Transcript kraus_workshop

Neurological Exam:
Still Important After All These Years
Eric Kraus, MD
Neurology
Neurological “Levels”
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Brain
Brain stem
Spinal cord
Motor neuron
Peripheral nerve
Neuromuscular junction
Muscle
Case 1
This is a 62 year-old male with chronic right leg weakness
progressing over 6 months.
How do you use the motor exam to localize the problem
to either a peripheral or central process?
Motor Exam
Strength
 Tone
 Bulk
 Fasciculations
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MOTOR
HOMUNCULUS
UPPER MOTOR
NEURON
LOWER MOTOR
NEURON
MUSCLE
Motor Exam
Central (UMN)
Peripheral (LMN)
Strength
Decreased
Decreased
Tone
Spasticity
Normal or decreased
Bulk
Normal
Atrophy
Fasciculations
No
Yes (motor neuron dis., PN)
Case 1 Revisited
This is a 62 year-old male with chronic right leg weakness
progressing over 6 months.
Does changing the history to acute right leg weakness
over one day change your findings?
Central (UMN)
Peripheral (LMN)
Strength
Decreased
Decreased
Tone
Spasticity
Normal or decreased
Bulk
Normal
Atrophy
Motor Exam
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Grading
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5 = normal
4 = weak with resistance
3 = antigravity w/o resistance
2 = less than antigravity
1 = twitch
0 = none
Grade only full effort
Isolate each muscle
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Functional testing
Pronator drift
Arm rolling test
Hoover sign
Spasticity in legs
Bulk - symmetry and
experience
Case: Facial Weakness
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Forehead has bilateral innervation
Central weakness
R
L
» Pyramidal system
» Forehead spared
» Palpebral fissure normal
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CENTRAL
Peripheral weakness
» 7th cranial nerve (Facial)
» Forehead involved
» Palpebral fissure large
CN7
– Not ptosis!
» Hyperacusis
» Abnormal taste
» Mastoid pain
R
III
L
Case 2
This is a 62 year-old male with chronic bilateral leg
weakness progressing over 6 months.
How do you use the reflex exam to localize the problem to
either a peripheral or central process?
Reflex Exam
Reflexes
Central
Peripheral
Increased
Decreased
Plantar stimulation Upgoing toe
Downgoing toe
Upgoing toe = Babinski sign
UPPER MOTOR
NEURON
LOWER MOTOR
NEURON
MUSCLE
GOLGI RECEPTOR
SENSORY NERVE
Reflexes Revisited
This is a 62 year-old male with chronic bilateral leg
weakness progressing over 6 months.
Would changing the history to acute bilateral leg
weakness over one day change your findings?
Reflexes
Central
Peripheral
Increased
Decreased
Plantar stimulation Upgoing toe +/-
Downgoing toe
Reflex Exam
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Grading
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4 = Clonus
3 = Hyperactive
2 = Average
1 = Hypoactive
0 = none
Symmetry is critical
Threshold testing
Augmentation
0
3
1
3
0
2
2
2
2+
2
Reflex Exam
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Downgoing
» “Mute” symmetrically is normal
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Upgoing
» Whole leg may flex
» Reproducible
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Withdrawal?
» Movement at ankle, knee and hip
» Variable movement
» Decrease stimulation may help
Case 3
This is a 48 year-old woman with 2 years of numbness in
her feet.
How do you use the sensory history and exam to localize
the problem to either a peripheral or central process?
Sensory Exam
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Posterior columns
» Vibration
» Proprioception
» Light touch
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SENSORY
HOMUNCULUS
THALAMUS
Spinothalamic tract
» Pain
» Temperature
POSTERIOR COLUMN
SPINOTHALAMIC
TRACT
DORSAL ROOT
GANGLION
Sensory Exam
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Brain
» Hemisensory
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Brain stem
SENSORY
HOMUNCULUS
» Hemisensory
» Crossed face - body
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Spinal cord
» Sensory level
» Separation of posterior column spinothalamic
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Peripheral nerve
» Symmetric - length dependent
» Symmetric - proximal and distal
» Focal or multifocal
THALAMUS
TRIGEMINAL NERVE
POSTERIOR COLUMN
SPINOTHALAMIC
TRACT
DORSAL ROOT
GANGLION
Sensory Exam
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Subjective
Tuning fork
Proprioception
Sharp stick or pin
Romberg
Other “cortical” tests
Examples: Sensory
This is a 71 year-old woman with diabetes mellitus who
noted onset of numb feet 6 months ago. On exam she
can’t feel vibration until the ankle and light touch
normalizes at the mid-shin.
