Neurological Exam: Bates Chapter 16 pgs 535-546 and 555-592 The Nervous System: Chapter 16 (p. 535-546) I.

Anatomy and Physiology A. Central Nervous System 1. Brain - four regions: cerebrum, diencephalon, brainstem, and cerebellum - cerebral hemispheres subdivided into frontal, parietal, temporal, occipital lobes - other components of brain: neurons, axons, gray matter *cell bodies(, white matter (neuronal axons with myelin), basal ganglia (affect mvt), thalamus (sensory impulses, relays), hypothalamus (homestasis, temp/HR/BP), internal capsule, brainstem (connects to spinal cord, has three parts- midbrain, pons, medulla), reticular activating system, cerebellum 2. Spinal Cord - nerve tissue encased in bony vertebral column from medulla to first/second lumbar vertebra (motor, sensory, reflexes) - Five segments: Cervical (C1-8), thoracic (T1-12), lumbar (L!-5), Sacral (S1-S5), and coccygeal - Central Nervous System consists of brain and spinal cord - Peripheral Nervous System consist of 12 pairs of cranial nerves, and spinal and peripheral nerves *containing both motor and sensory fibers) - Cauda Equina: lumbar and sacral roots travel longest intraspinal distance (roots fan out like a horses tail at L1-2), therefore lumbar punctures performed at L3-4 vertebral interspace B. Peripheral Nervous System 1. Cranial Nerves - 12 pairs, some have motor/sensory functions, others specialized Producing smell/vision/heraring (I, II, VIII)
No. I II III Cranial Nerve Olfactory Optic Oculomotor Function Sense of Smell Vision Pupillary constriction, Opening eye, most of Extraocular mvt. downward, inward eye mvt. Lateral deviation of eye Motor: temporal/masseter Muscles (jaw clenching), also Lateral mvt of jaw Sensory: facial, never has Three divisions (ophthalmic, Maxiallary, madibular)

IV VI V

Trochlear Abducens Trigeminal

VII

Facial

Motor: facial mvt, facial Express9ion, closing eye/mouth Sensory: taste for salty, sweet, sour, etc ant 2/3 of tongue Hearing (cochlear division) and Balance (vestibular division) Motor- pharynx Sensory: post. Portion of Eardum, ear canal, posterior Tongue Motor: palate, pharynx, larynx Sensory: pharynx, larynx Motor: SCM, upper trapezius Motor: toungue

VIII IX

Acoustic Glossopharyngeal

X XI XII

Vagus Spinal Accessory Hypoglossal

2. Peripheral Nerves

thirty-one pairs of nerves attach to spinal cord (8 cervical, 12 throacic, 5 lumbar, 5 sacral, 1 coccygeal) sensory (afferent) and motor (efferent) fibers nuclei of gray matter, white matter (nerve fiber tracts) 3. Spinal Reflexes: The Deep Tendon Response relayed over structures of both CNS and PNS DT reflex: involuntary stereotypical response (simplest reflex) that may involve as few as two neurons across a single synapsein the arms and legs

To elicit: briskly tap tendon of partially stretched muscles, for reflect to first all components of arc must be intact Each DTR involves specific spinal segments: abnormal reflex can help locate pathological lesion Ankle Reflex Sacral 1 primarily Knee Reflex Lumbar 2, 3, 4 Supinator (brachioradialis) Cervical 5, 6 Biceps Reflex Cervical 5, 6 Triceps Reflex Cervical 6, 7 stimulating skin (as well as muscle) Abdominal reflexes- upper thoracic 8, 9, 10 Lower thoracic 10, 11, 12 Plantar response lumbar 5, sacral 1 4. Motor Pathways motor pathways contain UMN (cerebral cortex, several brainstem nuclei), synapses in brainstem or spinal cord, and LMN (cell bodies in spinal cord)

three kinds of motor pathways: cotricospinal tract, basal ganglia system, cerebellar system (also pathways in brainstem that mediate flexor, extensor tone) all higher motor pathways affect mvt. Through LMN (final common pathway) 5. Sensory Pathways sensory impulses not only participate in reflex activity but also give rise to conscious sensation, calibrate body position in space, help regulate internal ANS sensory fibers: pain, temp, position, touch, two tracts through which reach sensory cortex (spinothalamic tracts, posterior columns) fibers conducting sensations of pain/temp pass and fibers conducting crude touch sensation perceived as light touch but wo/accurate localization into

posterior horn of spinal cord, synapse with secondary sensory neurons composing Spinothalamic Tracts into thalamus

fibers conducting position, vibration, fine touch pass into posterior columns of cord, upward to medulla and synapse in medulla with secondary sensory neurons (cross to opposite side at medullary level) thalamic level: quality of sensation (pain, cold, pleasant etc.) perceived sensory cortex: full perception, stimuli localized, discriminations made dermatomes; band of skin innervated by sensory root of single spinal nerve, overlap (slightly more across midline); aid in localizing neurological lesion

