1. Neurological Exam: Still Important After All These Years Eric Kraus, MD Neurology

2. Neurological “Levels” Brain Brain stem Spinal cord Motor neuron Peripheral nerve Neuromuscular junction Muscle

3. 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?

4. Motor Exam Strength Tone Bulk Fasciculations

5. Motor Exam Central (UMN)Peripheral (LMN) StrengthDecreasedDecreased ToneSpasticityNormal or decreased BulkNormalAtrophy FasciculationsNoYes (motor neuron dis., PN)

6. 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) StrengthDecreasedDecreased ToneSpasticityNormal or decreased BulkNormalAtrophy

7. Motor Exam Grading »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 Functional testing Pronator drift Arm rolling test Hoover sign Spasticity in legs Bulk - symmetry and experience

8. Case: Facial Weakness Forehead has bilateral innervation Central weakness »Pyramidal system »Forehead spared »Palpebral fissure normal Peripheral weakness »7th cranial nerve (Facial) »Forehead involved »Palpebral fissure large –Not ptosis! »Hyperacusis »Abnormal taste »Mastoid pain

9. 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?

10. Reflex Exam CentralPeripheral ReflexesIncreasedDecreased Plantar stimulationUpgoing toe Downgoing toe Upgoing toe = Babinski sign

11. 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? CentralPeripheral ReflexesIncreasedDecreased Plantar stimulationUpgoing toe +/-Downgoing toe

12. Reflex Exam Grading »4 = Clonus »3 = Hyperactive »2 = Average »1 = Hypoactive »0 = none Symmetry is critical Threshold testing Augmentation

13. Reflex Exam Downgoing »“Mute” symmetrically is normal Upgoing »Whole leg may flex »Reproducible Withdrawal? »Movement at ankle, knee and hip »Variable movement »Decrease stimulation may help

14. 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?

15. Sensory Exam Posterior columns »Vibration »Proprioception »Light touch Spinothalamic tract »Pain »Temperature

16. Sensory Exam Brain »Hemisensory Brain stem »Hemisensory »Crossed face - body Spinal cord »Sensory level »Separation of posterior column - spinothalamic Peripheral nerve »Symmetric - length dependent »Symmetric - proximal and distal »Focal or multifocal

17. Sensory Exam Subjective Tuning fork Proprioception Sharp stick or pin Romberg Other “cortical” tests

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. Case 4 This is a 22 year-old female who feels clumsy. How can you tell if poor coordination localizes to the cerebellum?

24. Cerebellar Exam Very difficult exam »Finger-nose-finger »Heel-knee-shin »Rapid alternating movements »Tandem gait Interfering issues »Weakness »Sensory loss »Vertigo »Normal imperfection »Side-to-side differences

25. 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?

26. Visual Field Exam Monocular blindness Bitemporal hemianopia Left homonymous hemianopia Left superior quadrantanopia Left homonymous hemianopia with central sparing

27. Visual Field Exam Methods: »Static »Kinetic Good (+)LR = 4.2-6.8 Poor (-)LR: Absence of a defect does not rule one out Arcuate defect

28. 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?

29. Gait Exam Peripheral »Nerve –Peripheral neuropathy »Muscle –Muscular dystrophy »Vision –Macular degeneration »Vestibular –Meniere’s disease »Joint –Hip arthritis Central »Pyramidal –Stroke »Extrapyramidal –Parkinson disease »Frontal lobes –Normal pressure hydrocephalus »Cerebellar –Multiple sclerosis »Psychiatric –Conversion disorder

30. Gait Exam Walk down the hall Motor Reflexes Sensory Cerebellar Vision

31. Gait Exam Peripheral »Nerve –Foot drop or steppage gait »Muscle –Trendelenburg or waddle gait »Vision »Vestibular »Joint –Antalgic gait Gluteus medius

32. Gait Exam Central »Pyramidal –Hemiparetic or circumduction gait »Extrapyramidal –Shuffling gait »Frontal lobes »Cerebellar –Ataxic gait »Psychiatric

33. Case: Writing Trouble Patient 1 »Progressive for 2 months »Slow hand movements »No sensory loss Patient 2 »Progressive for 2 months »Slow hand movements »No sensory loss

34. Writing Trouble Patient 1 »Progressive for 2 months »Slow hand movements »No sensory loss »Right arm 4/5 + drift »Increased reflexes right arm »Action tremor Patient 2 »Progressive for 2 months »Slow hand movements »No sensory loss »No weakness or drift »Normal reflexes »Tone increased (cogwheel) »Rest tremor

35. Writing Trouble Patient 1 »Progressive for 2 months »Slow hand movements »No sensory loss »Right arm 4/5 + drift »Increased reflexes right arm »Action tremor Patient 2 »Progressive for 2 months »Slow hand movements »No sensory loss »No weakness or drift »Normal reflexes »Tone increased (cogwheel) »Rest tremor Pyramidal: Brain tumorExtrapyramidal: Parkinson disease

36. Summary The neurological exam is not any one part, but rather, the addition of multiple parts to localize the lesion. Brain Brain stem Spinal cord Motor neuron Peripheral nerve Neuromuscular junction Muscle CENTRAL PERIPHERAL

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