Pearls in the Neurologic Exam: Don’t miss findings Andy Jagoda, MD, FACEP Professor and Chair of Emergency Medicine Mount Sinai School of Medicine Department of Emergency Medicine New York, New York 1 1 1 1

Why the Neurologic Exam in Emergency Medicine Facilitates communication Provides baseline Directs testing Identifies need for life-saving therapies Risk management 3 3 3 3

Pearls Sudden severe headache or back pain = vascular emergency Spinal cord lesions cause hyperreflexia; peripheral nerve lesions cause hyporeflexia Low back pain = exam motor, sensory, bowel, and bladder CN II, III, IV, and IV in patients with headache or suspected ICP Optic nerve disease causes an afferent defect Unilateral ptosis = 3ird nerve or sympathetic chain deficit Patients with dizziness / vertigo must have careful assessment of the posterior circulation including cerebellar testing and gait 73 42 44 44

Risk Management 18 medical legal case reviews: 4 missed cauda equina 4 missed subarachnoid 5 missed vertebral or carotid artery dissections 3 cerebellar strokes Other

Risk Management: Case #1 A 46 you female with a long history of migraine headaches presented c/o a severe occipital HA that was different form her past headaches in location and intensity. Neuro exam “WNL”. Patient was treated with prochlorperazine, 10 MG IV, with “Resolution of Headache” and discharged home to “Follow-Up With PMD”. 18 Hours later, patient was brought in by EMS comatose 4 4 4

Risk Management: Case #2 A 64 year old male presented with lower back pain which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. patient was prescribed ibuprofen and told to follow-up with his PMD. Patient developed irreversible renal damage. 5 5

Neuroanatomy Central versus peripheral If central, what is the level: symmetrical vs asymmetrical If central, what is the level: Cerebrum Brain Stem Spinal cord If peripheral, is it Nerve, muscle, NMJ 7 5 6 6

Anatomy of the Spinal Cord Corticospinal Tracts: motor from cerebral cortex: cross in the lower medulla Spinothalamic Tracts: pain and temperature: cross 1 or 2 levels above entry Posterior Column: proprioception and vibration 9 9

UMN increased DTR (after SS) LMN decreased DTR UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR UMN muscle tone increased LMN tone decreased, atrophy UMN no fasciculations LMN fasciculations 11 11

The Neuro Exam: History History often provides the key since the neuro exam may be normal Subarachnoid Hemorrhage Carbon Monoxide Poisoning Subdural Hematoma Nonconvulsive Seizures 15 9 13 13

The Neuro Exam: History Time of Onset Type of Onset Progression Trauma Associated Symptoms Factors that make it better/worse Past Symptoms / Events Past Medical History Occupational / Environ Exposures 16 10 14 14

The Neuro Exam: Physical Mental Status Cranial Nerves Motor Sensory Reflexes Coordination 18 12 16 16

Mental Status Exam AVPU GCS Orientation Mini-mental status exam Confusion assessment method (CAM) 19 14 18 18

Symmetrical vs symmetrical Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs symmetrical 23 17 20 20

Evaluation of II, III, IV, VI Visual acuity Visual fields Examine the cornea, pupil, fundi Check afferent function Extraocular movements 24 18 21 21

Swinging flashlight test Cranial Nerve II Visual acuity Visual fields Fundoscopy Swinging flashlight test 25 19 22 22

III Cranial Nerve Parasympathetics Levator Palpebrae Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles SR IO IO SR LR MR MR LR IR SO SO IR 28 21 24 24

III Cranial Nerve Paralysis Ptosis Dilated Pupil Paralyzed eye is deviated out and down; SO and LR control eye SR IO IO SR LR MR MR LR IR SO SO IR 29 22 25 25

IV Cranial Nerve Superior oblique Causes eye to turn in and down When paralyzed, eye can not turn down when it is rotated in SR IO IO SR LR MR MR LR IR SO SO IR 31 24 27 27

VI Cranial Nerve Lateral rectus Long course; goes through the CS, not within the wall Paralysis impairs abduction SR IO IO SR LR MR MR LR IR SO SO IR 32 25 28 28

Forehead has bihemispheric innervation centrally Cranial Nerve VII Motor Forehead has bihemispheric innervation centrally Taste anterior 2/3 36 29 32 32

Motor Exam Strength Tone Bulk Fasciculation Tenderness primary concern: can patient breathe key test: drift of extremity Tone hypertonia: subacute or chronic corticospinal lesion hypotonia: LMN lesion or acute UMN rigidity: basal ganglia disease Bulk wasting correlates with LMN Fasciculation anterior horn cell lesion Tenderness metabolic / inflammatory muscle disease 39 31 34 34

Motor Exam 0 = no movement 1 = flicker but no movement 2 = movement but can not resist gravity 3 = movement against gravity but can not resist examiner 4 = resists examiner but weak 5 = normal 40 32 35 35

Sensory Exam Pain / Temp - cross at entrance, ascend in spinal thalamic tract Light touch - ascend in posterior column, cross in the brain stem Vibration - posterior column, cross in the brain stem

Coordination Requires integration of cerebellar, motor, and sensory functions Balance requires (2 of 3) vision vestibular sense proprioception Falling with eyes open or closed = cerebellar Falling only with eyes closed = posterior column or vestibular 38 40 40

Reflexes Symmetry / upper vs lower 0 = absent 1 = hyporeflexia 2 = normal 3 = hyperreflexia 4 = clonus (usually indicates organic disease) Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus) Pathologic reflexes: babinski: 49 39 41 41

Pitfalls In The Neurologic Exam Not getting a complete history utilizing family or observers Not performing a systematic exam Jumping to conclusions before gathering all the data 72 41 43 43

Pearls Sudden severe headache or back pain = vascular emergency Spinal cord lesions cause hyperreflexia; peripheral nerve lesions cause hyporeflexia Low back pain = exam motor, sensory, bowel, and bladder CN II, III, IV, and IV in patients with headache or suspected ICP Optic nerve disease causes an afferent defect Unilateral ptosis = 3ird nerve or sympathetic chain deficit Patients with dizziness / vertigo must have careful assessment of the posterior circulation including cerebellar testing and gait 73 42 44 44