INTEGRATED BLOCK 2002-2003

IB WCS 12

CNS2
Dr. Raymond Cheung (Neurology)

Prof. Virginia Wong (Paediatrics)

Sat 31-08-02
PHYSICAL EXAMINATION

Elicit Physical Signs
General Examination
Neurological Examination
Other Examinations

COMPONENTS OF NEUROLOGICAL EXAMINATION

Higher Mental Functions
Speech & Language
Cranial Nerves
Limbs
Paediatric Neurological Examination

NEUROLOGICAL EXAMINATION OF ARMS & LEGS

Motor System
Tendon Reflexes
Testing Co-ordination
Screening Sensory System

MOTOR EXAMINATION OF ARMS

Muscle Bulk & Wasting - Distribution (distal / peripheral neuropathy)

Fasciculation or Tremor (active muscle denervation due to dying off of anterior horn cells)

Abnormal Posturing or Movements

Test Muscle Tone (passive resistance to movt over jt) Over Elbow & Wrist - Normal or Rigidity (resistance same regardless of movt) or Spasticity (resistance = kinetic dependent)

Test Muscle Power in Groups @ individual jt ® more than one muscle involved for each movt

Pronator Drift For Mild Weakness, Ataxia or Loss of Position Sensation (most prominent with eyes closed)

Shoulder (C5-6) - ‘Hold your arms up at the shoulder level’ (Deltoid; Axillary Nerve)

Elbow Flexion (C5-6) - ‘Keep your elbow bent’ (Biceps; Musculocutaneous Nerve) ® brachialis, brachioradialis

Elbow Extension (C7-8) - ‘Keep your elbow straightened’ (Triceps; Radial Nerve)

Wrist & Finger Extension (C6-8) - ‘Keep your wrist and fingers straightened’ (Extensor Carpi Radialis Longus, Extensor Carpi Ulnaris, Long Finger Extensors; Radial Nerve) ® long extensors

Hand Grip (C8-T1) - ‘Squash my fingers hard and stop me pulling them out’ (Long Finger Flexors, Small Hand Muscles; Median & Ulnar Nerves) ® long flexors

Suspecting Ulnar Neuropathy ("claw hand") - ‘Spread your fingers widely apart’ for Finger Abduction (Dorsal Interossei); ‘Hold a piece of paper between straightened fingers and stop me pulling it out’ for Finger Adduction (Palmar Interossei) + opposition

Suspecting Median Neuropathy (at night numbness, esp. over radial 3 fingers) - ‘Point your thumb towards the ceiling with your hand down flat and your palm upwards’ for Thumb Abduction (Abductor Pollicis Brevis); ‘Keep your thumb and little finger together and stop me pulling them apart’ for Thumb Opposition (Opponens Pollicis)

UPPER LIMB REFLEXES

Biceps Jerk for C5-6
Supinator Jerk for C5-6
Triceps Jerk for C7-8
Finger Jerk for C8-T1
Hoffmann Sign for C8-T1 hyperreflexia: usually in cervical myelopathy or UMN lesions above T1

TEST CO-ORDINATION

Finger-Nose Test For Intention Tremor & Past-Pointing
Rapid Tapping or Alternating Movements For Dysdiadochokinesia

SCREEN SENSORY SYSTEM

Cotton Wool For Light Touch
Pin For Pain

Spinothalamic

Tuning Fork (125 Hz) For Vibration: start distally (move proximally if no sensation)

Thumb Movement For Position Sensation

Dorsal column
MOTOR EXAMINATION OF LEGS

1^st examination = walking

Muscle Bulk & Wasting - Distribution

Fasciculation or Tremor

Abnormal Posturing or Movements

Test Muscle Tone Over Hip & Knee - Normal or Rigidity or Spasticity

Test Muscle Power in Groups

Hip Flexion (L2-3) - ‘Lift up your leg’ (Iliopsoas; Nerve to Iliopsoas)

Hip Extension (L4-5 S1) - ‘Keep your leg on the bed against me’ (Glutei - maximus/ medius/ minimus; Gluteal Nerves)

Hip Abduction (L5 S1) - ‘Spread your legs apart’ (Gluteus Medius & Tensor Fascia Lata; Gluteal Nerve

Hip Adduction (L3-4) - ‘Keep your legs together’ (Hip Adductors; Obturator Nerve)

Knee Extension (L3-4) - ‘Keep your leg straightened’ (Quadriceps Femoris; Femoral Nerve)

Knee Flexion (L5 S1) - ‘Bend your knee against me’ (Hamstrings; Sciatic Nerve)

Ankle Dorsiflexion (L4-5) - ‘Cock up your toes’ (Toe Extensors; Peroneal Nerve)

Ankle Plantar Flexion (S1-2) - ‘Push your foot down against me’ (Toe Flexors; Popliteal Nerve ® co-ordination ® sensory screening)

