NEUROLOGICAL EXAMINATION IN CLINICAL PRACTICENeurological i:xamination in Clinical Prac Ce sar = 2 fi UIBRA RY EDWIN R. BICKERSTARES\ ei toareu MD (Birm) MR C P.(London) RR, Consultant Neurologist to the Midland Centre for Neurosurgery and to the Birmingham Regional Hospitals BLACKWELL SCIENTIFIC PUBLICATIONS OXFORDUbwne 12 13 Contents Preface Part I The Introductory Stages Approaching a Neurological Problem Equipment The History First Impressions The General Physical and Mental Examination Part 11 The Crania) Nerves The Olfactory Nerve The Optic Nerve The Oculomotor, Trochlear and Abducent Nerves The Trigeminal Nerve The Facial Nerve The Auditory Nerve The Glossopharyngeal and Vagus Nerves The Accessory Nerve “ra “the Hypoglossaf Nerve Part WI = The Motor System 15 Development and Wasting 16 Muscle Tone Ou w& 20 33 36 50. 68 3 81 89 94 WS 105 11217 18 20 2 22 23 24 25 26 27 238 29 30 31 32 33 34 35 36 37 38 Muscle Power Posture, Stance, Spinal Movement and Gait Ynvoluntary Movements PartIV The Sensory System Basic Principles for Exammation of Sensation Pain, Touch and Temperature The Proprioceptive Sensations Stereognosis, Discriminative Sense and Graphaesthesia Common Patterns of Sensory Abnormality Part V The Motor-Sensory Links The Reflexes Co-ordmation Par¢ V1 Examinations of Particular Difficulty The Unconscious Patrent Disorders of Speech Apraxia Agnosia and Disorders of the Body Image Exammmation of Small Children The Autonomic Nervous System Part VII Laboratory Investigations Blood, Urme and Faeces The Cerebro spinal Fluid Biopsy Part ViVi The Ancillary Services. The Practical Use of the Neuroradiographic Services The Value and Abuse of Electroencephalography The Application of Electrodiagnosts Mi M7 138 145 161 167 170 173 176 187 205 215 228 237 240 246 254 261 269 282 289 309 319> Conclusion The Indications for Full Investigation an Certain Common Neurological Disorders Appendixes Recording the Neurological Examination First Examination in the Qut-Patient Department or Consulting Room Index vu 325 33} 334 337Preface Those of us who teach neurology to postgraduates soon find that most students have a general rdea of the different parts of the neurological examination, but are uncertain of the best methods of carrying out the various tests, of the purpose that lies behind them, of the true meaning of abnormal findings, and of how to overcome technical difficulties and to avoid arriving at false conclusions This boot 1s intended to present in some detail those methods which have stood the tests of trme, and to select from the newer methods those which are rapidly proving their value Itts not in any sense a text book of neurology, nor one of neuro- logical diagnosis I think, however, that the reader who follows the instructions will become sufficiently conversant with examination tech- nique to be able to approach a neurolog'cal case with that confidence whtch 1s so often lacking References have been omitted from the text to make for greater ease im reading, but a selected list of papers, reviews and monographs 1s given at the end of many of the chapters These are recommended for further reading, and will be a source of a more detailed bibliography I have personally drawn widely on the publications of those pioneers who have so greatly increased the accuracy of neurological diagnosis in recent years, and in particular I have abstracted the Medical Research Council publications on peripheral nerve inyuries, and the untque work of Andre- Thomas and his colleagues on the examination of the new-born child With the invaluable help of Dr Philip Moxon, an extensive section has been devoted to the wise use of the all important neuroradiological services I have had the help of several clinical photographers in obtamung the lusteatvons, but si thes respect I mest parcculsrly thank Mr Gordon Gasser, FIMLT, Chief Technician in our own laboratory Messrs Charles C Thomas have kindly allowed the charts of sensory derma- tomes to be reproduced from Pain by Wollf and Wolf, and Mr Per Saugman and Mr J L_ Robson of Blackwell Scientific Publications have been of the greatest help to me throughout 1xPART I The Introductory StagesCHAPTER 1} Approaching a Neurological Problem The solution of a neurological problem can be the most fascinating exercise in logical deduction in the whole of clinical medicine All too freauently, however, the pieces of this diagnostic jigsaw are neither sought out nor fitted together in an organised manner, and the approach to the puzzle is coloured by a premonition of eventual diagnostic failure The examination thus starts off at a disadvantage which ts never over- come, and hesitation and uncertanty may become all too apparent to the patent There 1s not a great deal of difference between a physician facing a neurological problem and a detective investigating a crime Indeed many physicians whe enjoy mystery