Cervico-Thoracic
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Transcript Cervico-Thoracic
Neurology examinations
Dr Massud Wasel
M.D D.O. N.D
Registered osteopath
P.G.C.A.P
Fellow of Higher Education Academy
General rules
Explain carefully to patient what you want them
to do
Ask patient to copy your action
Compare one side with the other side
Organize your examination into categories
Mental state
Cranial nerves
Motor function
Reflexes
Coordination and gait
sensation
Equipments
Pen torch
Snellen eye chart
Ophtalmoscope
Tendon hammer
Tunning forks 512 Hz and 128 Hz
Cotton wool
Neuropins
Motor system
Inspection:
Body position :observe the patient’s body
position during movement and at rest
(hemiplegia in stroke)
Involuntary movements :if present, observe
location, quality, rate, rhythm, amplitude
(tremor, fasciculations, tics, chorea)
Size, shape of the limbs, asymmetry, deformity
(joints muscles, bones), scars, colour of skin,
T, texture, muscle wasting, fasciculation,
hypertrophy and muscle myokimia
Palpation of muscles look for tone, bulk
(atrophy)
Ensure that the patient is relaxed, and assess
tone by alternately flexing and extending the
elbow or wrist
Muscle tone :assess resistance to passive stretch
of arms and legs (spasticity, rigidity, flaccidity)
Patient : to be warm and relaxed
Avoid jerky movement and application of
excessive force – pain, induction of spasm
Compare both sides
Start :proximal to distal or distally to proximal
UEX C4 – T1
LEX
L1 – S2
Hand shaking, flexion, extension, compare
Standing: forearm flapping, compare
Shaking of elbow, GH joint
Supine: elevation of elbow, GH joint
Muscle strength :test and grade the major
muscle groups
If a pyramidal weakness is suspected (i.e. a
weakness arising from damage to the motor
cortex or descending motor tracts
Ask the patient to hold arms outstretched with
the hand supinated for up to one minute.
The eyes are closed (otherwise visual
compensation occurs)
The weak arm gradually pronates and drifts
downwards
With nerve root (LMN) essential to test
individual muscle groups to localise the lesion
When testing muscle groups, think of root and
nerve supply
Muscle strength
Grades:
0 – No muscular contraction detected
1 – A barely detectable trace of contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and
some resistance
5 – Active movement against full resistance
Upper limbs
Test for Serratus anterior C5, C6, C7 long
thoracic nerve
Patient presses arms against the wall
Look for winging of scapula
Shoulder abduction :
C5, C6 roots Axillary nerve
Arm abducts against resistance
Elbow flexion biceps C5, C6 roots
Musculocutaneous nerve
Arm flexed against resistance with the hand
fully supinated
Brachioradialis : C5, C6 Radial nerve
Arm flexed against resistance with hand in
semi position
Elbow extension triceps C6, C7, C8 roots
Radial nerve patient extends arm against
resistance
Finger extension extensor digitorum C7, C8
roots posterior interosseous nerve patient
extends fingers against resistance
Thumb extension—terminal phalanx
extensor pollicis longus and brevis C7, C8
roots posterior interosseous nerve thumb is
extended against resistance
Finger flexion—terminal phalanx flexor
digitorum profundus I and II: C7, C8 roots
flexor digitorum profundus III and IV: C7, C8
roots ulnar nerve (examiner tries to extend
patient’s flexed terminal phalanges
Thumb opposition opponens pollicis: C8, T1
roots median nerve patient tries to touch the
base of the 5th finger with thumb against
resistance
Finger abduction 1st dorsal interosseous: C8,
T1 roots ulnar nerve abductor digiti minimi
C8, T1 roots ulnar nerve
Sensation
PAIN:
Pin prick with a sterile pin provides a simple
method of testing this important modality
Firstly, check that the patient detects the pin
as ‘ sharp’ then rapidly test each dermatome
in turn
C7 extends down the middle finger
If pin prick is impaired, then more carefully map
out the extent of the abnormality, moving
from the abnormal to the normal areas
Light touch
This is tested in a similar manner, using a wisp
of cotton wool
Temperature
For additional information
Use a cold object or hot and cold test tubes
Joint position sense
Hold the sides of the patient’s finger or
thumb and demonstrate ‘up and down’
movements
Repeat with patient’s eyes closed ask patient
to specify the direction of movement
Vibration
Tunning fork 128 Hz
Bony prominence
If ipaired move more proximally and repeat
Vibration testing is of value in the early
detection of demyelinating disease and
peripheral neuropathy, but otherwise is of
limited benifit
IF THE ABOVE SENSORY
FUNCTIONS ARE NORMAL AND A
CORTICAL LESION IS
SUSPECTED, IT IS USEFUL TO
TEST FOR THE FOLLOWING:
Two point discrimination
The ability to discriminate two points when
simultaneously applied to the finger, 5 mm
apart
Sensory inattention
The ability to detect stimuli (pin prick or
touch) in both limbs , when applied to both
simultaneously
The ability to recognise objess placed in the hands
STEREOGNOSIS
The ability to recognise numbers or letters traced out on the palm
GRAPHAESTHESIA
Reflexes
Biceps jerk C5, C6 roots . Musculocutaneous
nerve
Ensure patient’s arm is relaxed and slightly
flexed.
