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Authors Editors!eurological History!eurologicE"aminationE"amination of theHigher #unctionsE"amination of theCranial !ervesE"amination of theSensory and MotorSystemsE"amination of

Refle"es$Cerebellum$ andMeningesSystem Survey and

Ancillary Signs%efinition of &ermsMultimediaReferences

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cine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~DefinitionofTerms%23section~DefinitionofTermshttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~References%23section~Referenceshttp://www.emedicine.com/

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%eurological istory and Physical E&amination

Article Last 0pdated, /ct 1$ 2334

A'()* A%+ E+I()* I%$)*MA(I)%

Section 1 o 11

Authors and Editors

!eurological History

!eurologic E"amination

E"amination of the Higher #unctions

E"amination of the Cranial !erves

E"amination of the Sensory and Motor Systems

E"amination of Refle"es$ Cerebellum$ and Meninges

System Survey and Ancillary Signs

%efinition of &erms

Multimedia

References

Author, -alaric"al )ommen, M+$ Professor of !eurology$ Chief$ Section ofEpilepsy$ %irector$ !P #ello5ship Program$ 0niversity of /'lahoma HealthSciences Center$ %irector of Program for Epilepsy$ 6ice %irector of Clinical!euroscience$ 0niversity of /'lahoma Medical Center

Editors, Ste.hen A /erman, M+, Ph+$ Professor$ %epartment of .nternalMedicine$ Section of !eurology$ %artmouth Medical School7 Chief$ !eurologyService$ 8hite River 9unction 6eterans Medical Center7 $rancisco (alavera,Pharm+, Ph+, Senior Pharmacy Editor$ eMedicine7 *ichard J Caselli, M+$Professor$ %epartment of !eurology$ Mayo Medical School$ Rochester$ M!7 Chair$%epartment of !eurology$ Mayo Clinic of Scottsdale7 Matthe J /a"er, M+$Consulting Staff$ Collier !eurologic Specialists$ !aples Community Hospital7%icholas !oreno, M+$ Chief Editor$ eMedicine !eurology7 Consulting Staff$

http://www.emedicinehealth.com/http://www.topmedconsultants.com/emedicine/evaluations/mainsurvey.asp?ecik=0060632&website=1mailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Neurological%20History%20and%20Physical%20Examination&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://www.emedicine.com/neuro/TOPIC632.HTM%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20%20To%20explore%20eMedicine%20today,%20visit%20http://www.emedicine.com.http://cme.emedicine.com/wc.dll?cmeAddToCart~addtest~&type=ARTICLE&dir=neuro&topic=Neurological+History+and+Physical+Examinationhttp://www.emedicine.com/specialties.htmhttp://www.emedicine.com/neuro/neuroindex.shtmlhttp://www.emedicine.com/neuro/neuroINTRODUCTORY_TOPICS.htmhttp://www.emedicine.com/neuro/topic632.htm#section~AuthorsandEditors%23section~AuthorsandEditorshttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicExamination%23section~NeurologicExaminationhttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheHigherFunctions%23section~ExaminationoftheHigherFunctionshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheCranialNerves%23section~ExaminationoftheCranialNerveshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheSensoryandMotorSystems%23section~ExaminationoftheSensoryandMotorSystemshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~DefinitionofTerms%23section~DefinitionofTermshttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~References%23section~Referenceshttp://www.emedicine.com/neuro/fulltopic/topic632.htm#section~NeurologicalHistoryhttp://www.emedicinehealth.com/http://www.topmedconsultants.com/emedicine/evaluations/mainsurvey.asp?ecik=0060632&website=1mailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Neurological%20History%20and%20Physical%20Examination&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://www.emedicine.com/neuro/TOPIC632.HTM%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20%20To%20explore%20eMedicine%20today,%20visit%20http://www.emedicine.com.http://cme.emedicine.com/wc.dll?cmeAddToCart~addtest~&type=ARTICLE&dir=neuro&topic=Neurological+History+and+Physical+Examinationhttp://www.emedicine.com/specialties.htmhttp://www.emedicine.com/neuro/neuroindex.shtmlhttp://www.emedicine.com/neuro/neuroINTRODUCTORY_TOPICS.htmhttp://www.emedicine.com/neuro/topic632.htm#section~AuthorsandEditors%23section~AuthorsandEditorshttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicExamination%23section~NeurologicExaminationhttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheHigherFunctions%23section~ExaminationoftheHigherFunctionshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheCranialNerves%23section~ExaminationoftheCranialNerveshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheSensoryandMotorSystems%23section~ExaminationoftheSensoryandMotorSystemshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~DefinitionofTerms%23section~DefinitionofTermshttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~References%23section~References

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!eurology Specialists and Consultants

Author and Editor +isclosure

Synonyms and related "eyords history and physical$ history physical$ H and

P$ HP$ presenting illness$ chief complaint$ symptom$ symptoms$ family history$past history$ neurologic history and physical e"am$ neurological history$neurological physical e"amination

%E'*)!)3ICA! IS()*4

Section 2 o 11

Authors and Editors





E"amination of the Sensory and Motor Systems E"amination of Refle"es$ Cerebellum$ and Meninges


%efinition of &erms

Multimedia

References

:#rom the brain and the brain only arise our pleasures$ ;oys$ laughter and ;ests$ as5ell as our sorro5s$ pains$ griefs$ and tears(((( &hese things 5e suffer all come from

the brain$ 5hen it is not healthy$ but becomes abnormally hot$ cold$ moist or dry(:

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information,

• Symptom onset ?eg$ acute$ subacute$ chronic$ insidious@

• %uration

•

Course of the condition ?eg$ static$ progressive$ or relapsing and remitting@• Associated symptoms$ such as pain$ headache$ nausea$ vomiting 5ea'ness$

and seiures

Pain should be further defined in terms of the follo5ing,

• Location

• Radiation

• Buality• Severity or uantity

• Precipitating factors

• Relieving factors

.mportant miscellaneous factors of the history include the follo5ing,

• Results of previous attempts to diagnose the condition

• Any previous therapeutic intervention and the response to those treatments

A complete history often defines the clinical problem and allo5s the e"aminer toproceed 5ith a complete but focused neurologic e"amination(

