NEUROLOGICAL EXAMINATION

1. NEUROLOGICAL EXAMINATION MOTOR & SENSORY FUNCTION AN ANATOMICAL GUIDE Kaan Yücel M.D., Ph.D. 22.March.2012 Thursday

2. Basic Components of the Neurologic Examination History Cerebral function (mental status) Cranial nerve function Motor function Sensory function Cerebellar function Reflex function Gait and stance NeurologicExam Susan R. Winkler, Pharm.D. BCPSSpring 1998

3. TESTING THE MUSCLES

4. SHOULDER Shoulderabduction Axillarynerve Deltoid Thearm is abducted, startingfromapproximately 15°, againstresistance. Ifactingnormally, thedeltoid can easily be seenandpalpated.

5. SHOULDER Initiatesabduction of the arm Suprascapularnerve Supraspinatus Abductionof thearmfrom fullyadductedpositionagainstresistance. Palpatedsuperiortoscapularspine. Supraspinatus & middledeltoidtestedtogether. Infraspinatus Laterallyrotatesthehumerus Suprascapularnerve Thepersonflexestheelbowandadductsthearm. Thearmthenlaterallyrotatedagainstresistance. Infraspinatus & teres minortestedtogether. Palpatedinferiortoscapularspine.

6. SHOULDER Degenerativetendonitis of therotatorcuff Theperson is askedtolowerthefullyabductedlimbslowlyandsmoothly. Fromapproximately 90° abduction, thelimbwillsuddenlydroptotheside in an uncontrolledmanneriftherotatorcuff (especiallysupraspinatuspart) is diseasedand/ortorn

7. ANTERIOR ARM Forearm flexor & supinator Musculocutaneousnerve Bicepsbrachii Elbow joint is flexed against resistance when the forearm is supinated. Ifactingnormally, themuscleforms a prominentbulge on theanterioraspect of thearmthat is easilypalpated.

8. ANTERIOR ARM Main flexor of the forearm Musculocutaneousnerve Brachialis Forearm is semipronated and flexed against resistance. If acting normally, the contracted muscle can be seen and palpated.

9. POSTERIOR ARM Forearm extension Radial nerve Tricepsbrachii The arm is abducted 90° and then the flexed forearm is extended against resistance provided by the examiner. If acting normally, the triceps can be seen and palpated.

10. Flexor & adductor of the wrist Ulnarnerve ANTERIOR FOREARM Flexorcarpiulnaris The person puts the posterior aspect of the forearm and hand on a flat table and is then asked to flex the wrist against resistance while the examiner palpates the muscle and its tendon. Flexor & abductor of the wrist Radial nerve Flexorcarpiradialis The person is asked to flex the wrist against resistance. Ifactingnormally, itstendon can be easilyseenandpalpated.

11. Accessory flexor of the wrist, opposes shearing forces on the skin of the palm during gripping Median nerve ANTERIOR FOREARM Palmarislongus The wrist is flexed and the pads of the little finger and thumb are tightly pinched together. If present and acting normally, the tendon can be easily seen and palpated.

12. Rotates radius over ulna duringpronation Median nerve ANTERIOR FOREARM Pronator teres The person's forearm is flexed at the elbow and pronated from the supine position against resistance provided by the examiner. If acting normally, the muscle is prominent and can be palpated at the medial margin of the cubital fossa.

13. Flexes the metacarpophalangeal joint and proximal interphalangeal joint of each finger; also flexes the wrist joint. Median nerve ANTERIOR FOREARM Flexordigitorumsuperficialis One finger is flexed at the proximal interphalangeal joint against resistance and the other three fingers are held in an extended position to inactivate the flexor digitorum profundus.

14. Flexes the distal phalanges of the medial four fingers Lateral half median nerve Medial half ulnar nerve ANTERIOR FOREARM Flexordigitorumprofundus The proximal interphalangeal joint is held in the extended position while the person attempts to flex the distal interphalangeal joint. The integrity of the median nerve in the proximal forearm can be tested by performing this test using the index finger, and that of the ulnar nerve can be assessed by using the little finger.