PALPATE THE BICEPS TENDON WITH THE
THUMB AND STRIKE WITH TENDON
HAMMER. Look for elbow flexion and biceps
contraction.
Supinator jerk C6,C7 roots. Radial Nerve
Strike the lower end of the radius with the
hammer and watch for elbow and finger
flexion.
Triceps jerk C6, C7, C8
roots. Radial nerve.
Strike the patient’s elbow a
few inches above the
olecranon process. Look for
elbow extension and triceps
contraction.
Hoffman reflex C7, C8
Flick the patient’s terminal phalanx, suddenly
stretching the flexor tendon on release.
Thumb flexion indicates hyperreflexia. ( May
be present in normal subjects with brisk
tendon reflexes).
Reflex enhancement
When reflexes are difficult to elicit,
enhancement occurs if the patient is asked to
‘clench the teeth’
Scale for grading reflexes
4+ Very brisk, hyperactive, with clonus
(rhythmic oscillations between flexion and
extension)
3+ Brisk than average; possibly but not
necessarily indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response
Co- ordination
Inco-ordination (ataxia) is often a prominent
feature of cerebellar disease. Prior to testing,
ensure that power and proprioception are
normal.
Inco-ordination
video
Finger-nose testing
Ask patient to touch his nose with finger
(eyes open)
Look for jerky movements- DYSMETRIA or
an INTENTION TREMOR ( tremor only
occurring on voluntary movement).
Ask patient to alternately touch his own nose
then the examiner’s finger as fast as he can.
This may exaggerate the intention tremor
and may demonstrate
DYSDIADOCHOKINESIA- an inability to
perform rapidly alternating movements.
This may also be shown by asking the patient
to rapidly supinate and pronate the forearms
or to perform rapid and repeated tapping
movements.
video
Arm bounce
Downward pressure and sudden release of
the patient’s outstretched arm causes
excessive swinging.
Rebound phenomenon
Ask the patient to flex elbow against
resistance.
Sudden release may cause the face to strike
the face due to delay in triceps contraction.
Examination-TRUNK
Test pin prick and light touch in dermatome
Levels to remember:
T5—at nipple
T 10—at umbilicus
T 12—at inguinal ligament
Abdominal reflexes
T 7-T12 roots
Stroke or lightly scratch the skin towards the
umbilicus in each quadrant in turn
Look for abdominal muscle contraction and
note if absent or impaired
Reflexes may normally be absent in obesity,
after pregnancy, or after abdominal
operations
Cremasteric reflexes
L1, L2 root.
Scratch inner thigh.
Observe contraction cremasteric muscle
causing testicular elevation.
Sphincters
Examine abdomen for distended bladder.
Note evidence of urinary or faecal
incontinence.
Note tone of anal sphincter during rectal
examination.
Anal reflex
S4, S5 root.
A scratch on the skin beside the anus causes a
reflex contraction of the anal sphincter.
EXAMINATION – LOWER LIMBS
MOTOR SYSTEM
Appearance: Note:
- asymmetry or deformity
- muscle wasting
- muscle hypertrophy
- muscle fasciculation
- muscle myokimia
Tone
Try to relax the patient and alternately flex
and extend the knee joint. Note the
resistance.
Roll the patient’s legs from side to side.
Suddenly lift the thigh and note the response
in the lower leg. With increased tone the leg
kicks upwards.
Clonus
Ensure that the patient is relaxed.
Apply sudden and sustained flexion to the
ankle. A few oscillatory beats may occur in
the normal subject, but when this persists it
indicates increased tone.
Power
When testing each muscle group, think of
root and nerve supply.
Hip flexion
Ilio-psoas:
L1, L2, L3 roots. Femoral nerve
Hip flexed against resistance
Hip extension
Gluteus maximus:
L5, S1, S2 roots.