%E'*)!)3IC E5AMI%A(I)%

Section 6 o 11

Authors and Editors








%efinition of &erms

Multimedia

References

&he neurologic e"amination is one of the most uniue e"ercises in all of clinical

http://www.emedicine.com/neuro/topic632.htm#section~AuthorsandEditors%23section~AuthorsandEditorshttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicExamination%23section~NeurologicExaminationhttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheHigherFunctions%23section~ExaminationoftheHigherFunctionshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheCranialNerves%23section~ExaminationoftheCranialNerveshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheSensoryandMotorSystems%23section~ExaminationoftheSensoryandMotorSystemshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~DefinitionofTerms%23section~DefinitionofTermshttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~References%23section~Referenceshttp://www.emedicine.com/neuro/fulltopic/topic632.htm#section~ExaminationoftheHigherFunctionshttp://www.emedicine.com/neuro/topic632.htm#top%23tophttp://www.emedicine.com/neuro/fulltopic/topic632.htm#section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~AuthorsandEditors%23section~AuthorsandEditorshttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicalHistory%23section~NeurologicalHistoryhttp://www.emedicine.com/neuro/topic632.htm#section~NeurologicExamination%23section~NeurologicExaminationhttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheHigherFunctions%23section~ExaminationoftheHigherFunctionshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheCranialNerves%23section~ExaminationoftheCranialNerveshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationoftheSensoryandMotorSystems%23section~ExaminationoftheSensoryandMotorSystemshttp://www.emedicine.com/neuro/topic632.htm#section~ExaminationofReflexesCerebellumandMeninges%23section~ExaminationofReflexesCerebellumandMeningeshttp://www.emedicine.com/neuro/topic632.htm#section~SystemSurveyandAncillarySigns%23section~SystemSurveyandAncillarySignshttp://www.emedicine.com/neuro/topic632.htm#section~DefinitionofTerms%23section~DefinitionofTermshttp://www.emedicine.com/neuro/topic632.htm#section~Multimedia%23section~Multimediahttp://www.emedicine.com/neuro/topic632.htm#section~References%23section~References

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medicine( 8hereas the history is the most important element in defining the clinicalproblem$ neurologic e"amination is performed to localie a lesion in the centralnervous system ?C!S@ or peripheral nervous system ?P!S@( &he statement hasbeen made$ :History tells you 5hat it is$ and the e"amination tells you 5here it is(:

&he history and e"amination allo5 the neurologist to arrive at the etiology andpathology of the condition$ 5hich are essential for treatment planning(

0nli'e many other fields of medicine in 5hich diseases are visible ?eg$ dermatology$ophthalmology@ or palpable ?eg$ surgery@$ neurology is characteried by conditionsthat may be detected only by applying specific e"amination techniues and logicaldeduction$ e"cept 5hen telltale cutaneous mar'ers or other stigmata ?see Mediafile DF@ suggest the diagnosis( Considerable insight and intuition are reuired tointerpret the symptoms and signs observed during neurologic e"amination( &hesefeatures ma'e the neurologic history and physical e"amination both challengingand re5arding(

A properly performed neurologic e"amination may ta'e G3 minutes or even longerfor the novice( E"perienced neurologists ta'e substantially less time and canfreuently grasp the essential features of a clinical condition uic'ly( 8hat mightappear to be a comple" problem of localiation for the referring physician may turnout to have a simple e"planation$ and the neurologic consultation may help to avoide"tensive testing(

%eurologic e&amination in the ear o imaging

8ith the advent of C& scanning in the early DG3s$ the future clinical role of the

neurologist 5as uestioned( %uring one of his visits to the 0nited States$ %rMc%onald Critchley 5as as'ed 5hat he thought 5ould be the future of neurology inthe era of C&( His ans5er 5as most enlightening, :C& scanning 5ill ta'e a5ay theshado5s of neurology$ but the music 5ill still remain(: &hese prophetic 5ords stillring true despite the advent of MR.$ positron emission tomography ?PE&@$ andfunctional neuroimaging of all types(

.t has been said that :neurology o5es more to its disorders than those disorderso5e to neurology(: &his is because much 'no5ledge has come from previousobservations of neurologic conditions$ because the eponyms for the diagnoses5ere sometimes long$ and because so little 5as previously offered in the terms of

cures such that the specialty 5as ridiculed as one that 5as :long on diagnosis andshort on treatment(: #ortunately$ technologic advances have changed thatperception(

Ste.s in the neurologic e&amination

.n e"amining a patient$ abnormalities of function lead to localiation and$ eventually$to the pathophysiology( #or the purpose of simplicity$ the neurologic e"amination is

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divided into several steps( 8hen mastered$ these steps become second nature tothe e"aminer$ and the process of evaluating the patient proceeds smoothly thoughthe steps are not al5ays necessarily performed in the same order( &hese stepsinclude the follo5ing,

• Higher functions

•

• Cranial nerves ?C!s@

•

• Sensory system

•

• Motor system

•

• Refle"es

•

• Cerebellum •

• Meninges

•

• System survey

(ools reuired

.n addition to the stethoscope and the usual office supplies ?eg$ gloves$ tonguedepressors@$ the neurologist should have an ophthalmoscope$ a refle" hammer$and a tuning for'(

A pin ?8artenberg@ 5heel 5as once a favorite tool of many neurologists because it5as easy to use for sensory ?pinpric'@ testing( 0nless it is disposable ?commerciallyavailable@$ this 5heel is no longer recommended because of the ris' of transmittinginfection( &he use of sterile safety pins ?to be discarded after each use@ isrecommended(

&he final section of this article includes a %efinition of &erms(

E5AMI%A(I)% )$ (E I3E* $'%C(I)%S

Section 8 o 11

Authors and Editors





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Ata&ic gait

.n ata"ia$ the patient spreads his or her legs apart to 5iden the base of support tocompensate for the imbalance 5hile standing or 5al'ing( .n severe cases$ patients

stagger as they 5al'( &he heeltotoe or tandem 5al'ing maneuvers and standingon D leg uncover subtle forms of ata"ia(

Ata"ia results from midline lesions of the cerebellum and may be isolated orassociated 5ith other cerebellar findings ?see Cerebellar signs@( 8hen the lesion isunilateral$ the patient may veer to the side of the lesion( 8ith bilateral cerebellarinvolvement$ the patient may fall to either side(

Shuling gait

&he individual ta'es short steps to the point of practically not moving for5ard or

ma'ing little progress( .n other 5ords$ the patient appears to shuffle his or her legsrather than put them for5ard( .n some patients$ the steps ?albeit short@ and pacemay vary 5ith a tendency for the patient to accelerate ?festinating gait@ as he or she5al's( Ioth types are seen in Par'inson disease and may be associated 5ith othere"trapyramidal signs(

Ste..age gait

.n steppage ?highstepping$ slapping@$ the individual ta'es high steps as if climbinga flight of stairs 5hile 5al'ing on a level surface( &his peculiar gait pattern resultsfrom the patient trying to avoid in;ury to the feet ?from dragging them@ by stepping

high( Ho5ever$ as the patient puts the feet do5n D by D$ they slap the ground$hence the description of a footslapping gait( &his is D condition that can bediagnosed even before the patient enters the room because the sound is socharacteristic(

Steppage gait is seen in chronic peripheral neuropathies and can be the result ofthe functional elongation of the legs due to bilateral drop foot(

S.astic or scissor gait

.n this condition$ the legs are held in adduction at the hip and the thighs rub against

each other as the patient 5al's( Spasm of the inner thigh muscles also occurs( .fthe spasm is severe$ 5ith each advancing step the 'nees tend to slide over eachother li'e the blades of a pair of scissors( &his is typically seen in cerebral diplegia$a form of cerebral palsy(

Antalgic gait

Patient favors the affected painful ?usually lo5er@ e"tremity and 5al's$ putting

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5eight on the normal leg( &he hand held over hip on the affected side is typical inpatients 5ith radicular pain(

S.eech

Speech enables communication bet5een individuals( Abnormalities includedysphonia$ dysarthria$ and dysphasia or aphasia(

+ys.honia or a.honia

%ysphonia is the impairment or inability to phonate( As a result$ the voice becomeshoarse( .n e"treme cases$ it is absent$ and the patient is mute(

