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Neurological Exam:

Still Important After All These Years

Eric Kraus, MD
Neurology
Neurological Levels

Brain
Brain stem
Spinal cord
Motor neuron
Peripheral nerve
Neuromuscular junction
Muscle
Case 1
This is a 62 year-old male with chronic right leg weakness
progressing over 6 months.

How do you use the motor exam to localize the problem


to either a peripheral or central process?
Motor Exam

Strength MOTOR
HOMUNCULUS

Tone
Bulk
Fasciculations
UPPER MOTOR
NEURON

LOWER MOTOR
NEURON
MUSCLE
Motor Exam

Central (UMN) Peripheral (LMN)


Strength Decreased Decreased
Tone Spasticity Normal or decreased
Bulk Normal Atrophy
Fasciculations No Yes (motor neuron dis., PN)
Case 1 Revisited
This is a 62 year-old male with chronic right leg weakness
progressing over 6 months.

Does changing the history to acute right leg weakness


over one day change your findings?

Central (UMN) Peripheral (LMN)


Strength Decreased Decreased
Tone Spasticity Normal or decreased
Bulk Normal Atrophy
Motor Exam

Grading Functional testing


5 = normal Pronator drift
4 = weak with resistance
Arm rolling test
3 = antigravity w/o resistance
Hoover sign
2 = less than antigravity
1 = twitch Spasticity in legs
0 = none Bulk - symmetry and
Grade only full effort experience
Isolate each muscle
Case: Facial Weakness
Forehead has bilateral innervation R L
Central weakness
Pyramidal system
Forehead spared
CENTRAL
Palpebral fissure normal
Peripheral weakness
7th cranial nerve (Facial) CN7

Forehead involved
Palpebral fissure large
Not ptosis!
Hyperacusis
R L
Abnormal taste
Mastoid pain
III
Case 2

This is a 62 year-old male with chronic bilateral leg


weakness progressing over 6 months.

How do you use the reflex exam to localize the problem to


either a peripheral or central process?
Reflex Exam

Central Peripheral
Reflexes Increased Decreased
Plantar stimulation Upgoing toe Downgoing toe

Upgoing toe = Babinski sign


UPPER MOTOR
NEURON

LOWER MOT OR
NEURON GOLGI RECEPT OR
SENSORY NERVE

MUSCLE
Reflexes Revisited

This is a 62 year-old male with chronic bilateral leg


weakness progressing over 6 months.

Would changing the history to acute bilateral leg


weakness over one day change your findings?

Central Peripheral
Reflexes Increased Decreased
Plantar stimulation Upgoing toe +/- Downgoing toe
Reflex Exam

Grading
4 = Clonus
3 = Hyperactive 0 3
2 = Average
1 = Hypoactive
1 3
0 = none 0 2
Symmetry is critical
Threshold testing 2 2
Augmentation 2+ 2
Reflex Exam

Downgoing
Mute symmetrically is normal

Upgoing
Whole leg may flex
Reproducible

Withdrawal?
Movement at ankle, knee and hip
Variable movement
Decrease stimulation may help
Case 3

This is a 48 year-old woman with 2 years of numbness in


her feet.

How do you use the sensory history and exam to localize


the problem to either a peripheral or central process?
Sensory Exam

Posterior columns SENSORY


HOMUNCULUS
Vibration
Proprioception
Light touch T HALAMUS

Spinothalamic tract
Pain
Temperature
POST ERIOR COLUMN
SPINOTHALAMIC
T RACT DORSAL ROOT
GANGLION
Sensory Exam
Brain
Hemisensory SENSORY
HOMUNCULUS
Brain stem
Hemisensory
Crossed face - body
THALAMUS
Spinal cord
Sensory level
Separation of posterior column -
spinothalamic
TRIGEMINAL NERVE
Peripheral nerve POSTERIOR C OLUMN
SPINOTHALAMIC
Symmetric - length dependent TRACT DORSAL ROOT
Symmetric - proximal and distal GANGLION

Focal or multifocal
Sensory Exam
Subjective
Tuning fork
Proprioception
Sharp stick or pin
Romberg
Other cortical tests
Examples: Sensory

This is a 71 year-old woman with diabetes mellitus who


noted onset of numb feet 6 months ago. On exam she
cant feel vibration until the ankle and light touch
normalizes at the mid-shin.