Inferior gluteal nerve
Patient attempts to keep heel on bed
against resistance
Hip abduction
Gluteus medius and minimus and tensor
fasciae latae:
L4, L5, S1 roots.
Superior gluteal nerve
Patient lying on back tries to abduct the leg
against resistance
Hip adduction
Adductors:
L2, L3, L4 roots.
Obturator nerve
Patient lying on back tries to pull Knees
together against resistance
Knee flexion
Hamstrings
L5, S1, S2 roots.
Sciatic nerve
Patient pulls heel towards the buttock and
tries to maintain this position against
resistance
Knee extension
Quadriceps:
L2, L3, L4 roots.
Femoral nerve
Patient tries to extend knee against
resistance
Dorsiflexion
Tibialis anterior:
L4, L5 roots.
Deep peroneal nerve
Patient dorsiflexes the ankle against
resistance. May have difficulty in walking
on heels.
Plantarflexion
Gastrocnemius, soleus:
S1, S2 roots.
Tibial nerve
Patient plantarflexes the ankle against
resistance. May have difficulty in walking on
toes before weakness can be directly
detected
Toe extension
Extensor hallucis longus, extensor digitorum
longus:
L5, S1 roots.
Deep peroneal nerve
Patient dorsiflexes the toes against
resistance
Inversion
Tibialis posterior:
L4, L5 root.
Tibial nerve
Patient inverts foot against resistance
Eversion
Peroneus longus and brevis:
L5, S1 roots.
Superficial peroneal nerve
Patient everts foot against resistance
Sensation
Dermatome distribution(?)
Test:
Pain
Light touch
(Temperature)
Follow the dermatome distribution as in
the upper limb
Joint position sense
Firstly, demonstrate flexion and extension
movements of the big toe. Then ask the
patient to specify the direction with the eyes
closed.
If deficient, test ankle joint sense in the same
way.
Vibration
Test vibration perception by placing a tuning
fork on the malleolus.
If deficient, move up to the head of the fibula
or to the anterior superior iliac spine
REFLEXES
Knee jerk:
L2, L3, L4 roots.
Ensure that the patient’s leg is relaxed by
resting it over examiner’s arm or by hanging
it over the edge of the bed. Tap the patellar
tendon with the hammer and observe
quadriceps contraction.
Note impairment or exaggeration.
Ankle jerk
S1, S2 roots.
Externally rotate the patient’s leg. Hold the
foot in slight dorsiflexion. Ensure the foot is
relaxed by palpating the tendon of tibialis
anterior. If this is taut, then no ankle jerk
will be elicited.
Tap the Achilles tendon and watch for calf
muscle contraction and plantarflexion.
Reflex enhancement
When reflexes are difficult to elicit, they may
be enhanced by asking the patient to clench
the teeth or to try to pull clasped hands apart
(Jendressik’s manoeuvre)
Plantar response
Check that the big toe is relaxed. Stroke the
lateral aspect of the sole and across the ball
of the foot.Note the first movement of the
big toe. Flexion should occur. Extension due
to contraction of extensor hallucis longus (a
“Babinski” reflex) indicates an upper motor
neuron lesion. This is usually accompanied by
synchronous contraction of the knee flexors
and tensor fasciae latae.
continued
Elicit Chaddock’s sign by stimulating the
lateral border of the foot. The big toe extends
with upper motor neuron lesions.
To avoid ambiguity do not touch the
innermost aspect of the sole or the toes
themselves.
Coordination
Coordination of muscle movement requires
that four areas of the nervous system
function in an integrated way:
The motor system, for muscle strenght
The cerebellar system, for rhythmic
movement and steady posture
The vestibular system, for balance and for
coordinating eye, head, and body
movements
The sensory system for position sense
To assess coordination, observe the patient’s
performance in:
Rapid alternating movements
Point-to-point movements
Gait and other related body movements
Standing in specified ways
Rapid Alternating
Movements
Arms: strike one hand
on the thigh
Raise the hand turn it
over and then strike
Observe the speed,
rhythm and
smoothness of the
movement
In cerebellar disease
one movement cannot
be followed quickly by
its opposite and
movements are slow,
irregular and clumsy.
This called
dysdiadochokinesis
Show the patient how
The nondominant side
to tap the distal joint of
the thumb with the tip
of the index finger
Again as rapidly as
possible
Observe the speed,
rhythm and
smoothness
often performs less
well
Legs:
Ask the patient to tap
your hand as quickly as
possible with the ball of
each foot in turn
Note any slowness or
awkwardness
The feet normally
perform less well than
the hands
Dysdiadochokinesis
(difficulty with rapidly
alternating movement)
in cerebellar disease
Cerebellar disease
causes incoordination
may get worse with
eyes closed.