&he most freuent cause of this problem is the common cold$ 5hich results indysphonia due to inflammation of the laryn"( %ysphonia may also occur in patients

5ith hypothyroidism$ as a result of thic'ening of the vocal cords from amyloiddeposits( !eurologic causes include unilateral recurrent laryngeal nerve paralysisand lesions of the vagus nerve( .ntermittent hoarseness may affect patients 5ithvagus nerve stimulator implants$ 5hich are used for the treatment of certainmedically intractable forms of epilepsy ?M.E@ and pharmacoresistent depression?PR%@(

+ysarthria or anarthria

%ysarthria is the inability to articulate spo'en 5ords( &he uality of oration isimpaired$ but the content remains intact ?eg$ slurred speech@( &he patient>s ability to

understand and synthesie speech remains intact( .t results from paralysis ofpharyngeal$ palatal$ lingual$ or facial musculature( .t also is observed 5ithcerebellar lesions and*or disease ?eg$ scanning or staccato speech@(

+ys.hasia or a.hasia

.n dysphasia$ the ability to process language is impaired$ resulting in an inability tounderstand ?ie$ receptive or sensory or 8ernic'e aphasia@$ transfer signals from the8ernic'e to the Iroca area ?ie$ conduction aphasia@$ or properly e"ecute speech?ie$ e"pressive$ motor$ or Iroca aphasia@( &he combination of Iroca and 8ernic'eaphasias is referred to as global aphasia(

&able D summaries the essential features of common dysphasias ?aphasias@(

&able D( Essential #eatures of Common %ysphasias

(y.e o +ys.lasia

$luency Com.rehension %aming !ocaliation

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Iroca !onfluent .ntact .mpaired Iroca area

8ernic'e #luent .mpaired .mpaired 8ernic'e area

Conduction #luent .ntact .mpaired Arcuate fasciculus

)lobal !onfluent .mpaired .mpairedIroca and 8ernic'e

areas

(ranscortical a.hasias

Another function that is impaired in all 1 of the aphasias mentioned above isrepetition( &his finding is important in the diagnosis of transcortical aphasias( 8henrepetition is preserved in a patient 5ith Iroca aphasia$ it signifies transcorticalmotor aphasia$ and the lesion is anterior to the Iroca area( 8hen repetition ispreserved in 8ernic'e aphasia$ it is called transcortical sensory aphasia$ and thelesion is posterior to the 8ernic'e area( &ranscortical mi"ed aphasia and globalaphasia are similar e"cept for the preservation of repetition$ and results from

combined lesions anterior to the Iroca and 8ernic'e areas$ respectively(

Mental status

Mental status evaluation includes testing of memory$ orientation$ intelligence$ andthe other aspects of the patient>s psychic state( /nly the first J are discussed here(8hen overt symptoms or signs of a psychic disturbance are present$ psychiatricevaluation should be considered(

Memory

Memory is the ability to register and recall prior sensory input( Recent and remotememory functions are differently affected depending on the disease process(Remote memory is relatively preserved in chronic dementing processes$ 5ith ma;or disturbances in the attention span and recent memory( /n the contrary$ all aspectsof memory are impaired in acute encephalopathies(

)rientation

/rientation is an individual>s cognitive sense of his status in time$ place$ andperson( &hese functions are affected in the same order as they are in organicdisease( .n other 5ords$ the sense of time is first to be impaired in organic

dysfunction$ and the sense of person is the last to be lost( Ho5ever$ the order maybe disturbed in psychological dysfunction(

A patient 5ho does not 'no5 5ho he or she is$ but at the same time can tell thetime and is oriented in place$ is more li'ely to have a psychological disturbancethan to have an organic etiology for the condition( !onetheless$ rare cases ofisolated amnesia have been reported(

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Intelligence

.ntelligence is the ability to uic'ly and successfully apply previous 'no5ledge to ane5 situation and to use reason in solving problems( 6ocabulary$ fund of

'no5ledge$ calculations ?eg$ serial calculations@$ abstraction ?eg$ use ofproverbs@$ and ;udgment ?eg$ 5hat to do 5ith a found 5allet@ are good indicators ofintelligence(

Psychological distur9ances

A brief survey of the other aspects of psychological function may be helpful inrevealing abnormalities of thought process ?eg$ circumstantiality and tangentiality@7of perception ?eg$ illusions and hallucination@7 or of thought content ?eg$ delusionsof grandeur@( Patients 5ith these findings should be referred for appropriateevaluation(

E5AMI%A(I)% )$ (E C*A%IA! %E*:ES

Section ; o 11

Authors and Editors






E"amination of Refle"es$ Cerebellum$ and Meninges System Survey and Ancillary Signs

%efinition of &erms

Multimedia

References

/f the D2 C!s$ some are named according to their function( E"amples of these arethe olfactory ?smell@$ optic ?vision@$ oculomotor ?eye movements@$ abducens

?abduction of the eye@$ facial ?facial e"pression@$ and vestibulocochlear orstatoacoustic ?hearing and balance@ nerves( /thers are named for their relationshipto neighboring structures ?trochlear nerve@$ appearance ?trigeminal nerve@$ e"tent of distribution ?vagus nerve@$ composition ?spinal accessory nerve@$ or location?hypoglossal nerve@(

• &rochlear, .ts midsection e"tends over a trochlea or pulley to reach itsinsertion on the inferior aspect of the globe(

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•

• &rigeminal, &he nerve divides into J divisions distal to the )asserianganglion(

•

• 6agus, &he vagabond or 5anderer$ it travels long distances in the body(•

• Spinal accessory, &his nerve is composed of rootlets from the spinal cord inaddition to its medullary component(

•

• Hypoglossal, .ts course is sublingual in the nec'(

Kno5ing the names of the C!s ma'es it easy to remember their function$ therebyma'ing their e"amination selfevident( &he follo5ing mnemonic is helpful inrecalling the names of the C!s, /h$ oh$ oh7 to tre' and feel a great valley7 ah ha

Another is this, /n old /lympus to5ering tops$ a #inn and )erman vie5ed somehops(

)lactory nerve < C% I

&he olfactory nerves consist of small unmyelinated a"ons that originate in theolfactory epithelium in the roof of the nasal cavity7 they pierce the cribriform plate of the ethmoid and terminate in the olfactory bulb( Lesions of the nerve result inparosmia ?altered sense of smell@ or anosmia ?loss of smell@(

&he common cold is the most freuent cause of dysfunction( %ysfunction can beassociated 5ith fractures of the cribriform plate of the ethmoid bone( #rontal lobetumors may compress the olfactory bulb and*or tracts and cause anosmia$ but this

is rare occurrence(

/lfactory function is tested easily by having the patient smell common ob;ects suchas coffee or perfume( Commercially available scented scratch papers may also beused(

).tic nerve < C% II

&he optic nerve is a collection of a"ons that relay information from the rods andcones of the retina( &he temporal derivations reach the ipsilateral and the nasalderivations the contralateral superior colliculi and the lateral geniculate bodies(

