Neurological Examination

The University of Newcastle

Faculty of Medicine and Health Sciences

Bachelor of Medicine

Year 2

Professional Skills

Neurology

YEAR TWO

Prepared by:

Dr I Kerridge

Dr M Parsons

Dr D Williams

THE NEUROLOGICAL EXAMINATION

CONTENTS Page

NEUROLOGY: PROFESSIONAL SKILLS..........................................................................3

MENTAL STATUS EXAMINATION...................................................................................4

HIGHER CENTRES.............................................................................................................. 5

SPEECH................................................................................................................................. 6

GAIT 8

CRANIAL NERVES.............................................................................................................. 9

UPPER LIMBS.................................................................................................................... 14

LOWER LIMBS................................................................................................................... 17

CEREBELLAR.................................................................................................................... 20

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NEUROLOGY: PROFESSIONAL SKILLS

The neurological examination may be divided into a number of parts. These are:

1. MMSE ]

2. Higher Centres ] Crossover

3. Speech ]

4. Cranial Nerves

5. Gait

6. Cerebellar

7. Upper limb

8. Lower limb

There is a huge amount of information that can be elicited in a neurological

examination, but a fairly complete examination can be done in 10-15 minutes if the examiner

is well-practised.

The general approach to neurological short case examinations is for the candidate to:

1. Listen to the examiner.

2. Be sensitive to the patient. This includes talk to the patients and making any

commands clearly. In many cases the exact wording of commands needs a lot

of practise.

3. Inspect : skin, scars

posture

drips/catheters

face

involuntary movements


voice.

4. Palpation

5. Tone

6. Power

7. Reflexes

8. Co-ordination

9. Sensation

The aim of the neurological examination is to recognize various patterns of signs that allow

you to decide:

1. What are the findings on examination? e.g. - Hemiparesis

2. Where is the lesion(s)? e.g. - Cortex

3. What is the underlying cause? e.g. - CVA


MENTAL STATUS

EXAMINATION

Folsteins’ Mini-Mental State Examination (MMSE)

The mini-mental state examination is a test of cognitive dysfunction. It is important

that a low score on a mini-mental state exam should not automatically lead the examiner to

state that the patient has dementia because there are a number of reasons why a person might

have cognitive dysfunction, including delirium and dementia and depression.

The major dificulty with using the MMSE is that the normal range of scores varies

with age and educational level. For example, the median score for a 50 year old with some

higher education is 30 (and the 25th percentile is 28), whereas the median score for n 85 year

old with less than 4 years education is 20 ( and the 25th percentile is 15).

Tables of normal values for the MMSE are available (see for example Crum RM,

Anthony JC, Bassett SS et al. “Population-based norms for the Mini-mental State

examination by age and educational level.” JAMA 269: 2386-91, 1993., however most

clinicians appear to simply remember a cut off score of about 23 in which those above are

thought of as normal and those below are thought of as impaired. If this approach is used, it

must be supplemented by the examiner -carefully looking at the responses to each question

and asking if the response is consistent with the age and educational level of the patient. For

example, a professor of English literature who cannot spell the word “world” backwards, has

clearly got a degree of cognitive decline, whereas an illiterate labourer wit the same answer

may be perfectly normal.

There are a number of other problems with the MMSE that the user should be aware

of. Some questions are known to be a little unclear, (for example the marking of question 4 is

unclear), and no time limit. Furthermore, other ethnic groups are known to score badly on

some items compared to English speakers (including season, county, spelling, serial


subtraction, and “no ifs ands or buts”) Some of the questions need to be modified slightly for

other countries (ie “county” has no meaning in Australia.)

With these limitations in mind, the MMSE is a useful screening test for cognitive

dysfunction.

Specific Test Function and Area Tested Points Score

1. What is the year/season/day/date/month? Orientation (frontal) 5

2. What is the state/county/town/

hospital/floor?

Orientation (frontal) 5

3. Repeat three items Registration (frontal) 3

4. Serial subtraction of sevens or spell

“World” backwards

Concentration (frontal) 5

5. Name wristwatch and pen Naming (dominant

Temporoparietal)

2

6. Say “no ifs, ands, or buts” Expressive speech (dominant

frontal)

1

7. Take this paper in your right hand, fold it

in half and put it on the table.

