Neurological examination

1. Neurological examination Dr. D. Barry

2. Many Parts in Full Neuro Exam • Inspection – alertness/GCS Dysmorphia (syndrome?) • Cranial Nerves • Peripheral Nerves Upper limb Lower limb 4) Co-ordination, Gait, Cerebellar signs • Developmental • Higher functioning Cognitive & Behavioural

3. 1) Neonate 2) Infant/toddler • Child with Neuro-disability • Older Child (age & ability - appropriate tests) [* that’s the child’s ability, not the examiners!*]

4. Examination texts/technique should be age-appropriate • CN II – XII > 5 years • ↑↓ with co-operation, sociability etc.

5. 1) Neonate • Alertness • Expose & observe • Dysmorphism; facies • OFC & plot on centile chart • Skeleton, spine, hands & feet (deformities) • Skin, genitalia, eyes • 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)

7. 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 *

8. 2) Infant • 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.

9. 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!

10. 3) Child with NeuroDisability • Alertness • Examination tests depend on level of disability • Speak to these children directly, introduce yourself • do they respond / react? • 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)

11. 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…

12. 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

13. General Neuro Inspection • Dysmorphic features • 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.

14. 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

15. Examine relative to child’s understanding • May need to improvise • Remember what your testing; • Eyes (vision, movement, pupils) • Face • Hearing • Speech (making sounds) & Swallow

16. 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

17. Squint (Strabismus) • 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)

18. Squint may be… • Paralytic or Concomitant • Divergent or Convergent • Horizontal or Vertical • Hypertropic or Hypotropic • Permanent or Intermittent • Pseudo-squint (epicanthic folds etc.)

19. 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 Squint (Strabismus)

20. 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?

21. 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! (see diagram) 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! Practice on each other!!!Think it out!

22. 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 • 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’

23. Vestibulo-cochlear (VIII) • Hearing • Examine external auditory meatus • ? Speech normal ? • Conductive or Sensorineural? • Rinne & Weber • Balance • (often tested with cerebellar signs/gait)

24. 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)

25. Cranial Nerves Summary • 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

26. 2) Peripheral Nerve Examination • Tone • Power • Reflexes • Co-ordination • Sensation

27. 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’

28. 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 ↑ Tone

29. Power • Know grades • Compare side to side • Muscle groups

30. 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

31. Reflexes • Know how to elicit reflexes!!!!! • Child must be still & relaxed • Therefore use distraction (conversation) • Absent (?or not elicited) • Normal • Increased/Brisk

32. Tendon Reflexes Triceps C7, 8 Biceps C5, 6 Supinator C5, 6 Knee L3, 4 Ankle S1, 2

33. “please examine this child’s upper limbs”

34. Upper Limbs; Inspect • Ideally undress child to waist • Stand with arms outstretched, fingers wide • Wasting • Fasciculations • Spontaneous purposeful movements • Involuntary movements • Asymmetry • ? handedness

35. 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

36. Upper Limbs; Power • 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

37. Upper Limb; Reflexes • Distract child with conversation • Lie arm semi-flexed over body • Biceps C5,6 • Triceps C7,8 • Supinator C5,6

38. 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!

39. Hoffman’s sign • If ? Brisk reflexes • Stabilise child’s middle phalanx (with your thumb & index finger) • Flick DIP • Thumb flexes; + test (hyper-reflexia)

40. Upper Limbs; Co-ordination • Composite function; motor, sensory & cerebellar systems • Ask handedness! • Finger-nose test • Dysdiadochokinesis • Writing • Drawing

41. Upper Limb; Sensation • 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)

42. Dermatomes

43. dermatomes

44. “please examine this child’s lower limbs”

45. Lower Limbs; Inspection • Ideally undress child from waist down, but expose leg is accepted • Comment on… • Wasting • Fasciculations • Spontaneous purposeful movements • Involuntary movements • Asymmetry

46. 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)

47. Lower Limb; Power • Infants – movements? Against pressure? • Toddler – pre-school; Gait • School-going; individual muscle groups • (next slide)

48. Lower Limbs; Power • Hip; flexion (L1,2) Extension (L5, S1) abduction adduction • Knee; extension (L3,4) Flexion (S1) • Plantar; flexion (L4,5) Extension (S1,2) • Foot; inversion (L4,5) Eversion (L5, S1) • Hallux; flexion (L5) • Pelvic Gridle power; • stand up from kneeling position with arms folded • stand up from lying position (? Gower’s sign ?)

49. 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

50. Lower Limb; Co-ordination • Gait • +/- stairs, running, hopping • Heel form opposite knee to ankle