The Neurological examination
Neurosurgical approach
Step 1 – CT and/or MRI
Step 2- Prof. Moshe Gomori
Just that!
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Mental status, cognition & language
Cranial nerves
Signs of meningeal irritation
Motor system
Sensory system
Cerebellar functions
Gait and balance
• Remember that normal
range of findings
dynamically changes
with age.
• We all have some soft
neurological signs – be
symptoms oriented
and try to look at the
entire picture and not
on a soft abnormal
finding.
Mental status, cognition & language
Glasgow Coma Scale
Glasgow Coma Scale – Children modified
Speech evaluation
• If during conversation you suspect any
language abnormality test spontaneous
conversation (fluency, paraphasia),
understanding commands, low and high
frequency naming, repetition, reading,
writing. Distinguished and define dysarthria.
• Aphasia/Disphasia → Globally/Sensory/Motor
Meningeal irritation - nuchal rigidity
Meningealism
Cranial Nerves
CN I - Olfactory
Anosmia
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Upper respiratory tract infection (e.g., sinusitis or the common
cold)
Nasal polyps
Idiopathic hypogonadotropic hypogonadism
Hypothyroidism
Head trauma, damage to the ethmoid bone
Dementia with Lewy bodies
Tumors of the frontal lobe
Fibromyalgia
Multiple sclerosis
Hypoglycaemia
Diabetes
Asthma or Allergy
Hayfever
Chronic obstructive pulmonary disease (COPD)
Long term alcoholism
Cushing's syndrome
Exposure to a chemical that burns the inside of the nose
Stroke
Epilepsy
Radiation therapy to the head and neck
Liver or kidney disease
Parkinson's disease
Alzheimer's disease
Toxins (especially acrylates, methacrylates[ and cadmium)
Old age
Kallmann syndrome
Primary ciliary dyskinesia
Post-perfusion syndrome
Laryngectomy with permanent tracheostomy
Esthesioneuroblastoma is an exceedingly rare
cancerous tumor that originates in or near the olfactory
nerve. Symptoms are anosmia (loss of sense of smell)
often accompanied by chronic sinusitis.[23]
Intranasal drug use
Samter's triad
Foster Kennedy syndrome
Cadmium poisoning
Smoking
Neurotropic virus
Schizophrenia
Pernicious anemia
Zinc deficiency
Bell's Palsy or nerve paralysis and damage
Idiopathic intracranial hypertension
Suprasellar meningioma
Refsum's disease
Adrenergic agonists or withdrawal from alpha blockers
(vasoconstriction)
Sarcoidosis
Zinc-based intranasal cold products, including remedies
labelled as "homeopathic"
Chronic atrophic rhinitis
Paget's disease of bone[
Cerebral aneurysm
Wegener's Granulomatosis
Primary amoebic meningoencephalitis
Myasthenia gravis
Foster-Kennedy Syndrome
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Optic atrophy in the ipsilateral eye
Papilledema in the contralateral eye
Central Scotoma in the ipsilateral eye
Anosmia ipsilaterally
“This syndrome is due to optic
nerve compression, olfactory nerve
compression, and increased ICP secondary to a mass.”
CN II - Ophthalmic
Visual
Acuity
Finger counting?
Hand movements?
Light perception?
Visual fields
(confrontation)
Pupils
(also CN III)
Optic
discs
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
Distant large movements in 6 directions plus convergence
Full coordinated movements, no pathological nystagmus
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
CN V - Trigeminal
Pinprick to compare
sides in the distribution
of the 3 branches
CN VII - Facial
Lower face
Smile or blow chicks
Upper face
Forcefully close eyes
or lift eye browses
CN VII - Facial
CN VIII - Vestibulocochlear
Rub fingers, hair or paper near each hear separately
CN VIII - Vestibulocochlear
Damage to the vestibulocochlear nerve may cause:
• hearing loss
• vertigo
• false sense of motion
• loss of equilibrium (in dark places)
• nystagmus
• motion sickness
• gaze-evoked tinnitus
CN IX & X – Glossopharyngeal and vagus
Look for deviation of the uvula,
lowering of palatal arch or a
coarse voice
CN IX & X – Glossopharyngeal and vagus
CN IX
• general sensory fibers → from the tonsils, the pharynx,
the middle ear and the posterior 1/3 of the tongue.
• sensory fibers → (taste) posterior one-third of the
tongue.
• visceral sensory fibers→ from the carotid bodies, carotid
sinus.
• parasympathetic fibers → parotid gland via the optic
ganglion.
