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Neurological Examination

Dr. Mahmoud Al SalhiNeurological ExaminationCranial nerves examination.Examination of old child.Examination of baby & toddlers.Cerebellar systemMotorsensoryreflexesUpperlimbslowerlimbstrunkCranial nervesGaitTonePowerMentalstatusNeurological examination is so difficult !!!Neurological examination of babies or toddler is the most difficult part !!!Minimal CooperationObserveObserveObserveOnly when you have obtained as much information as possible from observation proceed to the remainder of examinationDont rush in to put baby on bed & undress him Start with observing the baby fully dressed on parents lap or while playing with toys in an enjoyable nonthreatening environment. Observing what the baby choose to do is more instructive than their compliance with actions which you have requested them to carry out.Pediatric-Neuro Exam 6 month Behavior.flvGeneral inspection :Cerebral functions.Coordination.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & back.

Lower limbs.

Reflexes.General Inspection State of consciousness :

Conscious.Irritable.Lethargic (sleepy , arousable by fine stimuli).Obtundation ( arousable by sever stimuli ).Stupor (unarousable but respond to pain).Coma (unarousable & unresponsive).

Mentality :

the patient's level of awareness and interaction with the environment.Can be assisted b observing the baby while interacting with parents or toys.

Clues for retarded infant :Long periods without crying or interest in surroundings.Prolonged crying with no cause.Delayed speech.Delayed gross motor.Delayed fine motor.Handedness :

It became obvious between age of 1.5-5 years.Hand preference in infants < 1.5 years (hemiplegic).

Coordination :

Offer the child an interesting play & observe :

Does he reach out for it ?Is there is an intention tremor ?What sort of grasp ?Does he transfer objects between hands ? If Coordination is impaired , think of

Poor visual acuity.Cerebellar disease (Ataxic CP).Sensory loss

Neuro exam 18 Month- Behavior-Mental Status - Understanding.flvGeneral inspection :Cerebral functions.CoordinationSize & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & back.

Lower limbs.

Reflexes.Overall size & proportions of head/trunk/limbs :

Dysmorphic features:

Posture :

Frog like position :

Hip abducted & knee flexed in hypotoniaErbs palsy

Shoulder adducted & internally rotated , elbow extended & wrist flexed

Torticollis

Abnormal posture of head towards one sideOpisthotonus:

Involuntary extension of neck with arching of back occurs in meningitis , tetanus or CP.Scissoring of legs

Legs cross over each others in spastic diplegia Movement : (observe gross & fine motor)

General Paucity.Asymmetry.Accessory movements.

Tics : repeated identical movement.Tremors : involuntary rhythmical alternating movements (resting or intentional).Titubation : tremor of head & neck.Athetoid : Slow involuntary writhing movements usually of proximal limbs.Chorea : rapid involuntary irregular movements usually of face & extremities.Convulsions

General inspection :Cerebral functions.Coordination.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & back.

Lower limbs.

Reflexes.Head Shape . Size (HC) . Fontanelles. Sutures. VP shunt. Look for tongue fasciculation.HEAD

Shape :

Scaphocephaly

Head is long & narrow due to premature closure of sagittal suture

Trigonocephaly

Pointed forehead due to premature closure of metopic sutures

Plagiocephaly

Either frontal (unilateral closure of coronal suture) or occipital (Postural or unilateral closure of lambdoid suture)

Brachycephaly

Back of head is flat as in down syndrome or bilateral closure of coronal sutures.

Oxycephaly , Turricephaly or Acrocephaly.

Tower (tall) head due to premature bilateral closure of coronal suturesHead circumference : Microcephaly Macrocephaly.

Fontanelles : Anterior (diamond shape).Posterior (triangular).Third (Normal Down syndrome).Size. (Wide Narrow).Character : baby should be in setting position & calm. ( Normal tense bulging sunken ).

Sutures.VP shunt. General inspection :Cerebral functions.Coordination.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & back.

Lower limbs.

Reflexes.You can undress the baby to the nappy at this stageUpper limbsMotor system Posture.Deformities.Muscle bulk.Muscle fasciculation.Tone.Clonus.Power.

Sensation.

Reflexes.

Upper limbs (Motor) Posture & deformities :

Erbs palsy

CP

Shoulder adducted , elbow & wrist flexed

Claw hand

In radial nerve or lower plexus injury

Syndactyly

Polydactyly

Clinodactyly

Muscle bulk : Lost in LMNL , generalized wasting or disuse atrophy.

Muscle fasciculation's : LMNL.

Muscle tone :

Tone is resistance to passive movements.

Always compare both sides.Passively flex & extend the elbow & the wrist.

Hold both wrists in your hands & shakes them quickly to & fro.

Scarf Sign.

Handling the child (Shoulder girdle).

Head support.

Always remember to distract the baby by speaking with him

Scarf Sign

The tone of the shoulder girdle is assessed by taking the baby's hand and pulling the hand to the opposite shoulder like a scarf. The hand should not go past the shoulder and the elbow should not cross the midline of the chestneurology exam newborn-abnormal Tone-Upper Extremity Tone.flvjointsHand shakingNeuro exam 12 Month- Motor - Tone.flvjointsScarf signNeurology Exam, 3 Month Positions Vertical Suspension.flvHandling(normal)06Hipoton-a.MPG.flvHandling(Hypotonia)

Medical Videos - Muscle Strength and Tone.flvHypotoniaCentral. Atonic cerebral palsy.Down syndrome.Hypothyroidism.Cerebellar disease.Anterior horn cells.Peripheral nerves.Neuromuscular junction.Muscle.HypertoniaSpasticity :Initial resistance to passive movements followed by sudden release (Clasp Knife).Due to UMNL (CP).