#rom there$ a"ons e"tend to the calcarine corte" by means of the optic radiation$traversing the temporal ?Myer loop@ and parietal lobes( #ibers responsible for thepupillary light refle" bypass the geniculate body and reach the pretectal area$ from5here they innervate the parasympathetic ?midline@ portion of the thirdnervenucleus$ enabling the consensual pupillary refle"(

&he follo5ing testing is appropriate,

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• Acuity$ by using the Snellen chart ?near and distant vision@

•

• 6isual fields$ by means of confrontation or perimetry if indicated

•

• Color$ 5ith use of an .shihara chart or by using common ob;ects$ such as a

multicolored tie or color accent mar'ers•

• #unduscopy

Lesions of the visual path5ays result in blindness and pupillary abnormalities$ suchas the Marcus)unn pupil ?retinal or optic nerve disease@$ scotomata$ uadrant orhemianopsias ?optic tract and radiation@$ and hemianopsias 5ith macular sparing?calcarine corte"@(

)culomotor nerve < C% III

&he oculomotor nucleus of the nerve is located in the midbrain and innervates thepupillary constrictors7 the levator palpebrae superioris7 the superior$ inferior$ andmedial recti7 and the inferior obliue muscles( Lesions of C! ... result in paralysis of the ipsilateral upper eyelid and pupil$ leaving the patient unable to adduct and loo'up or do5n( &he eye is freuently turned out ?e"otropia@( .n subtle cases$ patientscomplain of only diplopia or blurred vision( Lesions at the nucleus of the third nervecause bilateral ptosis$ in addition to the findings mentioned above( &he e"otropiaseen in C! ... paralysis can be distinguished from that in internuclearophthalmoplegia because in the latter convergence is preserved(

Paralysis of C! ... is the only ocular motor nerve lesion that results in diplopia in

more than D direction$ distinguishing itself from C! .6 paralysis ?5hich also canresult in e"otropia@( Pupillary involvement is an additional clue to involvement of C!...( Pupilsparing C! ... paralysis occurs in diabetes mellitus$ vasculitides of variousetiologies$ and certain brainstem lesions such as due to multiple sclerosis(

(rochlear nerve < C% I:

&he nucleus of the nerve is located in the midbrain( .t innervates the superiorobliue muscle$ 5hich incycloducts and infraducts the eye( &rochlear nerve typicallyallo5s a person to vie5 the tip of his or her nose(

An isolated right superior obliue paralysis results in e"otropia to the right ?R@$double vision that increases on loo'ing to the ?L@$ and head tilt to the right ?R@( &hemnemonic is R$ L$ R ?ie$ the marching rule@( &he rule is L$ R$ L for left superiorobliue paralysis( &his rule and the lac' of ptosis and*or pupillary involvement allo5easy distinction of the e"otropia of C! .6 paralysis from that seen in C! ...paralysis(

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(rigeminal nerve < C% :

&he nucleus of the nerve stretches from the midbrain ?ie$ mesencephalic nerve@through the pons ?ie$ main sensory nucleus and motor nucleus@ to the cervical

region ?ie$ spinal tract of the trigeminal nerve@( .t provides sensory innervation forthe face and supplies the muscles of mastication(

Paralysis of the first division ?ophthalmic7 6D@ is usually seen in the superior orbitalfissure syndrome and results in sensory loss over the forehead along 5ith paralysisof C! ... and C! .6( Paralysis of the second division ?ma"illary7 62@ results in lossof sensation over the chee' and is due to lesions of the cavernous sinus7 it alsoresults in additional paralysis of 6D$ C! ... and C! .6( .solated 62 lesions resultfrom fractures of the ma"illa( Complete paralysis of C! 6 results in sensory lossover the ipsilateral face and 5ea'ness of the muscles of mastication( Attemptedopening of the mouth results in deviation of the ;a5 to the paralyed side(

A9ducens nerve < C% :I

&he nucleus of the nerve is located in the paramedian pontine region in the floor ofthe fourth ventricle( .t innervates the lateral rectus$ 5hich abducts the eye( .solatedparalysis results in esotropia and inability to abduct the eye to the side of the lesion(Patients complain of double vision on horiontal gae only( &his finding is referredto as horiontal homonymous diplopia$ 5hich is the sine ua non of isolated C! 6.paralysis( Paralysis of C! 6. may result from increased intra cranial pressure5ithout any lesion in the neura"is$ and it may result in false localiation if one is nota5are of it(

$acial nerve < C% :II

&he nucleus of the nerve lies ventral$ lateral$ and caudal to the C! 6. nucleus7 itsfibers elevate the floor of the fourth ventricle ?facial colliculus@ as they 5ind aroundthe C! 6. nucleus( &he nerve leaves the cranial cavity through the stylomastoidforamen and innervates the muscles of facial e"pression and the stapedius(

Although it is considered a pure motor nerve$ it also innervates a small strip of s'inof the posteromedial aspect of the pinna and around the e"ternal auditory canal(&he nervus intermedius of 8risberg conducts taste sensation from the anterior t5o

thirds of the tongue and supplies autonomic fibers to the subma"illary andsphenopalatine ganglia$ 5hich innervate the salivary and lacrimal glands(

A lo5ermotorneuron lesion of the nerve$ also 'no5n as peripheral facial paralysis$results in complete ipsilateral facial paralysis7 the face dra5s to the opposite sideas the patient smiles( Eye closure is impaired$ and the ipsilateral palpebral fissureis 5ider( .n an upper motor neuron lesion$ also 'no5n as central facial paralysis$only the lo5er half of the face is paralyed( Eye closure is usually preserved( .n

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peripheral facial paralysis$ different types of clinical presentations are seen 5ithnerve lesions at 1 levels$ as described belo5(

• Lesions of the meatal or canalicular segment, #acial paralysis 5ith hearing

loss ?5ithout hyperacusis@ and loss of taste in the anterior t5o thirds of thetongue imply lesions in the internal auditory canal from fracture of thetemporal bone or at the cerebellopontine angle from compression by atumor(

•

• Lesions of the labyrinthine or fallopian segment

•

o Lesions that spare hearing ?5ith hyperacusis@ indicate lesions further

do5n the course of the nerve(o

o Loss of taste in the anterior t5o thirds of the tongue and loss of

tearing imply lesions that involve the chorda tympani and thesecretomotor fibers to the sphenopalatine ganglion in the labyrinthinesegment$ pro"imal to the greater superficial petrosal nerve(

o

o 8ith lesions distal to the greater superficial petrosal nerve$lacrimation is normal but hyperacusis is still present( )eniculatelesions in this segment cause pain in the face(

•

• Lesions of the horiontal or tympanic segment, &he lesion is pro"imal to the

departure of the nerve to the stapedius and results in hyperacusis$ loss oftaste in the anterior t5o thirds of the tongue$ and facial motor 5ea'ness(

•

• Lesions of the mastoid or vertical segment, Hyperacusis is present if the

lesion is pro"imal to the nerve to the stapedius( .t is absent if the lesion isdistal to the nerve to the stapedius$ and only loss of taste and facial paralysisoccur( .f the lesion is beyond the chorda tympani in the vertical segment ?asin lesions of the stylomastoid foramen@$ taste is spared and only facial motorparalysis is seen(