Three-stage command

(frontal)

3


8. Read “close your eyes” and do it Reading (dominant

temporoparietal)

1

9. Remember the three items from

Part 3 above

Short-term memory

(dominant hippocampal)

3

10. Write a sentence Writing (dominant

temporoparietal)

1

11. Copy intersecting pentagons “Construction” (non-

dominant parietal)

1

TOTAL


There are a number of alternative tests to the Folstein’s MMSE including the “Blessed Six

Item Orientation-Memory-Concentration Test”.

Total score: < 8 - normal or minimal impairment;

9 to 19 - moderate impairment;

> 20 - indicates severe impairment.

Reference: Katzman et al American Journal of Psychiatry 140 (1983) 6.

Item Number of

errors

possible

Score given

for each error

Score

1. What YEAR is it now? 1 x 4

2. What MONTH is it now? 1 x 3

MEMORY PHRASE: Repeat this phrase after me:

“John Brown, 42 Market St, BRISBANE.”

3. About what TIME is it? (Within 1 hour) 1 x 3

4. Count backwards 20 to 1 2 x 2

5. Say the months in reverse order 2 x 3


6. Repeat the memory phrase 5 x 2

TOTAL /30


HIGHER CENTRES EXAMINATION

1. ASK PATIENT IF LEFT OR RIGHT-HANDED:

The text books have very conflicting data about handedness and dominance. One

often quoted figure is :

94% Right-handed persons - Dominant Left hemisphere

60% Left-handed persons - Left dominant

30% Left-handed persons - Mixed dominant

10% Left-handed persons - Right dominant

however there are many other figures suggested. In general, the important fact is that almost

all right handed people have left hemisphere dominance, but that some left-handed people

have right or mixed dominance.

2. ORIENTATION (MMSE)

3. SPEECH

4. PARIETAL LOBE FUNCTION

DOMINANT : "Gerstmann’s" ‘ Acalculia/Agraphia/Left-Right

disorientation/Finger Agnosia


NON-DOMINANT : Spatial neglect (clockface)/Apraxia (PJ's, house)

NON-LOCALIZING : Inattention (sensual and visual)/Homonomous

hemionopia.

Cortical sensory loss i.e. Proprioception, 2-point

discrimination, Inattention (visual and sensory),

Touch-localisation, Graphaesthesia (numbers),

Astereognosis (objects).

5. OCCIPITAL

- Homonomous Hemianopia

- "Cortical" blindness (bilateral)

- Topographical amnesia

- Unable to : recognize faces (prosopagnosia)

: read (alexia)

: recognize objects (visual agnosia)

6. TEMPORAL

- STM loss (4 words: honesty, brown, tulip, eyedropper)

- LTM loss (AWhen did WWII start? ... finish?)

- Confabulation (Have we met before?)

- Dysphasia (receptive) and Nominal dysphasia (angular gyms of

temporal lobe)

- Upper Quadrant Hemianopia


7. FRONTAL

- Anosmia

- Proverb interpretation

- Gait ataxia (wide-based, shuffling)

- Primitive reflexes: grasp, pout, snout, suck, palmar-mental

- Incontinence

- Expressive dysphasia (Dominant: Broca's area)

- Personality change : abulic (decreased initiation and spontaneity)

: impaired concentration/attention

: cannot pursue goals

: personality change

: disinhibition

SPEECH

Dysphasia : Disturbance in understanding or production of language.

: Dominant hemisphere lesion.

: Speech disorder is either fluent or non-fluent:

Fluent - Sentences are of normal length and words flow

easily but words are used incorrectly and


speech is difficult to understand. Patient

uses paraphrasias,

e g : literal paraphrasia, verbal

paraphrasia and/or neologisms.

Non-fluent - Speech slurred and lacks “fillers” (and,

the, so, to) therefore sounds like a

telegram.

: Most common dysphasias: expressive, receptive, conductive and

nominal.

