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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.
Strength MOTOR
HOMUNCULUS
Tone
Bulk
Fasciculations
UPPER MOTOR
NEURON
LOWER MOTOR
NEURON
MUSCLE
Motor Exam
Forehead involved
Palpebral fissure large
Not ptosis!
Hyperacusis
R L
Abnormal taste
Mastoid pain
III
Case 2
Central Peripheral
Reflexes Increased Decreased
Plantar stimulation Upgoing toe Downgoing toe
LOWER MOT OR
NEURON GOLGI RECEPT OR
SENSORY NERVE
MUSCLE
Reflexes Revisited
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
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
Monocular blindness
Bitemporal hemianopia
Methods:
Static
Kinetic
Good (+)LR = 4.2-6.8
Poor (-)LR: Absence of
a defect does not rule
one out
Arcuate
defect
Case 6
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
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
Brain
Brain stem
CENTRAL
Spinal cord
Motor neuron
Peripheral nerve
Neuromuscular junction PERIPHERAL
Muscle
END