Anti-gravity muscles = 1 nerve root higher than flexors for same joint

LOWER LIMB REFLEXES

Knee Jerk for L3-4
Ankle Jerk for S1-2
Plantar Response Down-going
Up-going Plantar Response = Babinski Sign for Upper Motor Neurone Lesion (upturned toe - normal < 1 yo, after 1 yo = abnormal)

TEST CO-ORDINATION

Heel-Shin Test For Intention Tremor & Past-Pointing
Heel-Toe Gait For Ataxic Gait

SCREEN SENSORY SYSTEM

Cotton Wool For Light Touch
Pin For Pain (spinothalamic)

Tuning Fork (128 Hz) For Vibration (dorsal column)
Big Toe Movement For Position Sensation

At minimum, perform Pin for pain and Tuning fork (more sensitive in their respective pathways)

ABNORMAL GAIT

Hemiplegia

Paraplegia: scissoring gait ® adductor spasm

Parkinsonism: shuffling gait ® feet rubbing against floor

Cerebellar Ataxia: wide base, unsteady

Sensory Ataxia: stamping gait, cannot walk steadily with eyes closed

Waddling Gait: proximal muscle weakness

NEUROLOGICAL EXAMINATION OF PAEDIATRIC PATIENTS

Direct intervention minimal

Normal Child Development ® age-appropriate tests (milestones)

Observation ® eg. Child's interaction with caregiver, playing, etc.

Playing

Interaction With Parents & Peers

UMN - Spastic Tetraplegia, Fisting of Hands, Cortical Thumb, Scissoring of Legs, Tip Toeing,

Dystonic Posturing, Spastic Grasp, Athetosis

LMN – Hypotonia, Frog-Like Supine Posture, Slipping Through Shoulder Sign, Inverted U-Shape

When Prone, No Head Lifting, Scarf Sign, Heel Ear Test

UPPER MOTOR NEURONE TYPE (Adult)

Spastic paralysis: hypertonia

Little atrophy
Hyperactive reflexes: brisk reflexes

Clonus
Babinski’s sign

Decorticated posture (UMN): scissoring of lower limbs, flexed arms, fisted hand, cortical thumb (thumb under other fingers), hyper-extended spine

LOWER MOTOR NEURONE TYPE

Flaccid paralysis
Atrophy
Reduced reflexes
Fasciculations and fibrillation

Note

Interpret signs in groups - don't just read individual signs

Conflict in signs

Correct in eliciting and interpreting signs?

Pt has a combination of both types of lesion?

NOTES ON DERMATOME

No C1 Dermatome
C5-T1 For Arm (C6-Thumb; C7-Middle Finger; C8-Little Finger)
C4 & T2 Contiguous Over Sternal Angle
Nipple=T4; Xiphisternum=T7; Umbilicus=T10; Symphysis Pubis=L1
L2-S2 For Leg (L5-Sole)
Saddle=S3; Perianal=S4/5

ANATOMICAL DIAGNOSIS

Single vs. Multiple vs. Diffuse
Localisation - Brain (Hemisphere, Brain Stem, Cerebellum), Spinal Cord, Spinal Root, Plexus,
Peripheral Nerve, Neuromuscular Junction, Muscle

HEMISPHERIC LESION

Impaired Higher Mental Functions
Dysphasia
Dyspraxia
Homonymous Hemianopsia
Upper Motor Neurone Type Motor Weakness

POSTERIOR FOSSA LESION

Cranial Nerve Deficits
Bilateral Upper Motor Neurone Type Motor Weakness BS
Bilateral Sensory Deficits
Cerebellar Ataxia

SPINAL CORD LESION

Motor or Sensory Level (Unilateral or Bilateral)
Upper Motor Neurone Type Below Level
Lower Motor Neurone Type at Level
Dissociated Sensory Loss
Sphincter Disturbance

SPINAL ROOT LESION

Segmental Distribution of Lower Motor Neurone Type Weakness
Segmental Sensory Deficits

PLEXUS LESION

Multi-Segmental Distribution of Lower Motor Neurone Type Weakness
Multi-Segmental Sensory Deficits

PERIPHERAL NERVE LESION

Glove & Stocking Distribution of Sensory Deficits: generalised peripheral neuropathy (long nerve = more problem); mononeuropathy: deficit in a particular nerve

Lower Motor Neurone Type Weakness in Peripheral Nerve Distribution
Sensory Deficits in Peripheral Nerve Distribution

NEUROMUSCULAR JUNCTION LESION

If pure NMJ problem, must have normal sensation (eg. MG)

Focal or Generalised Weakness With Fatigability
Normal or Reduced Tendon Reflexes
Normal Sensations

MYOPATHY

Proximal Weakness
Preserved Tendon Reflexes
Normal Sensations