SURG351 - Neurosurgical Examination

8/10/2019 SURG351 - Neurosurgical Examination

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Neurosurgical

Examination

Zain Alabedeen B. Jamjoom, M.D.

Professor & Consultant Neurosurgeon


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11/24/07 Neurosurgical Examination 2

Neurosurgical Examination

History

General Exam.

Neurological Examination


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History Extremely important!

Leads to diagnosis in up to 50% of cases. Gives good information about speech and

mental status of the patient.

First let patient describe his complaintspontaneously.

Clarify exactly what the patient means.

Avoid leading questions.

Initially all what the patient says is important.


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History

Chief complaint

Past medical history

Social history

Toxin exposure Family history

Systemic review


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History cont. Chief complaint:What?

When?

How? - sudden/gradual

Severity/extent

Time course:progression/remission/relapse

Pattern: duration/frequency

Precipitating or relieving factorsAssociated symptoms

Previous treatment & investigations


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History cont.Past medical history:

Previous illness, operation, trauma, etc.

Social history: Marital status, employment, education, habits,

hobbies.

Toxin exposure: Tobacco, alcohol, drugs, industrial toxins.

Family history: Familial illness, consanguinity.

Systemic review:Aim is to disclose other health problems that could

be relevant to present complaints


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ExaminationGeneral Examination

Neurological Examination Higher cerebral functions

Cranial nerves

Reflexes Motor system

Sensory system

Coordination & gait

Autonomic nervous system


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Equipment

Ophthalmoscope

Bright flashlight

Visual acuity cards

Stethoscope

Bld. pressure cuff

Reflex hammer

Tuning forks (128 &256 Hz)

Cotton-tipped swabs

Pins

Tape measure

Two test tubes

Bottles w. essences offamiliar odors

Assorted small objects(coin, safety pin, sandpaper, key)


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General Examination

Important for detecting systemicdisease with neurological complications.

Metabolic disorders

Vascular disease

Neoplasm

Systemic infections


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Neurological Examination

Higher cerebral functions

Cranial nerves

Motor system

Reflexes

Sensation

Co-ordination


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Higher Cerebral Functions

Speech

Orientation

Memory

Calculation

Abstract thought

Spatial cognitionApraxia


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Examination of SpeechAssess spontaneous speech:

Fluency Difficulty in finding the right words Correct use of words Voice level

Articulation

Test understanding

Assess repetitionWord finding

Reading & writing


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Speech Disorders Dysphasia:

Disorders of understanding, thought

and word finding. Dysphonia:

Disturbance of voice production.

Dysarthria:

Disturbance of articulation.

Dyslexia: Impairment of reading

Dysgraphia: Impairment of writing


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Orientation

Time:

Date - Day - Month - Year - Season

Place:

Ward - Hospital - District - City - Country Person:

Recognizing & naming relatives, etc.


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Memory Immediate recall & attention:

Patient is requested to repeat after the

examiner a series of numbers in same orderand backwards. Normal 7 numbers forwardand 5 numbers backwards.

Short-term memory:Patient is requested to repeat 3 unrelatednouns that were mentioned to him approx. 3

min. earlier. Long-term memory:

Test factual knowledge


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Apraxia Inability to perform a task when there

is no weakness, incoordination ormovement disorder to prevent it.

Tested by asking the patient to:

Perform an imaginary task (e.g. open adoor, comb the hair, etc)

Use simple common tools to perform atask ( e.g. a key to open a door etc)

Tests for parietal and pre-motor frontallobe function. Useful in dementia.


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Cranial Nerves

OlfactoryOptic

Oculomotor

Trochlear

Trigeminal

Abducent

Facial Vestibulotrochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossus


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Olfactory Nerve Examination:

Nasal passage must be free

Close other nostril and both eyes Test with 2-3 different familiar odors, e.g. coffee,

vanilla, etc (sufficient pauses in between)

Findings: Normosmia: Patient can smell & name different

odors equally in both nostrils

Hyposmia / Anosmia: Reduced or lost smell sensein one or both nostrils

Parosmia: Different odors smell the same, butdistorted and unpleasant


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Optic Nerve Examination:

Snellen chart for distant vision testing

Jaeger type cards for near vision testing

Ophthalmoscope

Torch

Fourcomponents:1 Pupils (shared with 3rd CN)