Diabetic, length-dependent, peripheral neuropathy.


Examples: Sensory

This is a healthy 31 year-old construction worker who


noted onset of numb hands 3 months ago. On exam
he has decreased light touch in the thumb, index and
middle fingers.

Carpal tunnel syndrome.


Examples: Sensory

This is a healthy 25 year-old woman with subacute


onset of numbness from the abdomen down, weak
legs, and urinary retention starting 2 days ago. On
exam she has a T10 sensory level to pinprick.

T10 transverse myelitis.


Examples: Sensory

This is a healthy 25 year-old woman with subacute


onset of numbness from the abdomen down, and
weak right leg starting 2 days ago. On exam she has
a T10 sensory level to pinprick on the left, and loss of
vibration in the right leg.

T8 multiple sclerosis plaque on the right.


Examples: Sensory

This is a 80 year-old man with diabetes mellitus, HTN


and hyperlipidemia who noted acute onset of left
face/arm/leg numbness 2 hours ago. On exam he has
decreased light touch on the left.

Right thalamic stroke.


Case 4

This is a 22 year-old female who feels clumsy.

How can you tell if poor coordination localizes to the


cerebellum?
Cerebellar Exam
Very difficult exam Interfering issues
Finger-nose-finger Weakness
Heel-knee-shin Sensory loss
Rapid alternating movements Vertigo
Tandem gait Normal imperfection
Side-to-side differences
Case 5

This is a 65 year-old male who keeps bumping into


furniture on the left and crashed his car when turning left.

Can bedside visual field testing pick up a defect?


Visual Field Exam

Monocular blindness

Bitemporal hemianopia

Left homonymous hemianopia

Left superior quadrantanopia

Left homonymous hemianopia


with central sparing
Visual Field Exam

Methods:
Static
Kinetic
Good (+)LR = 4.2-6.8
Poor (-)LR: Absence of
a defect does not rule
one out

Arcuate
defect
Case 6

This is a 63 year-old male with trouble walking.

How do you use the gait exam to localize the problem to


either a peripheral or central process?
Gait Exam

Peripheral Central
Nerve Pyramidal
Peripheral neuropathy Stroke
Muscle Extrapyramidal
Muscular dystrophy Parkinson disease
Vision Frontal lobes
Macular degeneration Normal pressure hydrocephalus
Vestibular Cerebellar
Menieres disease Multiple sclerosis
Joint Psychiatric
Hip arthritis Conversion disorder
Gait Exam

Walk down the hall

Motor
Reflexes
Sensory
Cerebellar
Vision
Gait Exam

Peripheral
Nerve
Foot drop or
steppage gait
Muscle
Trendelenburg or
waddle gait
Gluteus
Vision medius
Vestibular
Joint
Antalgic gait
Gait Exam

Central
Pyramidal
Hemiparetic or
circumduction gait
Extrapyramidal
Shuffling gait
Frontal lobes
Cerebellar
Ataxic gait
Psychiatric
Case: Writing Trouble

Patient 1 Patient 2
Progressive for 2 months Progressive for 2 months
Slow hand movements Slow hand movements
No sensory loss No sensory loss
Writing Trouble

Patient 1 Patient 2
Progressive for 2 months Progressive for 2 months
Slow hand movements Slow hand movements
No sensory loss No sensory loss
Right arm 4/5 + drift No weakness or drift
Increased reflexes right arm Normal reflexes
Action tremor Tone increased (cogwheel)
Rest tremor
Writing Trouble

Patient 1 Patient 2
Progressive for 2 months Progressive for 2 months
Slow hand movements Slow hand movements
No sensory loss No sensory loss
Right arm 4/5 + drift No weakness or drift
Increased reflexes right arm Normal reflexes
Action tremor Tone increased (cogwheel)
Rest tremor

Pyramidal: Brain tumor Extrapyramidal: Parkinson disease


Summary
The neurological exam is not any one part, but rather,
the addition of multiple parts to localize the lesion.

Brain
Brain stem
CENTRAL
Spinal cord
Motor neuron
Peripheral nerve
Neuromuscular junction PERIPHERAL
Muscle
END