Dysarthria : Difficulty with articulation.

: Cerebellar disease, bulbar palsy, pseudobulbar palsy, extrapyramidal

disease. (Differentiation is difficult in terms of the quality of speech

alone. Diagnosis can usually be made by the associated neurological

abnormalities!).

Dysphonia : Altered quality of voice.

: Laryngeal disease, recurrent laryngeal nerve palsy, hysteria,

myopathy.

To Test:

1. Introduce yourself and shake hands.


2. Free speech : How long have you been in hospital?

: What sort of work do you do?

3. Comprehension : Do you understand what I am saying?

: Close your eyes (1-step command).

: With your right finger touch your nose and then

your ear (2-step command).

: I would like you to pick up this piece of paper,

fold it in half and then place it back on the

bed/table (3-step command).

4. Repetition/Dysarthria

assessment : Please repeat after me......”No ifs, ands or buts.”

...”West Register Street.”

...”British Constitution.”

: Repeat PUH (lip weakness), TUH (tongue) KUH

(palate).

5. Naming objects : Shirt, sleeve, cuff, button.

Watch, band, face, hand, tell time.

6. Reading : “Read what it says on this card and do what it

says”.


7. Writing : “Please write a sentence”.


TYPES OF DYSPHASIA

NON-FLUENT FLUENT

EXPRESSIVE RECEPTIVE CONDUCTIVE NOMINAL

Understands but cannot

answer.

Speech fluent but

disorganized. Unable to

understand written or

spoken

words/commands.

Repeats statements and

names objects poorly but

can follow commands.

Cannot name objects

but all other aspects

of speech normal.

SITE BROCA’S AREA

Dominant Third Frontal

Gyrus

WERNICKE’S AREA

Dominant Temporal

First Gyrus

TEMPORAL LOBE

Arcuate Fasciculus

Linking W and B area.

Dominant Posterior

Temporoparietal

area: Angular gyrus

NAMING Poor Poor Poor Poor

REPETITION May be possible with

effort.

Poor Poor Normal

COMPREHENSION Normal Poor Normal Normal

READING May have dyslexia Neologisms paraphrasias Poor Normal

WRITING Abnormal content Impaired Normal

OTHER Hemiparesis Gerstmann’s

Hemianopia

Paraphrasia Use long sentences to

overcome

word-finding

difficulty

(circumlocution)

GAIT

Complex. For locomotion need :Basal ganglia

:Locomotor Region (mesencephalon)

:Cerebellum

:Spinal cord

:Sensory input from joints/muscular afferents

1. Ask ... "May I walk Mr/Mrs ....."

2. Ask someone else to assist. YOU WATCH

3. Observe: posture

arm swing

stride

base

involuntary movements

4. Tandem Gait (walk heel-to-toe)

5. Rhombergs (Need 2 of 3: eyes, vestib, JPS)

6. Screening: Arms held in front with eyes closed + touch nose + lift arms up

straight and then down to the horizontal.

7. Stand on toes (weak gastrocnemius)

8. Stand on heels (foot-drop)

9. Squat (proximal myopathy)

+/-

10. If suspect cerebellar:

1. Walk around chair (fall to side of lesion)

2. March on spot (unterbergers: turn to side of lesion)

COMMON GAIT DISORDERS

1. High stepping : Unilateral foot drop

2. High and slapping : 1. Bilateral foot drop (Peripheral neuropathy, HMSN)

2. Sensory ataxia (MS, Tabes dorsalis, Spinocerebellar

Degeneration, sensory neuropathy)

3. Waddling (shoulders swap/tilt trunk/flex knee + hip) ‘ Weak hip abductors (proximal

myopathy, OA)

4. Hemiparetic: Arm flexed, foot extended, circumduction.

5. "Scissor" (Spastic Paraparetic): both legs circumduct. (Cerebral Palsy, M.S.)

6. Parkinsonian: (freeze, no arm swing, festination, propulsion, retropropulsion)

7. Broad-based shuffle and small steps: (marche à petit pas) [Normal Pressure

Hydrocephalus (Dementia, incontinence), Multi-infarct Dementia (Hyper-reflexic,

brisk jaw jerk).]