• motor fibers → to stylopharyngeus muscle, the only
motor component of this cranial nerve.
• pharyngeal plexus.
CN X - Pneumogastric nerve
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Auricular nerve
Pharyngeal nerve
Superior laryngeal nerve
Superior cervical cardiac branches of vagus nerve
Inferior cervical cardiac branch
Recurrent laryngeal nerve
Thoracic cardiac branches
Branches to the pulmonary plexus
Branches to the esophageal plexus
Anterior vagal trunk
Posterior vagal trunk
Hering-Breuer reflex in alveoli
CN XI - Accessory
Sternocleidomastoid – ask
patient to turn head against
resistance (contralateral to
turning direction)
Trapezius - press shoulder
against patient resistance
CN XII - Hypoglossal
Look for atrophy or fasciculations
while mouth slightly open and
tongue rests on the floor of the
mouth
Ask patient to stick tongue out
CN XII - Hypoglossal
Motor System
• Observe
•Passive tone
• Muscle force
• Reflexes
Observe exposed limb / trunk
No asymmetry, atrophy (hypertrophy)
or fasciculations. No involuntary movements,
or abnormal posture.
Test passive tone by asking the patient to relax and
moving his upper and lower limbs.
Look for mild weakness by asking patient to close his
eyes, stretch his arms with his palms up.
Pronator drift
Muscle strength grading
Compare muscle force on both sides:
Deltoid
Biceps
Triceps
Grip (many muscles)
Iliopsoas
Quadriceps femoris
Gastrocnemius
Tibialis anterior
Hamstrings (opposite)
Deep Stretch reflexes
Muscle
Nerve
Root
Biceps
Musculocutaneous
C 5-6
Triceps
Radial
C 6-8
Brachioradialis
Radial
C 5-6
Quadriceps femoris Femoral
L 2-4
Gastrocnemius
S 1-2
Tibial
Use reflex hammer as a pendulum:
Biceps
Triceps
Quadriceps femoris
Gastrocnemius
Brachioradialis
Test for pathological pyramidal release sign (Babinski):
Equivalent signs:
Plantar-flexion of toe
Babinski
Suspect pathological increased reflexes or wish to better
localize lesion?
Hoffman
Tromner
Ankle clonus:
Abruptly dorsoflexed ankle.
Supra-patellar reflex
Pectoral reflex
Cross-adductors reflex
Suspect frontal lesion? Neurodegenerative disease? Check
frontal release signs.
Palmo-mental
Snout
Grasp
Glabellar tap
What is the origin of muscle weakness?
Upper motor neuron
Lower motor neuron
Atrophy (in chronic disease)
Severe with fasiculations
None or mild due to disuse
Tone
Decreased
Spastic in chronic stage,
spastic or decreased in
acute stage
Deep tendon reflexes
Decreased
Increased
Babinski sign
Negative
Positive
Remember – motor system is not just about weakness but also deals with abnormal
involuntary movements, fine movements etc and possible localization is not just upper vs.
lower motor neurons but also frontal lobes, basal ganglia and cerebellum.
Sensory Exam
Sensory Exam
Pinprick to compare sides and proximal vs. distal sensation.
Ignore uncertain differences.
Suspect peripheral neuropathy, spinal posterior
columns involvement or hemi-spinal syndrome?
Use you tuning fork.
Ask patient to stand, close eyes and stretch arms
(Romberg test)
Remember you are testing proprioception (large diameter fibers, posterior spinal columns)
and the integrative function of the vestibular system rather then cerebellar functions.
Cerebellar functions
Finger to nose test (slow):
Alternating palm movements:
Finger on target without significant
corrections (dysmetria) or tremor at
the end of the movement (intention
tremor)
Smooth and regular movements
(no dysdiadochokinesia)
Heel-to-shin test is the equivalent to finger-tonose test
Gait & Balance
While patient is bared-foot (if possible):
Natural walking:
Tandem walking (heel to toe):
Steps are regular and in normal
length, base in narrow and posture
is erect.
Patients younger than 65 years
are expected to succeed
- CVA
- Head Trauma
- Brain Tumor
- CP
- MS
- UMN lesion
- Parkinson
- Liver failure
- Multiple sclerosis
- Spinal cord trauma
- Spinal cord tumor
- Syphilitic meningomyelitis
- Foot drop
- Polio
- MS
- Guillain-Barré
- Spinal disc herniation
- Fibular nerve Injury
- Spondylolisthesis
- Myopathy gait
- Pregnancy
- Cong. hip dysplasia
- Muscular dystrophy
- Spinal musc. atrophy
Thanks!