:esti9ulocochlear nerve < C% :III

&he vestibulocochlear or statoacoustic nerve enters the brainstem at the

pontomedullary ;unction and contains the incoming fibers from the cochlea and thevestibular apparatus$ forming the eighth C!( .t serves hearing and vestibularfunctions$ each of 5hich is described separately( Hearing loss may be conductiveor sensorineural( &hree tests help in evaluating the auditory component of thenerve(

&he 8eber test involves holding a vibrating tuning for' against the forehead in themidline( &he vibrations are normally perceived eually in both ears because bone

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conduction is eual( .n conductive hearing loss$ the sound is louder in the abnormalear than in the normal ear( .n sensorineural hearing loss$ lateraliation occurs to thenormal ear( &he sensitivity of the test can be increased ?up to dI@ by having thepatient bloc' his or her e"ternal ear canals by simultaneously pressing the inde"

fingers at the introit(

&o perform the Rinne test$ the vibrating tuning for' is placed over the mastoidregion until the sound is no longer heard( .t is then held at the opening of the earcanal on the same side( A patient 5ith normal hearing should continue to hear thesound( .n conductive hearing loss$ the patient does not continue to hear the sound$since bone conduction in that case is better than air conduction( .n sensorineuralhearing loss$ both air conduction and bone conduction are decreased to a similare"tent(

.n the Sch5abach test$ the patient>s hearing by bone conduction is compared 5ith

the e"aminer>s hearing by placing the vibrating tuning for' against the patient>smastoid process and then to the e"aminer>s( .f the e"aminer can hear the soundafter the patient has stopped hearing it$ then hearing loss is suspected(

&he vestibular portion of the nerve enters the brainstem along 5ith the cochlearportion( .t transmits information about linear and angular accelerations of the headfrom the utricle$ saccule$ and semicircular canals of the membranous labyrinth tothe vestibular nucleus( Linear acceleration is monitored by the macules in theutricles and saccules7 angular acceleration is monitored by the cristae contained inthe ampullae in the semicircular canals( &hese signals reach the superior?Iechtere5@$ lateral ?%eiters@$ medial ?Sch5albe@$ and inferior ?Roller@ nuclei and

pro;ect to the pontine gae center through the medial longitudinal fasciculus7 to thecervical and upper thoracic levels of the spinal cord through the medialvestibulospinal tract7 to the cervical$ thoracic$ and lumbosacral regions of theipsilateral spinal cord through the lateral vestibulospinal tract7 and to the ipsilateralflocculonodular lobe$ uvula$ and fastigial nucleus of the cerebellum through thevestibulocerebellar tract(

&he Romberg test is performed to evaluate vestibular control of balance andmovement( 8hen standing 5ith feet placed together and eyes closed$ the patienttends to fall to5ard the side of vestibular hypofunction( 8hen as'ed to ta'e stepsfor5ard and bac'5ard$ the patient progressively deviates to the side of the lesion(

Results of the Romberg test may also be positive in patients 5ith polyneuropathies$and diseases of the dorsal columns$ but these individuals do not fall consistently toD side as do patients 5ith vestibular dysfunction(

Another test is to as' the patient to touch the e"aminer>s finger 5ith the patient>shand above the head( Consistent past pointing occurs to the side of the lesion(Provocative tests include the !ylenINrNny test and caloric testing ?see Ancillary

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signs@(

3losso.haryngeal nerve < C% I5

&he nucleus of the nerve lies in the medulla and is anatomically indistinguishablefrom the C! = and C! =. nuclei ?nucleus ambiguous@( .ts main function is sensoryinnervation of the posterior third of the tongue and the pharyn"( .t also innervatesthe pharyngeal musculature$ particularly the stylopharyngeus$ in concert 5ith thevagus nerve(

6ascular stretch afferents from the aortic arch and carotid sinus$ as 5ell aschemoreceptor signals from the latter$ travel in the nerve of Herring to ;oin theglossopharyngeal nerve7 they reach the nucleus solitarius$ 5hich in turn isconnected to the dorsal motor nucleus of the vagus and plays a part in the neuralcontrol of blood pressure(

Lesions affecting the glossopharyngeal nerve result in loss of taste in the posteriorthird of the tongue and loss of pain and touch sensations in the same area$ softpalate$ and pharyngeal 5alls( C! .= and C! = travel together$ and their clinicaltesting is not entirely separable( &herefore$ e"amination of C! .= is discussed 5iththat of the vagus nerve(

:agus nerve < C% 5

Starting in the nucleus ambiguous$ the vagus nerve has a long and tortuous courseproviding motor supply to the pharyngeal muscles ?e"cept the stylopharyngeus and

the tensor veli palati@$ palatoglossus$ and laryn"( Somatic sensation is carried fromthe bac' of the ear$ the e"ternal auditory canal$ and parts of the tympanicmembrane$ pharyn"$ laryn"$ and the dura of the posterior fossa( .t innervates thesmooth muscles of the tracheobronchial tree$ esophagus$ and ). tract up to the

;unction bet5een the middle and distal third of the transverse colon(

&he vagus provides secretomotor fibers to the glands in the same region andinhibits the sphincters of the upper ). tract( Along 5ith visceral sensation from thesame region$ the nerve participates in vasomotor regulation of blood pressure bycarrying the fibers of the stretch receptors and chemoreceptors ?ie$ aortic bodies@ of the aorta and providing parasympathetic innervation to the heart(

&he pharyngeal gag refle" ?ie$ tongue retraction and elevation and constriction ofthe pharyngeal musculature in response to touching the posterior 5all of thepharyn"$ tonsillar area$ or base of the tongue@ and the palatal refle" ?ie$ elevation of the soft palate and ipsilateral deviation of the uvula on stimulation of the soft palate@are decreased in paralysis of C! .= and C! =( .n unilateral C! .= and C! =paralysis$ touching these areas results in deviation of the uvula to the normal side(

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Sensory system

%oncortical sensory system

&his is constituted by the peripheral nerves 5ith their central path5ays to thethalamus( Light touch$ pain$ heat$ cold$ and vibration sensations can be included inthis group(

Light touch is tested by touching the s'in 5ith a 5isp of cotton or tissue( Pain istested by using a sharp ob;ect such as an open safety pin( &emperature can betested by touching the patient>s s'in 5ith 2 test tubes$ D 5ith 5arm 5ater and theother 5ith cold 5ater( Compare the 2 sides and also to a benchmar'$ such as thepatient>s o5n forehead ?assuming sensation there is normal@( 6ibration is tested5ith a tuning for'$ preferably 5ith a freuency of D2F H( Compare findings on the 2sides$ and also compare findings 5ith those in the same body part of the e"aminer(

Cortical sensory system

&he cortical sensory system includes the somatosensory corte" and its centralconnections( &his system enables the detection of the position and movement ofthe e"tremities in space ?ie$ 'inesthetic sensation@$ sie and shape of ob;ects ?ie$stereognosis@$ tactile sensations of 5ritten patterns on the s'in ?ie$ graphesthesia@$and tactile localiation and tactile discrimination on the same side or both sides ofthe body(

Position sensation is tested 5ith the patient>s eyes closed( &he e"aminer moves

various ;oints$ being sure to hold the body part in such a 5ay that the patient maynot recognie movement simply from the direction in 5hich the patient may feel thepressure from the e"aminer>s hand(