8. Ataxic/ wide-based. ‘ 1. Unilateral cerebellar (falls to side of lesion)

2. Midline (staggers in all directions)

CRANIAL NERVES

CN 1: OLFACTORY

sensory

usually not tested

may wish to test in the presence of personality disturbance, hemiparesis or visual loss

Test each nostril separately (use easily recognized substance e.g. peppermint oil, oil

of cloves).

CN 2: OPTIC

1. Observe : Level of eyelid - Ptosis (CN 3 lesion, myasthenia,Horner’s)

- Lid retraction

: Position of eye - Exopthalmos (Graves, tumour)

- Enopthalmos (Horner’s)

2. Acuity : (Using two acuity cards - patient may use glasses)

- "What is the smallest line you can read?" (Snellen card)

- If less than 6/60: Counting fingers

:Hand waving

:Perception of light and dark

3. Gross visual fields/visual inattention: Finger confrontation.

4. Visual fields (red pin)

Test with red pin: White objects more easily seen than red.

Central vision ‘ Colour : cones

Peripheral vision ‘ B+W : rods

Therefore earlier peripheral loss with red pin.

Fig.1. The visual pathways as seen from above the brain. Letters A-F refer to visual field defects following

lesions in the corresponding brain areas. Circles indicate

what the left and right eyes see (the left and right visual

fields). Black areas represent visual field defects.

A. Constricted field left eye (e.g. end-stage glaucoma). When constricted fields are bilateral, it

sometimes signifies hysteria.

B. Central scotoma (e.g. optic neuritis in multiple sclerosis).

C. Total blindness of the left eye.

D. Bitemporal hemianopia (e.g. pituitary gland tumor).

E. Right homonymous hemianopia (e.g. stroke).

F. Right superior quadrantopia.

5. Blind spot (red pin)

6. Pupils

Afferent - optic nerve

Efferent - PNS component of CN 3

20% difference in size - Normal (Anisocoria)

Small pupil - SNS lesion

Large pupil - PNS lesion

: Light Reflex - direct

- consensual

: Accommodation

: Swinging light test:

Normal : Pupil always constricts

Abnormal : Pupil dilates to light

‘ Afferent pupillary defect

‘ Marcus Gunn pupil

‘ Anterior to chiasm (optic neuritic or

compression of the optic nerve)

Fig. 2. The pathways for the pupillary light reflex and accommodation. LGB, lateral geniculate body. The

depicted lesions presumably also interrupt light reflex fibers crossing from the opposite side of the brian stem.

The pathway shown innervating the eye is highly schematic; the light reflex pathway involves only pupillary

constriction, whereas the accommodation pathway affects both pupillary constriction and ciliary body

accommodation.

7. Fundoscopy using Opthalmoscope

: Red reflex

: Retina: Locate vessel: follow to disc then periphery

: Venous pulse : (at cup)

: Retinal background

: Dilate pupil with tropic amide (DO NOT USE IN GLAUCOMA)

CN 3: OCULOMOTOR

CN 4: TROCHLEAR

CN 6: ABDUCENS

Motor to eye

Autonomic

Eye movements have complex control including: 1. Saccadic/command (frontal)

2. Pursuit (occipital/parietal)

3. Vestibular/positional

(cerebellar/vestibular nuclei)

Test 1. Observe: position of head (head tilted away from the side of a CN 4 lesion).

: eyelid (ptosis suggest CN 3 lesion or a Horners)

: eye position (one eye looking up or down suggests skew deviation).

2. Screen: Instruct patient to “look up, look down, look to the left, look to the

right.”

3. Pursuit movements : following a pin

4. Saccadic movements : finger to fist

5. Accommodation/convergence : "Look in to the distance ... now at my finger"

6. Consider Cover Test

Note: * Diplopia (double vision) is usually maximal in the direction of gaze of the

affected muscle. This indicates the abnormal cranial nerve.

* In diplopia the false image is usually the outer image. This indicates the

abnormal eye,

e.g. CN 6 : Diplopia on lateral gaze.