15. Flexes the thumb Median nerve ANTERIOR FOREARM Flexorpollicislongus The proximal phalanx of the thumb is held and the distal phalanx is flexed against resistance.

16. Relatively weak flexion of forearm; maximal when forearm is in midpronatedposition Radialnerve POSTERIOR FOREARM & HAND Brachioradialis Elbowjoint is flexedagainstresistancewiththeforearm in themidproneposition. Ifthebrachioradialis is actingnormally, themuscle can be seenandpalpated.

17. Extend & abduct hand @ wrist Radialnerve POSTERIOR FOREARM & HAND Extensorcarpiradialislongus Wristis extended& abductedwithforearmpronated. Itstendon can be palpatedproximaltothewrist.

18. POSTERIOR FOREARM & HAND Extends medial four digits primarily @ metacarpophalangealjoints, secondarily @ interphalangealjoints Deep branch of radial nerve Extensordigitorum Forearmis pronatedandthefingersareextended. Thepersonattemptstokeepthedigitsextended@ metacarpophalangealjoints as theexaminerexertspressure on theproximalphalangesbyattemptingtoflexthem. Tendons on thedorsum of thehand

19. POSTERIOR FOREARM & HAND Extends and adducts hand @ wrist Deep branch of radial nerve Extensorcarpiulnaris Forearmpronated & fingersareextended Extendedwrist is thenadductedagainstresistance. Muscleseenandpalpated proximalpart of theforearm& tendonfeltproximaltoulnarhead

20. Extends 5th digit primarily @metacarpophalangealjoint, secondarily @ interphalangealjoint Deep branch of radial nerve POSTERIOR FOREARM & HAND Extensordigiti minimi Littlefinger is extendedagainstresistance whileholding digits 2-4 flexed@ metacarpophalangealjoints

21. POSTERIOR FOREARM & HAND Abducts thumb and extends it @ carpometacarpal joint Posteriorinterosseousnerve Abductorpollicislongus Thumbis abductedagainstresistance at themetacarpophalangealjoint. Tendonseenandpalpated at thelateralside of theanatomicalsnuffboxand on thelateralside of theadjacentextensorpollicisbrevistendon.

22. POSTERIOR FOREARM & HAND Extendsproximalphalanx of thumb@ metacarpophalangealjoint; extendscarpometacarpaljoint Posteriorinterosseousnerve Extensorpollicisbrevis Thumbis extendedagainstresistance at themetacarpophalangealjoint. Tendon @ lateralside of theanatomicalsnuffboxand on themedialside of theadjacentabductorpollicislongustendon

23. Extendsdistalphalanx of thumb@ interphalangealjoint; extendsmetacarpophalangeal& carpometacarpaljoints Posteriorinterosseousnerve POSTERIOR FOREARM & HAND Extensorpollicislongus Thumbis extendedagainstresistance at theinterphalangealjoint. Tendon on themedialside of theanatomicalsnuffbox

24. Abductsthe thumb, principally @ metacarpophalangeal joint Mediannerve POSTERIOR FOREARM & HAND Abductorpollicisbrevis Abductthethumbagainstresistance Flexes metacarpophalangealjoint of the thumb Mediannerve Flexorpollicisbrevis Flexthethumbagainstresistance

25. Participatein flexing metacarpophalangealjoints & extending the interphalangeal joints Medial 2 ulnarnerve Lateral 2 mediannerve POSTERIOR FOREARM & HAND Lumbricals Withthepalmfacingsuperiorlypatientis askedtoflexthemetacarpophalangeal (MP) jointswhilekeepingtheinterphalangealjointsextended. Theexaminerusesonefingertoapplyresistancealongthepalmarsurface of theproximalphalanx of digits 2-5 individually.

26. Majorabductors of the index, middle, and ring fingers @metacarpophalangeal joints Ulnarnerve POSTERIOR FOREARM & HAND Dorsalinterossei Examinerholdsadjacentextendedandadductedfingersbetweenthumbandmiddlefinger, Providingresistance as theindividualattemptstoabductthefingers (theperson is askedto “spread thefingers apart”).