Stereognosis is tested by placing some familiar ob;ect ?eg$ ball$ cube$ coin@ in thepatient>s hand 5hile his or her eyes are closed and as'ing the patient to identify theob;ect( .nability to recognie the sie or shape is referred to as astereognosis(

Agraphesthesia is the inability to recognie letters or numbers 5ritten on thepatient>s s'in( &hese abilities are impaired in lesions of the right parietal region(

Motor system

(ro.hic state

Assess the J Ss, sie$ shape$ and symmetry of a muscle( Atrophy$ hypertrophy$ orabnormal bulging or depression in a muscle is an important diagnostic finding in thepresence of different muscle diseases or abnormalities( Hypertrophy occurs 5ithcommensurate strength from use and e"ercise7 on the other hand$ hypertrophy 5ith5ea'ness is seen commonly in %uchenne muscular dystrophy( &he shape may

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also be altered 5hen the muscle or tendon is ruptured(

Muscle tone

Muscle tone is the permanent state of partial contraction of a muscle and isassessed by passive movement( &he muscle may be hypotonic or hypertonic(Hypotonia is defined as decreased tone and may be seen in lo5er motor neuronlesions$ spinal shoc'$ and some cerebellar lesions( Hypertonia may manifest asspasticity or rigidity(

Pyramidal lesions result in spasticity that may manifest as a clasp'nifephenomenon ?ie$ resistance to passive movement 5ith sudden giving 5ay$ usuallyto5ard the completion of ;oint fle"ion or e"tension@( Iilateral frontal lobe lesionsmay result in paratonia or gegenhalten ?)erman for againststop@$ in 5hichresistance increases throughout fle"ion and e"tension( Rigidity refers to increased

tone associated 5ith e"trapyramidal lesions7 it may result in a cog5heel ?step5ise@or leadpipe ?uniform@ resistance to passive movement(

Muscle strength

0se this musclestrength scale 5hen assessing and documenting muscle strength?&able 2@(

&able 2( MuscleStrength Scale

Score +escri.tion

3 Absent voluntary contraction

D #eeble contractions that are unable to move a ;oint

2 Movement 5ith gravity eliminated

J Movement against gravity

1 Movement against partial resistance

#ull strength

Involuntary movements

.nvoluntary movements include fibrillations$ fasciculations$ asteri"is$ tics$myoclonus$ dystonias$ chorea$ athetosis$ hemiballismus$ and seiures(

#ibrillations are not visible to the na'ed eye e"cept possibly those in the tongue(

#asciculations may be seen under the s'in as uivering of the muscle( Althoughfasciculations are typically benign ?particularly 5hen they occur in the calf@$ if5idespread$ they can be associated 5ith neuromuscular disease$ including

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amyotrophic lateral sclerosis ?ALS@(

Asteri"is can be elicited by having the patient e"tend both arms 5ith the 5ristsdorsifle"ed and palms facing for5ard and eyes closed( Irief ;er'y do5n5ard

movements of the 5rist are considered a positive sign( Asteri"is is commonly seen5ith metabolic encephalopathies(

&ics are involuntary contractions of single muscles or groups of muscles that resultin stereotyped movements( )illes de la &ourette syndrome can manifest 5ithmultiple tics and elaborate$ comple" movements and vocaliations(

Myoclonus$ as the 5ord implies$ is a muscle ;er'7 it is a brief ?O3(2 seconds@$generalied body;er'$ 5hich is sometimes asymmetric( &hese occur alone or inassociation 5ith various primarily generalied epilepsies(

%ystonias are muscle contractions that are more prolonged than myoclonus andresult in spasms( E"amples include blepharospasm$ spasmodic torticollis$oromandibular dystonia$ spasmodic dysphonia$ and 5riter>s cramp(

.n athetosis$ the spasms have a slo5 5rithing character and occur along the longa"is of the limbs or the body itself7 the patient may assume different and oftenpeculiar postures(

&he term chorea means dance( Buasipurposeful movements affect multiple ;oints5ith a distal preponderance(

Hemiballismus is a violent flinging movement of half of the body( .t is associated5ith lesions of the subthalamic nucleus ?ie$ body of Louis@(

Seiures may result in orofacial or appendicular automatisms$ repeated eye blin's$or tonic or clonic motor activity(

E5AMI%A(I)% )$ *E$!E5ES, CE*E/E!!'M, A%+ ME%I%3ES

Section 7 o 11

Authors and Editors








%efinition of &erms

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Multimedia

References

*ele&es

&he different refle" responses may be grouped into J categories on the basis oftheir clinical significance(

Primitive rele&es

&hese include the glabellar tap$ rooting$ snout$ suc'ing$ and palmomental refle"es( As a rule$ these signs are generally absent in adults( 8hen present in the adult$these signs signify diffuse cerebral damage$ particularly of the frontal lobes ?hence

the term frontallobe release signs@(

Su.ericial rele&es

&hese are segmental refle" responses that indicate the integrity of cutaneousinnervation and the corresponding motor outflo5( &hese include the corneal$con;unctival$ abdominal$ cremasteric$ anal 5in'$ and plantar ?Iabins'i@ refle"es(

&he corneal and con;unctival refle"es may be elicited by gently touching theappropriate structure 5ith a sterile 5isp of cotton( &he normal response is bilateral5in'ing( Absence of such a response implies C! 6 paralysis( Ilin'ing of only D eye

suggests 5ea'ness of C! 6.. on the side that does not 5in'(

&he abdominal refle" can be elicited by dra5ing a line a5ay from the umbilicusalong the diagonals of the 1 abdominal uadrants( A normal refle" dra5s theumbilicus to5ard the direction of the line that is dra5n(

&he cremasteric refle" is elicited by dra5ing a line along the medial thigh and5atching the movement of the scrotum in the male( A normal refle" results inelevation of the ipsilateral testis(

&he anal 5in' refle" is elicited by gently stro'ing the perianal s'in 5ith a safety pin(

.t results in puc'ering of the rectal orifice o5ing to contraction of the corrugatorcutisani muscle(

&he best 'no5n of this group of refle"es is the plantar refle"( &his refle" may beelicited in several 5ays$ each 5ith a different eponym( &he most commonlyperformed maneuver is stro'ing the lateral aspect of the sole 5ith a sharp ob;ect(&he normal response is plantar fle"ion of the great toe$ 5hich is considered anabsent ?negative@ Iabins'i sign( %orsifle"ion of the great toe ?Iabins'i sign

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present@ suggests an upper motor neuron lesion and also is referred to as apositive Iabins'i sign( %orsifle"ion of the big toe also may be associated 5ithfanning out of the other toes$ as detailed in Iabins'i>s original description$ but mostneurologists consider this an unnecessary accompaniment of an abnormal

response(

#le"ion of the 'nee and hip may occur in the paretic leg 5ith urinary and fecalincontinence( &his is referred to as the enmass refle"( Lac' of either response mayindicate absence of cutaneous innervation in the SD segment or loss of motorinnervation in the L segment ipsilaterally(