The Nervous System, Chapter16 (p. 555-592 ) I. Techniques of Examination * notes, with health individuals, exam will tend to be relatively brief a. Important Qs i. Is the mental status intact? Are right-sided and left-sided finding symmetric? If finding are asymmetric or otherwise abnormal, does the causative lesion lie in CNS or PNS? b. Integration of certain portions i.e. survey patients mental status and speech during interview, or some of cranial nerves during musculoskeletal c. Important Areas i. Mental Status - General survey begins with first words of interview - components include; appearance and behavior, speech and language, mood, thoughts and perception, cognitive function (including memory, attention, information and vocabulary, calculation, and abstract thinking and constructional ability) *most assessed in interview o appearance and behavior: level of consciousness, posture and motor behavior, dress/grooming/personal hygiene, facial expression, manner/affect/relationship to persons and thing o speech and language: quantity (talk a lot, or less), rate of speech, loudness, articulation, fluency o mood: assess during interview by exploring patients own perception of it o thought and perceptions: thought processes (assessing logic, relevance, organization, coherence of patients thought processes, patterns of speech that suggest disorders of thought processes), thought content, perceptions, insight and judgment o cognitive functions: orientation, attention, remote memory, recent memory, new learning ability o higher cognitive function: information and vocabulary, calculating ability, abstract thinking, constructional ability ii. Cranial Nerves I- XII - I Smell II Visual acuity, visual fields, ocular fundi II/III Pupillary reactions III/IV/VI Extraocular movements V Corneal reflexes, facial sensation, jaw mvt VII Facial Movements

VIII Hearing IX, X Swallowing and rise of palate, gag reflex V, VII, X, XII Voice and Speech XI Shoulder and neck mvt. XII Tongue symmetry and position - Cranial Nerve I: Olfactory o Sense of smell by presenting patient with familiar/nonirritating odors, compress once side of nose at a time (patient should be closing both eyes) - CN II: Optic o Test visual acuity (Snellen Eye Chart) o Inspect optic fundi with ophthalmoscope (optic discs) o Screen visual field by confrontation - CN II and III: Optic and Oculomotor o Inspect size, shape of pupils, comparing one side with other o Papillary reactions to light; if abnormal, check near response also - CN III, IV, VI: Oculomotor, Trochlear, Abducens o Extraocular movements in six cardinal directions of gaze o Check convergence of eyes (id nystagmus if present) o Look for ptosis (drooping of eyelids) - CN V: Trigeminal o Motor: palpate temporal and masseter muscles in turn, ask patient to clench teeth (check strength) o Sensory: test forehead, cheeks, jaw on each side for pain sensationpatients eyes are closed, alternate tweting between sharp and dull touch, confirm abnormality by testing temperature sensation; test for light touch (wisp of cotton; test corneal reflex (patient looks up and away, approach from other side, touch cornea lightly---look for blinking eyes (normal reaction-sensory in V and motor in VII) - CN VII: Facial o Inspect face (note asymmetry tics etc.); ask patient to raise both eyebrows, frown, close both eyes tightly, show both upper/lower teeth, smile, puff out both cheeks - CN VIII: Acoustic o Assess hearing; if hearing loss present test for lateralization, and compare air/and bone conduction o Tests of vestibular function seldom included - CN IX and X: Glosso. and Vagus o Listen to voice, check for difficulty swallowing o Ask patient to say ah and watch for mvt of soft palate and pharynx: soft palate normally rises symmetrically and uvula remains midline, and each side of posterior pharynx moves medially o Check gag reflex: stimulate back of throat lightly on each side in turn - CN XI: Spinal Accessory o Inspect for atrophy, compare one side with other

