OFC)
Position, Posture
Movements & Muscle Bulk
External Supports nb. (?Catheter/urine bag/ splints/ etc.)
• if in a wheelchair / sitting out; “ideally I’d 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)
4) Older child
• At > 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…
May be asked…
• Examine this child’s lower limbs
• Examine this child’s gait
• Examine this patient’s visual fields / eye
movements / for squint
• Demonstrate this child’s reflexes
• Examine this child for signs of cerebellar
dysfunction
– Any individual / isolated part of neuro exam
General Neuro Inspection
• Dysmorphic features
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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.
1) 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
• Examine relative to child’s understanding
• May need to improvise
• Remember what your testing;
– Eyes (vision, movement, pupils)
– Face
– Hearing
– Speech (making sounds) & Swallow
Eyes; 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 child’s 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 child’s head still
– “follow my finger”
– ? Ask re double vision if old enough
Squint (Strabismus)
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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)
Squint may be…
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Paralytic or Concomitant
Divergent or Convergent
Horizontal or Vertical
Hypertropic or Hypotropic
Permanent or Intermittent
• Pseudo-squint (epicanthic folds etc.)
Squint (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
Cover/Uncover test
• If Normal, (ie. no squint & normal binocular
vision), both eyes maintain steady fixation on
distant object
• => 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 => squint!
• But which eye?
• 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!
• 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!
• (see diagram)
Practice on each other!!!
Think it out!
Face (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
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Do these with the child, so they can see it!
‘raise your eyebrows’
‘shut them tight & don’t let me open’
‘smile, show me your teeth’
Vestibulo-cochlear (VIII)
• Hearing
– Examine external auditory meatus
– ? Speech normal ?
– Conductive or Sensorineural?
– Rinne & Weber
• Balance
– (often tested with cerebellar signs/gait)
Bulbar
• 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)
Cranial Nerves Summary
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Comment on pupils, eye position & reactivity
Visual fields
Eye movements
“I’m going to leave acuity, & fundoscopy to the end if that’s ok…”
Comment on facial symmetry
‘raise eye brows’
‘shut your eyes, don’t 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’
“I’m also going to come back to hearing assessment when I’ve
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
2) Peripheral Nerve Examination
• Tone
• Power
• Reflexes
• Co-ordination
• Sensation
Tone
• 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’
↑ 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
Power
• Know grades
• Compare side to side
• Muscle groups
Power
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
Reflexes
• Know how to elicit reflexes!!!!!
• Child must be still & relaxed
• Therefore use distraction (conversation)
• Absent (?or not elicited)
• Normal
• Increased/Brisk
Tendon Reflexes
Triceps C7, 8
Biceps C5, 6
Supinator C5, 6
Knee L3, 4
Ankle S1, 2
“please examine this child’s
upper limbs”
Upper Limbs; Inspect
• Ideally undress child to waist
• Stand with arms outstretched, fingers wide
– Wasting
– Fasciculations
– Spontaneous purposeful movements
– Involuntary movements
– Asymmetry
– ? handedness
Upper limbs; Tone
• “is there any pain, is it ok if I move your
arm; we’ll do it together, ok?”
• Wrist, elbow, +/- shoulder – passively
move
Upper Limbs; Power
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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
Upper Limb; Reflexes
• Distract child with conversation
• Lie arm semi-flexed over body
• Biceps C5,6
• Triceps C7,8
• Supinator C5,6
Finger jerk; (C7,8, T1)
– If ? Brisk reflexes
– Child’s hand relaxed, palm down
– Place your fingers (facing up) under child’s
fingers
– Tap (with hammer) your fingers
– Child’s fingers flex briskly!
Hoffman’s sign
• If ? Brisk reflexes
• Stabilise child’s middle phalanx (with your
thumb & index finger)
• Flick DIP
• Thumb flexes; + test (hyper-reflexia)
Upper Limbs; Co-ordination
• Composite function; motor, sensory &
cerebellar systems
• Ask handedness!
• Finger-nose test
• Dysdiadochokinesis
• Writing
• Drawing
Upper Limb; Sensation
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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)
Dermatomes
dermatomes
“please examine this child’s
lower limbs”
Lower Limbs; Inspection
• Ideally undress child from waist down, but
expose leg is accepted
• Comment on…
– Wasting
– Fasciculations
– Spontaneous purposeful movements
– Involuntary movements
– Asymmetry
Lower 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
(>3 sustained contractions)
Lower Limb; Power
• Infants – movements? Against pressure?
• Toddler – pre-school; Gait
• School-going; individual muscle groups
– (next slide)
Lower Limbs; Power
• Hip; flexion (L1,2)
abduction
• Knee; extension (L3,4)
• Plantar; flexion (L4,5)
• Foot; inversion (L4,5)
• Hallux; flexion (L5)
Extension (L5, S1)
adduction
Flexion (S1)
Extension (S1,2)
Eversion (L5, S1)
• Pelvic Gridle power;
– stand up from kneeling position with arms folded
– stand up from lying position (? Gower’s sign ?)
Lower Limb; Reflexes
• Head in central position
• Distraction (Jendrassik’s 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
Lower Limb; Co-ordination
• Gait
• +/- stairs, running, hopping
• Heel form opposite knee to ankle
Lower Limb; Sensation
• Modalities & Dermatomes (as per upper
limb assessment)
“please examine this child’s
cerebellar function / gait /
co-ordination”
Cerebellar signs
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speech
past-pointing
intention tremor
nystagmus
dysdiadochokinesis
ataxic gait
Romberg’s sign
Gait!
Observe walking firstly
Qs; Walk on heels
Tip-toes
Run
Stand on one leg (x 5 secs)
Hop
Walk straight line x 20 steps
Tandem (heel-toe) walking
Crouch down (distal muscles)
& stand up (proximal muscles)
[3 yrs]
[4 yrs]
[5 yrs]
[7 yrs]
Gait abnormalities
• Broad-based;
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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
Spinal Cord
• Adult; to L1 (lower border)
• Infant; to L3
• Vertebral column growth > spinal cord
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Exaimine spine ? Spina bifida?
Bowel & Bladder
Pelvic girlde / posture
Lower limbs (as before)
Upon completing your neuro
examination, try to elicit a pattern…
• Which cranial nerves (if any)?
• Which peripheral modalities (tone/weakness/parasthesia 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
Neuro Tutorial
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1)
2)
3)
4)
5)
I’ll ask you to assess…
Upper limb/Lower limb
Cranial Nerves
Cerebellar / Co-ordination
Neuro exam of neonate
Infant/toddler exam