CN4 : Diplopia maximal looking down and in.

Images at an angle. Unable to look down and

out.

* Comment on Nystagmus

- Nystagmus defined in direction of fast movement.

- When testing take inward looking eye to edge of caruncle - any further

will cause physiological nystagmoid jerks.

- Peripheral (vestibular) disease causes symmetrical nystagmus with the

fast phase away from the side of the lesion. The fast phase remains in

the same direction despite the direction of gaze. The amplitude of

nystagmus is sometimes increased by looking in the direction of the fast

phase.

- Central (brainstem) disease cause asymmetrical nystagmus. It is

rotatory or vertical (always implies brainstem dysfunction in the

absence of drugs) and may demonstrate fast phase changes with change

in gaze direction.

- Cerebellar disease classically cause nystagmus with the fast phase

towards the side of the lesion, however, there is often distortion of the

brainstem and nystagmus may be much more complex. Vermis lesions

can cause up-beating nystagmus.

* Internuclear opthalmoplegia: eye movements frequently normal when each

eye tested individually but abnormal when pursuit movements are tested

together.

e.g. Left INO : Left eye fails to adduct

Right eye develops nystagmus

Fig.3. The pathway for lateral conjugate gaze.

PPRF - pontine paramedian reticular formation.

CN 5: TRIGEMINAL

Sensorimotor

Motor to temporalis and masseter sensory to face.

Large sensory nucleus extending from Pons to upper cervical cord: light touch in

Pons, pain/temparature in Medulla/cervical. (Therefore pontine lesions may

demonstrate loss of light touch with preservation of pain and temperature.

Test: 1. Corneal reflex (CN5 to feel CN7 to blink)

2. Sensation: (Test pin-prick/soft-touch in each of the three anatomical

divisions - opthalmic, maxillary and mandibular).

3. Motor:i “Clench your jaw.” Palpate temporalis/masseter bulk.

ii Strength of jaw opening. “Hold your jaw open.” (Look

for deviation to the side of weakness.)

iii Jaw-jerk.

Fig.4. Trigeminal nerve sensory dermatomes.

CN 7 : FACIAL

Sensory, motor, autonomic

Motor : Facial musculature

Ear : Tensor tympani and stapedius

Taste : ( via chordae tympani) to the anterior 2/3 of the tongue.

Test: 1. "Smile"

2. "Show me your teeth"

3. "Screw up your eyes"

4. "Look up to the ceiling"

5. "Whistle"

6. "Blow out your cheeks"

CN 8 : AUDITORY

Auditory/vestibular function.

Test: 1. Hearing : Whispering numbers (at arms length whilst

occluding the opposite ear).

2. Webers : 512 Hz tuning fork held on the centre of the head.

"Where is it louder?"

3. Rinne's : 512 Hz tuning fork held on the mastoid then in front

of the ear to test bone and air conduction. Normally

air conduction better than bone conduction.

4. Vestibular : Gait

Nystagmus

Caloric testing

not usually part of CN exam

WEBERS RINNE’S IN DEAF EAR

Conductive Deafness

Sensorineural Deafness

Heard in deaf ear

Heard in normal ear

BC>AC

AC>BC

CN 9 : GLOSSOPHARYNGEAL

Sensory : Posterior 1/3 of tongue, soft palate, pharynx.

Motor : Stylopharyngeus

Test : Gag reflex (bilaterally)

CN 10 : VAGUS

Sensory : External ear

Motor : Palate, pharynx, larynx (via recurrent laryngeal)

Test : 1. Cough, voice quality

2. "Say Ahh" - Observe soft-palate movement. If normal

uvula stays in midline

- If weak uvula deviates (pulled over) to the

normal side.

3. Gag (Sensory - CN 9, Motor - CN 10)

CN 11: SPINAL ACCESSORY

Motor : Supplies - ipsilateral trapezium

- ipsilateral sternomastoid

Test : 1. Shoulder elevation (trapezius)

2. Lateral head rotation (opposite sternomastoid)

3. Pushing forehead forward against resistance (bilateral

sternomastoid, weakness, myopathy).