iii. -

(not strength and contraction of trap) ask patient to turn head to each side against hand; observe contraction of opposite SCM and note strength CN XII: Hypoglossal o Listen to articulation of patients words (depends on CN V, VII, and X as well) o Look for any atrophy/fasiculations o Ask patients to protrude tongue ( look for asymmetry, atophy, deviations etc.) Motor System: muscle bulk, tone, strength, coordination, gait, stance can use sequence, or each components in arms/legs/trunk o body position: observe during mvt. and at rest o involuntary mvt: watch for involuntary mvt. (note location/quality/rate/rhythm as related to posture/activity/fatigue etc.) o muscle bulk: compare size and contours of muscles (look flat or concaveatrophied etc.) o muscle tone: normal muscle (with intact nerve supply) maintains slight residual tension called tonebest assessed by feeling muscles resistance to passive stretch; check for clonus if decreased resistance suspected o muscle strength: check for range of motion again resistance in flexion and extension; if too weak overcome resistance, test them against gravity; graded on a 0-5 scale (0 w/no muscular contraction detected, and 5 w/active mvt. against full resistance wo/evident fatigue (normal); can use +/ Upper extremity: flexion (C5, C6-biceps) and extension (C6, C7, C8-triceps) @elbow; test grip(C7, C8, T1); test finger abduction (C8, T1, ulnar nerve); test opposition of thumb (C8, T1, median nerve) Trunk: flexion, extension, lateral bending of spine and thoracic expansion and diaphragmatic excursion during respirations--- test flexion of hip (L2, L3, L4 iliopsoas), test adduction at hips (L2, L3, L4 adductors); test abduction of hips (L4, L5, S10gleteus medius and minimus); test extension @hips (S1-gluetus maximus) Lower extremity: test extension @knee (L2, L3, L4quadriceps, the strongest muscle of body); test flexion @knee (L4, L5, S1, S2hamstrings); test dorsiflexion (L4, L5); plantar flexion (S1) @ankle o Coordination: requires that four area of NS function integrativelymotor, cerebellar, vestibular, sensory BY observing patients performance in rapid alternating mvt/point-to-point mvt/gait/standing Rapid alternating mvt. (pattycake or tapping distal joint of thumb with tip of index finger rapidly; tap o

o ask patient to shrug both shoulders upward against hands

hand as quickly as possible with ball of each foot in turn) Point-to-Point Mvt: arms- they touch your index finger and then their nose ( first with eyes open and then closed; normally a person can touch examiners finger successfully w/eyes open); legs- one heel on opposite knee Gait: walk across room, walk heel-to-toe (tandem walking); walk on toes then on heels, hop in place, do a shallow knee bend, risking from a sitting position wo/arm support and stepping up on sturdy stool Stance: differ only in patients arm position, and in what you are looking Romberg Test: mainly test position sensepatient stand with feet together and eyes open, and then close both eyes for 20 to 30 secs wo/support Pronator Drift: patient should stand for 20 to 30 seconds with both arms straight forward, palms up, w/eyes closed; tap the arms briskly downward iv. Sensory System: pain and temp. (Spinothalamic), position and vibration (Posterior Columns), light touch (both Spinothalamic and Posterior Columns), discrimination - patterns of testing: pay attention to areas where there are symptoms such as numbness/pain, where there are motor reflex abnormalities that suggest lesion of spinal cord/or PNS, or where there are trophic chances such as absent/excessive sweating/atrophic skin/cutaneous ulceration); the following help id sensory deficits accurately/efficiently o compare symmetric areas on two sides o compare distal with proximal areas when testing pain, temp, touch sensation and scatter stimuli to sample most of dermatomes and major Perip. Nerves (shoulders, inner/outer aspects of forearms, thumbs and little fingers, fronts of thigh, medial/lateral aspects of both calves, little toes, medial aspect of each buttock) o testing vibration/position sensationtest fingers/toes (can then assume proximal areas are normal) o vary pace of testing o map out areas of sensory loss/hypersensitivity - Pain: sharp or dull? - Temperature - Light Touch: cotton wisp - Vibration: low-pitched tuning fork (128 Hz). Over DIP of finger, interphalangeal joint of big toeask what patient feels - Position: grasp pateients big toe on sidesask for up or down - Discriminative sensations: test ability of sensory cortex to correlate/analyze/interpret sensations o Stereognosis, graphestesia, two-pt. discrimination, point localization, extinction v. Deep tendon, abdominal plantar reflexes

to elicit: patient must relax, limbs positions, strike tendon briskly w/quick and direct strike, pointed end for striking small areas (finger over biceps tendon) and flat end over brachoradialis reflexes graded on 0-4+ scale (0-no response and 4 very brisk w/clonus) reflex depends partly on force Differences bts. Sides easier to assess use reinforcement if patients reflexes symmetrically diminished or absent (provides isometric of other muscles); clench teeth for arm reflexes etc. Biceps reflex (C5-C6), Triceps Reflex (C6, C7), Supinator or Brachioradialis Reflex (C5, C6), Abdominal Reflexes (briskly stroking each side of abdomen; above-T7/T8/T9, below umbilicusT10/T11/T12)contraction of abdominal muscles and deviation of umbilicus; Knee Reflex (L2, L3, L4); Ankle Reflex (S1); Plantar Response (L5, S1) Clonus: test for ankle clonus if reflexes seem hyperactivesupport knee in partly flexed position, and with other hand dorsiflex and plantar flex foot a few times while encouraging patients to relax look and feel for rhythmic oscillations btw. Dorsiflexion and plantar flexion (clonus may be elicited at other joints, i.e. patella)