+ee. tendon rele&es

&hese are monosynaptic spinal segmental refle"es( 8hen they are intact$ integrityof the follo5ing is confirmed, cutaneous innervation$ motor supply$ and cortical

input to the corresponding spinal segment(

&hese refle"es include the biceps$ brachioradialis$ triceps$ patellar$ and an'le ;er's(&he musculocutaneous nerve supplies the biceps muscle( &he radial nervesupplies the brachioradialis and triceps( &he femoral nerve supplies the uadricepsfemoris$ 5hich enables the 'nee ;er'$ and the tibial nerve supplies thegastrocnemius and the soleus(

Spinal roots that subserve these refle"es are listed belo5(

&able J( Muscles and Spinal Roots

Muscle S.inal *oots

Iiceps C$ 4

Irachioradialis C4

&riceps C

Patellar L21

Achilles S1

/n occasion$ these root numbers are offset by D 5hen the cervical and*or

lumbosacral ple"uses are prefi"ed or postfi"ed(

Several systems for refle" grading e"ist( An e"ample is provided belo5(

&able 1( Refle")rading System

Score *ele&es

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3 Absent

D Hypoactive or present only 5ith reinforcement

2 Readily elicited 5ith a normal response

J Iris' 5ith or 5ithout evidence of spread to the neighboring roots

1 Associated 5ith a fe5 beats of unsustained clonus

Sustained clonus

All te"tboo's no5 use a 31 scale to grade deep tendon refle"es$ 5ithout a numberassigned for sustained clonus( &he addition of the number allo5s for easyrepresentation by using a stic' figure( #or a uic' method of recording the refle"pattern$ see Media file D(

Cere9ellar signs

&he cerebellum provides an important feedbac' loop for coordination of muscleactivity by integrating the functions of the corte"$ basal ganglia$ vestibularapparatus$ and spinal cord( Midline cerebellar dysfunction results in ata"ia of gait$difficulty in maintenance of upright posture$ and truncal ata"ia( Acute neocerebellarhemispheric lesions result in additional signs(

&he follo5ing are various cerebellar signs,

• Ata"ia$ atonia$ and asthenia

•

• .ntention tremor

•

• %yssynergia ?incoordination@

•

• %ysmetria

•

• %ysrhythmia

•

• %ysdiadocho'inesis

•

• %ysarthria ?staccato or scanning speech@

)ait is tested by having the patient 5al' normally and in tandem( .n the latter$ thepatient is as'ed to 5al' 5ith D foot immediately in front of the other ?ie$ heel to toe@(

A tendency to s5ay or fall to D side indicates ata"ia$ suggesting ipsilateralcerebellar dysfunction( Atonia and asthenia can occur in other lesions of thenervous system and are not specific to the cerebellum7 their testing is describedelse5here(

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.ntention tremor refers to an oscillating tremor that accelerates in pace onapproaching the target( %yssynergia or incoordination results in loss of smoothnessof e"ecution of a motor activity( %ysmetria results in overshooting or undershootingof a target 5hile attempting to reach an ob;ect( All J of these can be elicited by

having the patient attempt to touch alternately his or her nose and the e"aminer>sfinger(

%ysrhythmia refers to the inability to tap and 'eep a rhythm( .t can be tested bytapping the table 5ith a hand ?or the floor 5ith a foot@ and as'ing the patient torepeat the maneuver( %ysdiadocho'inesis is the inability to perform rapidalternating movements7 it can be tested by as'ing the patient to tap D hand on theother ?or on the thigh@ repeatedly 5hile simultaneously pronating and supinating thehand( 6arious combinations of the above signs appear$ depending on the e"tentand location of the lesion in the cerebellum(

%ysarthria is usually a sign of diffuse involvement of the cerebellum( .t ischaracteried by poor modulation of the volume and pitch of the speech$ causingoscillations of these 2 ualities(

Meningeal signs

Signs of meningeal irritation indicate inflammation of the dura7 these signs aredescribed belo5(

!uchal rigidity or nec' stiffness is tested by placing the e"aminer>s hand under thepatient>s head and gently trying to fle" the nec'( 0ndue resistance implies diffuseirritation of the cervical nerve roots from meningeal inflammation(

&he Irudins'i sign is fle"ion of both 'nees during the maneuver to test nuchalrigidity( &his indicates diffuse meningeal irritation in the spinal nerve roots(

&he Kernig sign is elicited by fle"ing the hip and 'nee on D side 5hile the patient issupine$ then e"tending the 'nee 5ith the hip still fle"ed( Hamstring spasm results inpain in the posterior thigh muscle and difficulty 5ith 'nee e"tension( 8ith severemeningeal inflammation$ the opposite 'nee may fle" during the test ?see Media file

2@(

&he Lasgue or straightleg raising ?SLR@ sign is elicited by passively fle"ing thehip 5ith the 'nee straight 5hile the patient is in the supine position( Limitation offle"ion due to hamstring spasm and*or pain indicates local irritation of the lo5erlumbar nerve roots( Reverse SLR is elicited by passively hypere"tending the hip5ith the 'nee straight 5hile the patient is in the prone position( Limitation ofe"tension due to spasm and*or pain in the anterior thigh muscles indicates local

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irritation of the upper lumbarnerve roots(

S4S(EM S'*:E4 A%+ A%CI!!A*4 SI3%S

Section > o 11

Authors and Editors








%efinition of &erms

Multimedia References

System survey

Autonomic nervous system

Autonomic dysfunction results in abnormalities in the follo5ing, s5eating$ s'in

temperature$ cyanosis or pallor$ trophic changes of s'in or nails$ and posturalchanges in blood pressure( /bservation ?and any necessary additional testing@easily demonstrates the presence or absence of these signs( 0nderstanding thesesigns helps the e"aminer assess the patient>s neurologic condition(

%eurovascular system

&he follo5ing may be tested by palpation of the pulses and use of appropriateinstruments,

• Irachial ple"us and bilateral blood pressures

•

• Cranial and peripheral pulses

•

• Arterial bruits

%eurocutaneous system

Several neurologic conditions have telltale cutaneous stigmata( Evaluation for the

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follo5ing can provide valuable diagnostic clues, loss of s'in pigmentation as invitiligo$ 5hite hairloc' in 6ogtHaradaKoyanagi disease$ cutaneous tumors or ashleaf spots in tuberous sclerosis ?see Media file J@$ and cutaneous eruptions over adermatome 5hich may signify herpes oster ?see Media file 1@(

Coffeebro5n pigmented ?ie$ caf é7 au lait@ spots of varying sies$ usually greaterthan D( cm in diameter$ and a"illary frec'ling ?see Media file @ are seen inneurofibromatosis( &hese are observed in addition to or in the absence of thecharacteristic blubbery subcutaneous tumors that give the condition its name(

&ufts of hair ?satyr>s tail@$ dimples$ and large moles along the spine may indicatespina bifida occulta or diastematomyelia of the spinal column(

S"eletal system < Cranium, s.ine, 9ones, ?oints

Palpation of the s'ull can reveal congenital anomalies that may indicate underlyingabnormalities of the brain( .n cephaloplegia$ one half of the s'ull may be smallerthan the other$ possibly signifying asymmetric brain development( Microcephaly ormacrocephaly may be detected by measuring the circumference of the head(/bservation of the spine may reveal the presence of myelomeningocele$ scoliosis$and*or 'yphosis( .n cases of prenatal brain in;uries$ the length of the long bonesmay be reduced on the side opposite the cephaloplegia(