27. POSTERIOR FOREARM & HAND Addduct thumb, index, ring, and little fingers @metacarpophalangeal joints Ulnarnerve Palmarinterossei A sheetof paper is placedbetweenadjacentfingers. Theindividual is askedto “keepthefingerstogether” topreventthepaperfrombeingpulledawaybytheexaminer.

28. Superior fibers elevate scapula • Middle fibers retract scapula • Inferior fibers depress scapula and lower the shoulder. • The superior and inferior fibers work together to rotate the lateral aspect of the scapula upward, which needs to occur when raising the upper limb above the head. • Spìnal accessory nerve (CN XI) SUPERFICIAL MUSCLES OF BACK Trapezius The shoulder is shruggedagainst resistance (the person attempts to raise the shoulders as the examiner presses down on them). If the muscle is acting normally, the superior border of the muscle can be easily seen and palpated.

29. Adductor of the humerus Extension, adduction, and medial rotation of the upper limb. Depresses the shoulder, preventing its upward movement. Thoracodorsal nerve SUPERFICIAL MUSCLES OF BACK Latissimusdorsi The arm is abducted 90° and then adducted against resistance provided by the examiner. If the muscle is normal, the anterior border of the muscle can be seen and easily palpated in the posterior axillary fold.

30. Retract and rotate the scapula, depressing its glenoid cavity. Assist the serratus anterior in holding the scapula against the thoracic wall. Dorsal scapular nerve SUPERFICIAL MUSCLES OF BACK Rhomboids Individualplaces thehands posteriorly on the hips and pushes the elbows posteriorly against resistance provided by the examiner. Palpatedalong the medial borders of the scapulae; because they lie deep to the trapezius, they are unlikely to be visible during testing. .

31. PECTORAL REGION Adduction and medial rotation of the arm Clavicular head flexeshumerus Sternocostal head extends it back Lateral and medial pectoral nerves clavicular head (C5, C6), sternocostal head (C7, C8, T1) Pectoralismajor Clavicular head The arm is abducted 90°; the individual then moves the arm anteriorly against resistance. If acting normally, the clavicular head can be seen and palpated. Sternocostal head The arm is abducted 60° and then adducted against resistance. If acting normally, the sternocostal head can be seen and palpated.

32. PECTORAL REGION Protracts scapula and holds it against thoracic wall; rotates scapula Long thoracic nerve Serratusanterior The hand of the outstretched limb is pushed against a wall. If the muscle is acting normally, several digitations of the muscle can be seen and palpated.

33. Greatextensor of the leg Femoralnerve THIGH & POPLITEAL FOSSA Quadricepsfemoris • Performedwiththeperson in thesupinepositionwiththekneepartlyflexed. • Personextendskneeagainstresistance.

34. Extension@ hip joint Flexion@ knee joint Tibialnerve THIGH & POPLITEAL FOSSA Hamstringmuscles • Personflexes his leg against resistance. • Normally, these muscles—especially their tendons on each side of the popliteal fossa—should be prominent as they bend the knee.

35. LEG Dorsiflexesankle& invertsfoot Deepfibularnerve Tibialisanterior • Theperson is askedtostand on theheelsordorsiflexthefootagainstresistance. • Ifnormal, itstendon can be seenandpalpated.

36. LEG Extends great toe &dorsiflexes ankle Deepfibularnerve Extensorhallucislongus • Great toedorsiflexedagainstresistance. • Ifactingnormally, itsentiretendon can be seenandpalpated. Extensordigitorumlongus Extendsthetoes& dorsiflexesfootat theanklejoint Deepfibularnerve • Lateralfourtoesdorsiflexedagainstresistance. • Ifactingnormally, thetendons can be seenandpalpated.

37. LEG Everts foot and weakly plantarflexes ankle Superficialfibularnerve Fibularislongusandbrevis • Thefoot is evertedstronglyagainstresistance. • Ifactingnormally, themuscletendons can be seenandpalpatedinferiortothelateralmalleolus. InitialPositionPatientplantarflexesandevertsfoot Final PositionExaminer forces the foot into inversion

38. LEG Plantarflexesankle; raises heel during walking; flexes leg at knee joint (soleus;steadiesleg on foot) Tibialnerve Tricepssurae • Thefoot is plantarflexedagainstresistance (e.g., by “standing on thetoes,” in whichcase body weight [gravity] providesresistance). • Ifnormal, thecalcanealtendonandtricepssurae can be seenandpalpated.