Diabetic, length-dependent, peripheral neuropathy.
Examples: Sensory
This is a healthy 31 year-old construction worker who
noted onset of numb hands 3 months ago. On exam
he has decreased light touch in the thumb, index and
middle fingers.
Carpal tunnel syndrome.
Examples: Sensory
This is a healthy 25 year-old woman with subacute
onset of numbness from the abdomen down, weak
legs, and urinary retention starting 2 days ago. On
exam she has a T10 sensory level to pinprick.
T10 transverse myelitis.
Examples: Sensory
This is a healthy 25 year-old woman with subacute
onset of numbness from the abdomen down, and
weak right leg starting 2 days ago. On exam she has
a T10 sensory level to pinprick on the left, and loss of
vibration in the right leg.
T8 multiple sclerosis plaque on the right.
Examples: Sensory
This is a 80 year-old man with diabetes mellitus, HTN
and hyperlipidemia who noted acute onset of left
face/arm/leg numbness 2 hours ago. On exam he has
decreased light touch on the left.
Right thalamic stroke.
Case 4
This is a 22 year-old female who feels clumsy.
How can you tell if poor coordination localizes to the
cerebellum?
Cerebellar Exam
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Very difficult exam
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Finger-nose-finger
Heel-knee-shin
Rapid alternating movements
Tandem gait
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Interfering issues
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Weakness
Sensory loss
Vertigo
Normal imperfection
Side-to-side differences
Case 5
This is a 65 year-old male who keeps bumping into
furniture on the left and crashed his car when turning left.
Can bedside visual field testing pick up a defect?
Visual Field Exam
Monocular blindness
Bitemporal hemianopia
Left homonymous hemianopia
Left superior quadrantanopia
Left homonymous hemianopia
with central sparing
Visual Field Exam
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Methods:
» Static
» Kinetic
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Good (+)LR = 4.2-6.8
Poor (-)LR: Absence of
a defect does not rule
one out
Arcuate
defect
Case 6
This is a 63 year-old male with trouble walking.
How do you use the gait exam to localize the problem to
either a peripheral or central process?
Gait Exam
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Peripheral
» Nerve
– Peripheral neuropathy
» Muscle
– Muscular dystrophy
» Vision
– Macular degeneration
» Vestibular
– Meniere’s disease
» Joint
– Hip arthritis
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Central
» Pyramidal
– Stroke
» Extrapyramidal
– Parkinson disease
» Frontal lobes
– Normal pressure hydrocephalus
» Cerebellar
– Multiple sclerosis
» Psychiatric
– Conversion disorder
Gait Exam
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Walk down the hall
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Motor
Reflexes
Sensory
Cerebellar
Vision
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Gait Exam
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Peripheral
» Nerve
– Foot drop or
steppage gait
» Muscle
– Trendelenburg or
waddle gait
» Vision
» Vestibular
» Joint
– Antalgic gait
Gluteus
medius
Gait Exam
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Central
» Pyramidal
– Hemiparetic or
circumduction gait
» Extrapyramidal
– Shuffling gait
» Frontal lobes
» Cerebellar
– Ataxic gait
» Psychiatric
Case: Writing Trouble
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Patient 1
» Progressive for 2 months
» Slow hand movements
» No sensory loss
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Patient 2
» Progressive for 2 months
» Slow hand movements
» No sensory loss
Writing Trouble
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Patient 1
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Progressive for 2 months
Slow hand movements
No sensory loss
Right arm 4/5 + drift
Increased reflexes right arm
Action tremor
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Patient 2
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Progressive for 2 months
Slow hand movements
No sensory loss
No weakness or drift
Normal reflexes
Tone increased (cogwheel)
Rest tremor
Writing Trouble
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Patient 1
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Progressive for 2 months
Slow hand movements
No sensory loss
Right arm 4/5 + drift
Increased reflexes right arm
Action tremor
Pyramidal: Brain tumor
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Patient 2
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Progressive for 2 months
Slow hand movements
No sensory loss
No weakness or drift
Normal reflexes
Tone increased (cogwheel)
Rest tremor
Extrapyramidal: Parkinson disease
Summary
The neurological exam is not any one part, but rather,
the addition of multiple parts to localize the lesion.
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Brain
Brain stem
Spinal cord
Motor neuron
Peripheral nerve
Neuromuscular junction
Muscle
CENTRAL
PERIPHERAL
END