&rophic changes in the ;oints can be associated 5ith denervation in tabes dorsalisor CharcotMarie&ooth ?CM&@ disease( &he distal muscular atrophy seen in CM&disease gives the legs the appearance of inverted champagne bottles ?see Media

file 4@( Muscular atrophy seen in the region of the temporalis muscles and f acialmusculature associated 5ith frontal balding is typical of myotonic dystrophy?see Media file @(

Pes cavus deformity ?see Media file F@ can be associated 5ith spina bifida andother spinal dysraphisms( A young per son 5ith mental retardation$ genu valgum$pes cavus$ and stro'e may have homocystinuria$ an inborn error of metabolismtypically associated 5ith mental retardation ?usually severe@ and intimal thic'eningand necrosis of the media of blood vessels$ resulting in stro'es and coronary arterydisease(

Ancillary signs

Anisocoria

&his refers to pupillary asymmetry$ 5hich may result from sympathetic orparasympathetic dysfunction( Sympathetic dysfunction results in Horner syndrome$in 5hich the pupil is small but reacts to light( Hippus$ a series of oscillating pupillarycontractions seen in response to light$ is a benign condition( ArgyllRobertson pupil$

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seen in neurosyphilis$ is irregular and small7 it does not react to light$ but doesaccommodate(

.n parasympathetic paralysis$ the affected pupil is larger and reacts poorly or not at

all to light( .n;ury to the ciliary ganglion or short ciliary nerves results in a tonic pupil$5hich is large and has slo5 or absent reaction to light( A benign form of tonic pupilis seen in Adie syndrome$ HolmesAdie syndrome ?ie$ tonic pupil 5ith absentpatellar and Achilles refle"es@$ and Ross syndrome ?ie$ tonic pupil 5ith hyporefle"iaand progressive segmental hypohidrosis@(

Anosognosia

&his refers to denial of illness and typically is seen in patients 5ith rightfrontoparietal lesions$ resulting in left hemiplegia that the patient denies( A form ofvisual anosognosia ?Anton syndrome@ is seen in patients 5ith bilateral occipital lobe

infarctions7 these patients 5ith double hemianopsia ?bilateral cortical blindness@deny that they are blind(

Asteri&is

&his is seen in patients 5ith metabolic encephalopathies( Momentary loss of toneand flapping of the hand are seen 5hen the patient e"tends his arms in front 5iththe 5rists dorsifle"ed(

Ata&ia

Heeltotoe tandem gait is tested by as'ing the patient to 5al' 5ith D foot directly infront of the other( Ata"ia can be demonstrated in this manner(

/eevor sign

&his is seen 5ith bilateral lo5er abdominal paralysis that results in up5arddeviation of the umbilicus 5hen the patient tries to raise his head and sit up fromthe supine$ recumbent position(

/enediction hand

&his is seen 5ith lesions of the median nerve in the a"illa and upper arm( 8henpresent$ the inde" finger remains straight and the middle finger partially fle"es5hen the patient tries to ma'e a fist ?assuming the position of the hand of aclergyman 5hile saying the benediction@(

/ielschos"y sign

&his refers to increasing separation of the images seen 5hen a patient>s head is

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tilted to5ard the side of a superior obliue ?trochlear nerve@ paralysis( &his sign byitself is not diagnostic and should be used only as a supplement to other tests insuspected C! .6 paralysis(

Chvoste" sign

&his is seen in hypocalcemia( &apping the chee' at the angle of the ;a5 precipitatestetanic facial contractions(

Cogan sign

&his is seen in myasthenia gravis( .t refers to transient baring of the sclerae abovethe cornea as the patient resumes the primary eye position after loo'ing do5n(

+alrym.le sign

&his refers to the upperlid retraction seen in thyroid ophthalmopathy(

+oll@ss inde" finger on the patient>s lo5er ;a5 andthen stri'ing it 5ith the refle" hammer( An e"aggerated refle" indicates thepresence of a pontine lesion( 8hen the rest of the e"amination findings are normal$it may indicate physiologic hyperrefle"ia(

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-ayser

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central lesions$ nystagmus may occur 5ith the head turned to either side$ 5ithoutdiscomfort to the patient$ and 5ithout latency of onset or fatigue(

)ndine curse

&his refers to the failure of autonomic control of breathing 5hen the patient fallsasleep(

)ommen sign

Have the patient close the eyes and place a pebble the sie of an MM candy onthe palm of the e"aminer>s left hand( Cross the patient>s middle finger over theinde" finger on its dorsal aspect( 8ith the e"aminer>s right hand$ hold the patient>scrossed fingers and have the patient>s 2 ?crossed@ fingertips touch the pebble at thesame time( As' the patient ho5 many pebbles are in the e"aminer>s hand( 8ith

normal stereognosis$ the patient should ans5er that there are 2 pebbles( .n casesof astereognosis$ the patient reports feeling only D pebble(

).soclonus

&his refers to largeamplitude saccadic oscillations of the eyes in all directions$often e"acerbated by refi"ation( &hey persist during sleep and are associated 5ithbrainstem and cerebellar lesions as 5ell as a remote effect of certain carcinomas(

).to"inetic nystagmus

&his is elicited by using a rotating$ striped drum or a moving$ striped piece of cloth( As the patient>s eyes fi"ate on a stripe$ nystagmus seen in healthy individuals isdue to the opto'inetic refle"( Lesions in the anterior aspects of the visual path5aysdecrease the response$ and lesions of the vestibular system result in a directionalpreponderance to the elicited nystagmus(

Phalen sign

&his refers to the aggravation of paresthesia and pain 5hen the 5rist is held infle"ion ?in patients 5ith carpal tunnel syndrome@(

*oger sign

&his is numbness of the chin in patients 5ith lymphoreticular ?and other types of@malignancies(

Stellag sign

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&his refers to decreased blin'ing freuency seen in thyroid ophthalmopathy(

Summers"ill sign

&his refers to the bilateral upper and lo5erlid retraction associated 5ith severeliver disease(

(inel sign

&his refers to the tingling sensation elicited by tapping along the path of aregenerating nerve follo5ing in;ury( .t helps to delineate the e"tent of nerveregeneration( &he &inel sign also can be observed in tardy ulnar palsy ?palpation atthe elbo5@ and carpal tunnel syndrome ?tapping at the 5rist@(

(rendelen9urg sign

&his refers to the pelvic tilt to5ard the side of the unaffected raised leg 5hen5al'ing in patients 5ith lesions of the superior gluteal nerve(

(rom9one tongue

&his is seen in patients 5ith chorea( .t refers to the unsteadiness of the tongue5hen the patient tries to protrude it outside the mouth(

(ullio .henomenon

&his refers to the induction of vertigo and nystagmus 5ith acoustic stimuli inpatients 5ith labyrinthine disease(

von 3raee sign

&his refers to the lid lag on do5n gae in patients 5ith thyroid ophthalmopathy(

+E$I%I(I)% )$ (E*MS

Section B o 11

Authors and Editors






E"amination of Ref le"es$ Cerebellum$ and Meninges


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N VIII

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