CN 12 : HYPOGLOSSAL

Motor to tongue

Test : 1. Observe in mouth for wasting, fasiculations.

2. Stick out the tongue: Tongue points toward (pushed) to the weak side.

3. Test tongue strength.

UPPER LIMBS

1) OBSERVE THE ENTIRE PATIENT

2) SHAKE HANDS (Grip strength, co-ordination, myotonia)

3) ASK PATIENT TO SIT ON THE EDGE OF THE BED

4) INSPECT: wasting (distal/proximal)

deformity

fasciculation

tremor

5) HOLD OUT ARMS/EYES CLOSED

Drift - UMN weakness (down)

- cerebellar (up: hypotonia)

- post column loss (impaired JPS)

6) PIANO PLAYING (SCREENING)

7) PALPATE : muscle bulk

tenderness

thickened nerves - median: wrist

ulnar : elbow

8) TONE : Clonus (> 3 beats)

Rigidity

Spasticity

Cog-wheeling

9) POWER (GRADE 0 - 5)

SHOULDER: Elevation - C3,4 + CN11

Abduction - C5 Deltoid (Axillary n.) + Supraspinatus

Adduction - C7 Pectoralis Major (Pectoral nerves)

Latissimus Dorsi

ELBOW: Flexion - C6 Biceps (Musculocutaneous n.)

Extension - C7 Triceps (Radial n)

Thumb up - C6 Brachioradialis (Radial n.)

WRIST: Flexion - C7 Flexor carpi ulnaris (Median)

Extension - C7 Extensor carpi radialis (Radial) wrist

drop.

FINGERS: Extension - C8 Extensor digitorum (Radial - post

interosseous n.)

Flexion - C8 Flexor digitorum superficialis and

profundus

Abduction - T1 1st Dorsal interossei, Abductor digiti

minimi (Ulnar)

Thumb - T2 Abductor pollicus brevis (Median)

10) REFLEXES : Biceps C5

Triceps C7

Brachioradialis C6

Finger C8

11) CO-ORDINATION :Finger-nose

:Dysdiadokokinesis

12) SENSORY

With sensory examination consider cortical, intracapsular, cord, dermatomal,

peripheral nerve distribution.

there is significant overlap between dermatomes and between peripheral

nerves therefore the area of sensory loss in dermatome or nerve lesions may be

less than illustrated/expected.

1. Pain/temperature (enters cord and crosses 1-2 segments above):

Pin

Chest wall first

Dermatomal.

Dull or sharp

Start proximally (unless cord compression or

peripheral neuropathy suspected)

Move from abnormal to normal

2. Vibration (128 Hz) (Dorsal column)

3. Proprioception (Spinocerebellar tract: Ipsilateral)

4. Light touch (Posterior column and Anterior spinothalamic tract)

C4 chest to shoulders

T2

Axilla C5 arm to below elbow

C6 thumb/wrist

T1

elbow

C8

little finger

Median nerve]

NOTE: Small muscles of hand supplied by: + T1 nerve root.

Ulnar nerve ]

Therefore look at Abductor digiti minimi, First dorsal interossei, Abductor pollicus

brevis.

1. APB weak : Median nerve

2. ADM and 1st DI weak : Ulnar

3. All three weak : Many causes; cord, root, plexus

lesion. Peripheral neuropathy.

Motor neuron disease etc.

LOWER LIMBS

1) GAIT : Can I walk Mr/Mrs ...? If yes ... see Gait exam: Rhombergs

Normal

Heel-toe

Stand on toes

Stand on heels

Squat

2) LIE DOWN

3) OBSERVE - Expose legs (use towel)

- ?IDUC

- Wasting: esp - 1. Generalized

- 2. Tibialus Anterior/EDB/Quadriceps

- 3. Pes cavus (High arch, clawed toes,

thick foot) HMSN, Friedreichs, Spina

bifida.

- Fasciculations

- Tremor

- Deformities

4) PALPATE - Tenderness

- Bulk

- Tap/flick for fasiculations

- Thickened nerves

5) TONE - Leg roll

- Knee (lift up with hand in popliteal fossa)

- Clonus : ankle (sustained rhythmical contractions ‘ UMN)

+/- patella clomnus.