39. LEG Flexesgreattoe at alljoints; weaklyplantarflexesankle; supportsmediallongitudinalarch Tibialnerve Flexorhallucislongus • Thedistalphalanx of thegreattoe is flexedagainstresistance. • Ifnormal, thetendon can be seenandpalpated on theplantaraspect of thegreattoe as it crossesthejoints of thetoe.

40. LEG Flexeslateralfourdigits; plantarflexesankle; supportslongitudinalarches of foot Tibialnerve Flexordigitorumlongus • The distal phalanges of the lateral four toes are flexed against resistance. • If they are acting normally, the tendons of the toes can be seen and palpated.

41. LEG Plantarflexesankle; invertsfoot Tibialnerve Tibialisposterior • Thefoot is invertedagainstresistancewithfootin slightplantarflexion. • If normal, thetendon can be seenandpalpatedposteriortothemedialmalleolus .

42. regIONS & SENSORy INNERVATION

43. Inferior lateral cutaneous nerve of arm Lateral & anterioraspects of the lower part of thearm Medial cutaneous nerve of forearm Medial surface of the forearm down to the wrist Posteriorcutaneousnerve of forearm Posterioraspect of thearmandforearm Medialcutaneousnerve of arm Medialside of thedistalthird of thearm Lateralcutaneousnerve of forearm Lateralhalf of theanterioraspectforearm supraclavicularnerves (medial,intermediate,lateral) the skin as far as themiddleline, the skin overthepectoralismajoranddeltoideus, the skin of theupperandposteriorparts of theshoulder, inferiorpart of thedeltoidmuscle

44. Superficialbranch of the radial nerve Dorsolateralaspect of the palm Dorsalaspects of the lateral3 ½ digits distallyto approximately the terminal interphalangeal joints Ulnarnerve Medialside of thepalm Medialhalf of thedorsum of thehand 5th finger & medialhalf of the 4th finger Anteriorsurfaces of themedial 1 ½ digits Mediannerve Thumb,index,middlefingers Lateralside of the ring [distalparts on thedorsum of thehand] Palmarsurface of thelateral 3 ½ digits Lateralside of thepalm & middle of thewrist

45. Superiorclunialnerves L1-L3 posterior rami Skin overlyingsuperiorandcentralparts of buttock Medialclunialnerves S1-S3 posterior rami Skin of medialbuttockandinterglutealcleft Inferiorclunialnerves Posteriorcutaneousnerve of thigh (S2-S3) Skin of inferiorbuttock (overlyingglutealfold Upperlateralquadrant lateralbranches of theiliohypogastric (L1) and 12th thoracicnerves (anterior rami)

46. Obturator nerve Superior medialthigh Genitofemoral nerve Middle anteriorthigh Posteriorcutaneous nerve of the thigh Posterior aspect of thethigh Intermediate cutaneous nerve of the thigh(femoral nerve) Variable area on the medial aspect of the thigh Medial cutaneous nerve of the thigh (femoral nerve) Medial aspect of the thigh

47. Saphenous nerve (femoral nerve) Medial aspect of leg Posterior cutaneous nerve of the thigh Upper part of the leg SuperficialfibularnerveAnterolateralleg SuralnervePosterolateralleg

48. Mediallysaphenousnerve, whichextendsdistallytothehead of 1st metatarsal Superiorly (dorsum of foot)superficial (primarily) anddeepfibularnerves Inferiorly(sole of foot) medialandlateralplantarnerves; Commonborder of theirdistributionalongthe 4th metacarpaltoeordigit Laterallysuralnerve, includingpart of theheel. Posteriorly (heel)medialandlateralcalcanealbranches of thetibialandsuralnerves, respectively

49. DERMATOMES

50. Thedermatomesfortheuppercervicalsegments C3 to 6 arelocatedalongthelateralmargin of theupperlimb C7 dermatome is situated on themiddlefinger C8, T1, and T2 alongthemedialmargin of thelimb