2 Visual acuity

3 Visual fields

4 Fundus


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Optic Nerve:

Visual Acuity

Monocular examination

Bed side testing: Blind

Light perception

Recognizes gross hand movementsAble to counts fingers

Able to read regular printed text

For precise quantitative testingassessment by ophthalmologist isrequired (incl. distant & near vision)


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Optic Nerve:

Visual Acuity


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Optic Nerve:

Visual Fields

Most important test for locating a lesion

in visual pathways

Bedside examination by confrontation

Perimetry: Goldman perimeter for peripheral visual

fields

Bjerrum screen for central area


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Optic Nerve:

Visual

Field

Defects


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Optic Nerve:

Funduscopy Examination:

A good ophthalmoscopeA large pupil

A still field

Abnormalities:

Optic disc: Papilledema, optic atrophy

Retina: Hemorrhage, exudates, pigmentn. Vessels: Lumen variability, thin arteries,v

enous compression, emboli, atheroma


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Optic Nerve:

PathologicalFunduscopic

Findings

Normal

Papilledema

Atrophy


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Oculomotor, Trochlear,

Abducens Nerves

Examination involves:

Eyelid

Pupils

Ocular movements


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Oculomotor, Trochlear, Abducens Nerves

The Eyelids Examination:

Note position of eyelid in relation to iris

Compare width of palpebral fissure

Abnormalities: Ptosis: hanging eyelid

Oculomotor: Sympathetic: Horner syndrome

Neuro-muscular: Myasthenia gravis

Lid retraction, lid lag

Exophthalmos: unilateral, bilateral Enophthalmos: Horners syndrome


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The Pupils Examination:

Inspection: size, shape, symmetry

Reaction to light: Prompt, sluggish, absent,symmetry

Accommodation reaction

Abnormalities: Miosis: sympathicus lesion

Mydriasis: parasympathicus lesion

Argyll Robertson Pupil: small, irregular pupil, notreacting to light but to accommodation

Myotonic pupil: in young females, unilaterallydilated pupil with failure to react, associated withareflexia


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Horners SyndromePtosis

MiosisEnophthalmus


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Ocular Movements


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Examination of Ocular Movements


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Oculomotor Nerve Palsy


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Trochlear Nerve Palsy


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Abducens Nerve Palsy


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Nystagmus Involuntary slow eye drift in one

direction with a fast correction in the

opposite direction Direction of nystagmus is described

after the fast phase

Causes: Physiological

Peripheral labyrinthine Central vestibular connections

Retinal


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Nystagmus

End-point N. (physiologic)

Symmetric lateral N. (toxic-metabolic)

Asymmetric lateral N. (one side > the

other) (labyrinthine or central) Dysconjugate N. (one eye > the other)

(always central)

Vertical or rotatory N. (usually central)


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Trigeminal NerveFunctions:

Sensation of face,anterior scalp, eye,

and anterior 2/3 of

tongue

Motor innervation of

muscle of mastication


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Facial NerveFunctions:

Innervation of the

facial expressionmuscles

The intermediatenerve carries: Secretory fibers to

lacrimal and salivaryglands

Sensation fiber oftaste from anterior2/3 of tongue


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Facial Nerve Examination:


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Facial Nerve Palsy:

Upper motor neurontype: forehead

spared

Lower motor neuron

type: all branchesaffected


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Vestibulo-cochlear nerve

Functions:

Vestibular nerve

Balance

Cochlear nerve

Hearing


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Examination of Hearing


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Glossopharyngeal & Vagus NervesFunctions:

Common sensation from pharynx,tonsils, soft palate & post. 1/3 of tongue

Taste sense from post. 1/3 of tongue

(glossopharyngeus)

Motor supply of palatal & pharyngeal

musclesMotor supply to vocal cord (vagus)


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A N


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Accessory Nerve


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Hypoglossal nerve Motor supply of the

tongue

Observe for:Atrophy

Deviation

Fibrillation General: size, color,

texture

Test: Unilateral weakness

Repetitive movements


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The Motor System

Normal movement depends on: Intact muscles

Intact innervation

Intact bones & joints

Intact coordination

Th M t S t


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The Motor SystemExamination: Inspection:

Posture

Movements: voluntary & involuntary Limb/joint anomalies/deformities

Muscle wasting

Abnormal muscle bulk Spontaneous contractions

Palpation

Measurements

Testing of muscle tone

Testing of muscle power

Muscle Examination:


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Muscle Examination:

AbnormalitiesMuscle atrophy:

General Proximal vs. distal With vs. without facial involvement Symmetrical vs. asymmetrical

Abnormal muscle bulk: Hypertrophy Pseudohypertrophy

Spontaneous contractions: Fasciculation, fibrillation

Muscle Examination:


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Muscle Examination:

Testing of Muscle Tone

Technique: Patient must be relaxedArms: pronation/supination, rolling hand around

wrist

Legs: Rolling straight leg from side to side, rapidpassive lifting of knee, flexing/dorsiflexing of foots

Abnormalities: Flaccidity

Spasticity Rigidity & cogwheel rigidity

Muscle Examination:


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Muscle Examination:

Testing of Muscle Power

Medical Research Council Scale:

0 = no movement

1 = flicker

2 = moves with gravity eliminated

3 = moves against gravity only

4 = moves against resistance5 = normal power


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Muscle Examination:


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Muscle Examination:

Testing of Arm Power

C5,6,7Thoracicus longusSerratus anteriorPush arms against wall

T1MedianAbduct poll brevThumb abduction

T1Ulnar2nd palmar

interosseous

Finger adduction

T1Ulnar1st dorsal

interosseous

Finger abduction

C8Median + UlnarFlexor digit.Finger flexion

C7,8Radial, post. interosExtensor digit.Finger extension

C6,7,8RadialTricepsElbow extension

C5,6MusculocutaneousBiceps brachiiElbow flexion

C5AxillaryDeltoidShoulder abduction

RootNerveMuscleMovement

Muscle Examination:


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Muscle Examination:

Testing of Leg Power

L5, S1Peroneus superficialisPeron long/brevFoot eversion

L2,3ObturatorAdductorsHip adduction

L5Peroneus profundusExten halluc longBig toe extension

S1Posterior tibialGastrocnemiusFoot plantarflexion

L4,5Peroneus profundusTibialis anteriorFoot dorsiflexion

L5, S1SciaticHamstringsKnee flexion

L3,4FemoralQuadriceps femorKnee extension

L5, S1Inferior glutealGluteus maximusHip extension

L1,2Lumbosacral plexusIliopsoasHip flextion

RootNerveMuscleMovement


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Involuntary Movements

Tremor Chorea

Dystonia

Myoclonic jerk


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Tendon Reflexes

S1,2TibialAnkle

L3,4FemoralKnee

C7RadialTriceps

C6,5RadialBrachioradial

C5,6MusculocuteneousBicepsRootNerveReflex


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Reflexes

Plantar responses:

Normal: flexion of all toes

Abnormal: Extension of big toe and flexion

and fanning of other toes (Babinski sign)

Hoffman sign:

Tapping on flexor side of finger tip elicits

brisk flexion of thumb and fingers


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Clonus

Repetitive muscle contractions after

sudden stretch of muscle

Sustained or un-sustained

Common cloni: Foot, patella

Indicated UMN-lesion


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Sensation

Light touch

Pain & temperature

Vibration

Position

Cortical

Coordination


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Coordination

Testing of balance:

In sitting

In standing: Romberg test

Rapid alternating movements:

Dysdiadochokinesis Targeting tests:

Finger-to-nose test

Heel-to-shin test

Gait:


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11/24/07Neurosurgical Examination 69

Hemiplegic gait Upper motor neuron(Stroke, MS)

Shuffling gait Extrapyramidal disorder

(Parkinson disease) Ataxic gait Cerebellar lesion

(MS, Tumor)

High stepping gait Drop foot(L5 root compression,Peroneal nerve palsy)

Waddling gait Pelvic girdl muscle weakness

(Proximal myopathy,

Congenital hip dislocations)

References


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11/24/07Neurosurgical Examination 70

References

Essential NeurosurgeryBy Andew H. Kaye,

3rd

Edition, Blackwell Publishing. Neurology and Neurosurgery Illustrated

By Kenneth W. Lindsay and Ian Bone,3rd Edition, Churchill Livingstone.

Neurological Examination Made EasyBy Geraint Fuller,2nd Edition, Churchill Livingstone.

Diagnosis in Color NeurologyBy Malcolm Parsons and Micheal Johnson,Mosby.

SURG351 - Neurosurgical Examination

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