Grade 0 5. Start proximally.

6) POWER

[1. LMN: Weak, wasted, flaccid, hyporeflexic, fasciculation.

[2. UMN: Spastic, clonus, hyper-reflexic, Babinski,

UMN pattern weakness - Arm: Abd + Ext]

Leg: Add+Flex]

HIP: Flexion - L2 Ilipsoas (Femoral n)

Extension - L5 S1-2 Gluteus Maximus (Inf glueal n)

Abduction - L4-5 S1 Gluteus medium/minimus + Tensor

fascia lata (Sup gluteal n)

Adduction - L2-3 (Obturator n)

KNEE: Flexion - L5 S1 Hamstrings (Sciatic n)

Extension - L3 Quadriceps (Femoral n)

ANKLE: Plantarflex - S1 Soleus/Gastrocnemius (tibial n)

Dorsiflex - L4-5 Tibialus Anterior (Common peroneal n)

Eversion - L5 S1 Peroneus Longus (Common peroneal n)

UMN

Inversion - L4 Tibialus Posterior (Tibial n) Root/Plexus

Dorsiflex toe - L5 S1 Ext digitarum longus (Deep peroneal n)

7) REFLEXES: Knee - L4 Quadriceps

Ankle - S1 Gastrocnemius

Plantar- S1 Plantar or babinski

Anal - S3-4-5

Ant Abdo - Upper - T6-8

Lower - T10-12

8) CO-ORDINATION: Heel-shin

Finger-toe

Foot-tap

9) SENSORY: Pin prick ]

Vibration sense ] If a sensory level is present: Go to the abdomen

Proprioception ] Check saddle sensation

Soft touch ] Check anal reflex

10) BACK: Deformity

Scars

Neurofibroma

L3 knee

L4 to heel (medial)

L5 lateral leg and large toe

S1 sole + small toe

S2 up middle of leg at posteriorly

CEREBELLAR

FUNCTION: Basically a servocontrol mechanism

1. Maintain posture/balance

2. Fine voluntary movements

3. Co-ordinate smooth tracking movements of eyes

4. Control trajectory, velocity and acceleration of movements.

STRUCTURE: Complex

Inputs: Ascending 1. spinocerebellar

2. vestib apparatus

Descending 1. pyramidal

2. extrapyramidal

Outputs: 1. Motor cortex

2. Basal ganglia

3. Red nucleus

4. Reticular formation

5. Vestib appartus

EXAMINATION TECHNIQUE

1. LISTEN: "This patient has a problem with co-ordination." (DDx : Cerebellar,

posterior column, extrapyramidal lesions)

2. EYES : Nystagmus (when look to side of lesion Central :Rapid to side of lesion.)

Labyrinthe :Rapid away from lesion.)

3. SPEECH: Impaired rate, rhythm and amplitude i.e.Jerky, explosive and loud with

irregular separation of syllables:

West Register Street

Irish Constabulatory

British Constitution

4. UPPER LIMBS : Drift

: Rebound

: Tremor (agonist hypotonia)

: Hypotonia (loss facilitatory influence on spinal motor neurons)

5. FINGER NOSE : Intention tremor

: Past-pointing

6. RAPID MOVEMENTS

7. DYSDIADOKOKINESIS

8. LEGS : tone

: heel-shin

: foot-tap

9. SIT ON BED : truncal ataxia

: reflexes (pendular)

10. GAIT

PATTERNS

Midline: Dysarthria gait and truncal ataxia

Hemispheric: Limb ataxia, tremor, nystagmus, hypotonia

I. UNILATERAL - Ischaemia (Lateral Medullary Sydnrome), MS,

Tumour, abscess, trauma, PNS

II. BILATERAL - Drugs (ETOH, Phenytoin), MS, SOL, PNS,

Friedreichs Ataxia, Hypothyroid, Arnold Chiar

malformation.

III. MIDLINE - PNS, Midline tumours

IV. ROSTRAL/VERMIS

(Spares arms) - Alcohol

Documents

Neurological Examination