Rigidity :Constant resistance to passive movements such as (lead pipe) or (Cogwheel).Due to lesions in basal ganglia.

Clonus :

Rhythmic series of involuntary contractions evoked by stretching the muscle.May be normal : Newborn (5 beats).Anxious babies.May be Abnormal (UMNL ) : Sustained.Asymmetrical.Most commonly evoked at ankle joint.

Muscle Power :

Impossible to test formally in this age group.

Power of hand muscles can be tested by :The tightness with which the child will grip objects.

Power of flexor muscles of arms can be tested by :Pulling the infant up by the arms from supine position , the infant with normal power will flex at the elbow to resist your pull..

Pediatric-Neuro Exam 6 month- Motor - Traction.flv Sensation :

It is difficult to test in infants .

Application of painful stimuli should never be used in exams.

Sensation can be assisted through the assessment of coordination.

Normal coordination requires normal sensation in hands.Upper limbsMotor system Posture.Deformities.Muscle bulk.Muscle fasciculation.Tone.Clonus.Power.Coordination.

Sensation.

Reflexes.

Better to be tested at the end of examinationGeneral inspection :Cerebral functions.Coordination.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & back

Lower limbs

Reflexes.General inspection :Cerebral functions.Coordination.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.Gait.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & Back.

Lower limbs.

Reflexes.TrunkAll children > 1.5 y should be able to get up from supine position. , if not (Proximal weakness).

All children > 10 m should be able to sit unsupported , if not ( Truncal weakness or ataxia).

With the child sitting give a gentle sideways push against the shoulder , if the child falls sideways it indicates weakness of trunk.

Hold the baby in the prone position by your hand & observe the axial tone.

Here the head drops much lower than one would expect, and the examiner has the sense that the infant could easily slip out of her hand without extra supportPediatric-Neuro Exam 6 month Postural Reflexes - Landau.flvHypotonia 5.flvBackExpose the back.

Inspect for:Dural sinusesSwellingTuft of hairDimple.Pigmentation

Palpate : Run your finger quickly over the spinous processes to detect spina bifida occulta.

Newborn Examination of the back and feet.flvGeneral inspection :Cerebral functions.Size & proportions of head/trunk/limbs.Dysmorphic features.Posture.Movement.

Eyes & Cranial nerves.

Head.

Upper limbs.

Trunk & Back.

Lower limbs.

Reflexes.Lower limbsMotor systemGaitPosture.Deformities.Muscle bulk.Muscle fasciculation.Tone.Clonus.Power.Coordination.

Sensation.

Reflexes.

Gait :Wide based gait

Normal in toddlers. Cerebellar disease. Ataxic CP.

Spastic diplegia gait

Hip & knee semiflexed. Legs are stiff & scissoring

Abnormal Gait Exam - Diplegic Gait Demonstration.flvSpastic diplegia gait

Hemiplegic gait

Hip & knee are extended (straight leg). Leg move stiffly by circumduction. Arm swinging is limited on the affected side.

Waddling gait

subject sways from side to side. due to a lack of hip stabilization. In DDH & duchenne muscle dystrophy.

Hemiplegia gait

Abnormal Gait Exam - Hemiplegic Gait Demonstration.flvWaddling gait

Abnormal Gait Exam - Myopathic Gait Demonstration.flvBowed Legs

Normal in toddlers. If extreme : Rickets. Osteogenesis imperfecta. Achondroplasia.Knock Knee

Rickets in preschool age.

Limp

Gait where less time is spent bearing weight on one leg than on the other. Examine legs for : Deformities. Scars.Joint swelling. Rashes. range of movements.Toe walking

May be normal. Spastic diplegia. Contractures.

Lower limbsMotor systemPosture.Deformities.Muscle bulk.Muscle fasciculation.Tone.Clonus.Power.Coordination.Gait.

Sensation.

Reflexes.

Deformity .

Muscle bulk .

Bilateral wasting

Spina bifida.Werdings Hoffmann diseaseUnilateral wasting

Hemiplegia

Hemi hypertrophy

Measure thigh & calf girth at fixed distances from kneesBilateral calf hypertrophy

Duchenne muscle dystrophy

Fasciculation :Rarely seen in infants.Always associated with muscle wasting in LMNL.

Fasciculations of lower leg muscles..flvMuscle tone :

Lightly left each leg & flex it at knee & hip for few times & feel the amount of tone you have to overcome.

Abduct each hip while the knee flexed & pelvis fixed by one hand.

Flick the knee joint off the bed :Normal : flexion of knee & the heel remain in contact with mattress.Spasticity : Whole leg is jerked into the air & remains straight.Hypotonia : the legs will remain straight on bed.Neuro exam 12 Month Motor - Tone3.flvClonus :Can be tested by sudden dorsiflexion of foot with the knee partially flexed.

Abnormal Motoric Exam - Tone - Lower extremity.flvPower :

Passively flex the legs & observe how hard the infant pushes against you.

The ability to stand up from lying position reflects good tone of pelvic girdle muscles.

Can be partly gauged from the gait.

Application of powerful stimuli to different sites (rarely used)physical exam -Newborn Normal Tone - Lower Extremity Tone.flvGowers SignGower's Sign.flv

Coordination:

Normal gait obviously implies normal coordination.

More sensitive tests can be used as :Running.Hopping.Tackling stairs.

Lower limbsMotor systemGaitPosture.Deformities.Muscle bulk.Muscle fasciculation.Tone.Clonus.Power.Coordination.

Sensation.

Reflexes.

Sensation :

It is difficult to test in infants .

Application of painful stimuli should never be used in exams.

Sensation can be assisted through the assessment of coordination.

Normal coordination requires normal sensation in hands.

Thank you