Point-to-Point Movements
Arms;
Ask patient to touch
your index and then his
nose alternately
several times
Change the directions
Observe accuracy and
smoothness
Watch for tremor
In cerebellar disease
movements are
clumsy, unsteady and
inappropriately varying
in their speed, force
and direction
The finger may initially
overshoot its mark but
finally reaches it fairly
well, such movements
are termed dysmetria
Legs;
Ask patient to place
one heel on the
opposite knee, and
then run it down the
shin to the big toe
Note the smoothness
and accuracy of the
movements
Repeat with patient’s
‘closed eyes’
In cerebellar disease
the heel may overshoot
the knee and there
oscillate from side to
side down the shin
When position sense is
lost the heel is lifted
too high and patient
tries to look
With eyes closed
performance is poor
EXAMINATION POSTURE AND GAIT
CO-ORDINATION
Ask patient to repeatedly run the heel from
the opposite knee down the shin to the big
toe. Look for ATAXIA (inco-ordination). Ask
patient to repeatedly tap the floor with the
foot.
Note any DYSDIADOCHOKINESIA (difficulty
with rapidly alternating movement).
GAIT
Note:
- Length of step and width of base
- Abnormal leg movements (e.g. Excessively
high step)
- Instability (gait ataxia)
- Associated postural movements (e.g. Pelvic
swinging)
If normal, repeat with tandem walking, i.e. Heel
to toe. This will exaggerate any instability.
Gait
Ask the patient to:
Abnormality of gait –
Walk across the room
falls
A gait that lacks
coordination with
reeling and instability is
called ataxia
Causes of ataxia:
cerebellar disease, loss
of position sense, or
intoxication
then turn and come back
Observe posture,
balance, swinging of the
arms, and movements of
the legs
Normally balance is easy
The arms swing at the
sides and turns are
accomplished smoothly
Walk heel-to-toe in a
straight line-a pattern
called tandem walking
Walk on the toes then on
the heels-sensitive tests,
respectively for plantar
flexion and dorsiflexion of
the ankles, as well as for
balance
Tandem walking may
reveal an ataxia
Walking on toes and heels
may reveal distal muscular
weakness in the legs.
Inability to heel-walk is a
sensitive test for
corticospinal tract
weakness
Hop in place on each foot
in turn
Hopping involves the
proximal muscles of the
legs as well as the distal
ones and requires both
good position sense and
normal cerebellar function
Difficulty with hopping
may be due to weakness,
lack of position sense or
cerebellar dysfunction
Do a shallow knee bend
first on one leg, then on
the other
Support the patient’s
elbow if the patient is
danger of falling
Difficulty here suggests
proximal weakness
(extensor of the hip),
weakness of the
quadriceps (knee extensor)
or both
Rising from a sitting
position without arm
support and stepping up on
a sturdy stool are more
suitable tests than hopping
or knee bends when
patients are old
Proximal muscle weakness
involving the pelvic girdle
and legs causes difficulty
with both of these
activities
Stance
The following two tests can often be
performed concurrently
In each case stand close enough to the
patient to prevent a fall
Romberg’s test
Ask patient to stand with the heels together,
first with the eyes open, then with the eyes
closed.(20-30 seconds)
Note any excessive postural swaying or loss
of balance
-Present when eyes open or closed=cerebellar
deficit (cerebellar ataxia)
-Present only when eyes are closed (‘positive’
Romberg’s) = proprioceptive deficit (sensory
ataxia).
Romberg’s test
In ataxia due to loss of position sense vision
compensates for the sensory loss
The patient stands fairly well with eyes open
but loses balance when they are closed a
positive Romberg sign
In cerebellar ataxia the patient has difficulty
standing with feet together whether the eyes
are open or closed
Test for pronator drift
Patient should stand for 20-30 seconds with
both arms straight forward, palms up eyes
closed
Who can not stand may be tested for a
pronator drift in the sitting position
In either case a normal person can hold this
arm position well
Test for pronator drift
The pronation of one forearm suggest a
contralateral lesion in the corticospinal tract;
downward drift of the arm with flexion of
fingers and elbow may also occur
These movements are called pronator drift
Test for pronator drift
Instructing the patient
A weak arm is easily
to keep arms up and
eyes shut tap the arm
briskly downward
The arm normally
return smoothly
This response requires
muscular strength,
coordination and a
good sense of position
displaced and remains
so
A patient lacking
position sense may not
recognize the
displacement
In cerebellar
incoordination the arm
returns to its position
but overshoots and
bounces