stories secretly feel that, given the opportunity, they could solve the problem more speedily themselves Neurological disease offers them that opportunity Detectives, how- ever, only succeed by working to a careful plan, and medical detection must start with a clear idea of the aims of the tnvestigation Each case poses and demands an answer to four vital questions (a) Is there a lesion of the nervous system present? This is deter- muned by analysis of the history and the physical examination (8) Is it possible to locate this Jesion to one site in the nervous system, or are multiple sites involved? This must be systematically worked out by relating the symptoms and signs to a basic knowledge of neuro anatomy It 1s probably because neuro anatomy frightened Most medical men in their student days that neurology frightens them now, but anatomical knowledge need only rarely be very detailed {c) What pathological conditions are known to be capable of causing lesions at this particular site or sites? (@) In this particular mdividual, first from careful analysts of the clues given in history and examination, and later by intelligent use of the laboratory, which of these suspected conditions 1s most likely to be present? 34 NEUROLOGICAL EXAMINATION Each step taken in the study of the case, from the first interview on- wards should um at answering each of these questions in turn Each examination or investigation should have behind it the planned purpose of meluding or excluding, one specific member of the ‘short-list’ of suspected conditions It 1s always the failure to have such an organised plan of approach that makes neurological problems so artificially difficult Routine steps must of course, be followed, but blind routine and blunderbuss investigations, ‘just so as not to miss anything,’ show that such a plan has not exusted Experience helps, and helps enormously, but diagnosis purely by comparison wath previous cases 1s reserved for the man who ts very experienced, remembers his cases truly accurately, and follows them carefully and critically and he1sararity The beginner will come nearer to diagnostic accuracy by the logical reasoning out of each step along the lines suggested Despite all this, however, the nmght approach will never be achieved until one particular stumbling block is overcome The view dies hard that the exact solution to a neurological problem will be of academic interest only, for there 1s no treatment Nowadays thts 1s arcant nansense It may be true that we know of no treatment for motor neurone disease, that we cannot cure the hereditary ataxias, and that we have not yet found a reliable method of preventing relapses in disseminated sclerosis, but, contrary to many peaple s belief, these occupy a relatively small part of the neurclogist’s time Think for a moment of the transformation in the last 30 years in the treatment of epilepsy, of meningitis, of neurosyphilis and of deficiency neuropathies, of the influence of ACTH and steroids ww hypersensitivity states, and in the reute episodes of demyelinative disease, of the enormous advances of neurosurgery in the great problems of intracranial haemorrhage extrapyramidal disease, some types of ethic cateree of bentgn cerebral and spinal compression Thus tice offers possibilities for therap Fhe an Which neurotogical prac: py which compare very favourably with vroe branches er medicine Complete eradication of the pathological may rarely be achieved, but this medicine as a whole Snnappiy also applies 18 Finally, remember that the solution of a neurological problem takes time It cannot be rushed, and > the examiner approach to be influenced by must never allow hus exhortations from o; a ptinustic colleagues to wee lance at ns ease while passing,’ or to ‘just run over the nervous » it Won't take yor , aster you five minutes” It will It always does, and so ttCHAPTER 2 Equipment The nervous system may be complex, but the equipment required for its chmeal examimition is relatively simple and, with one exception, in- expenase Everything cequired for bedside practice ts shown in Fig | Some additional notes and sugeestions may also be found helpful The Ophithalmoscope This must be good, but st need not be over-eltborate It must givea steady bright, even, white dise of hight accurately focussed to shine in the same plane as the examiner's sasual ais when the insteument ts held in the optimum position, which should also be the most comfortable position No model, however evcellent, will be of value if the batteries are allowed to detenorate, and an inadequite instrument 1s a potential danger Modern ‘feah-proof” butteries are essential The Torch Modern, well mamtaned pocket torches grvea fine, bright beam of hight and for most purposes are preferable to the diffuse Jieht of the larger vantety The Percussion Hammer The handle should be long and flexible, the ring of thick, resilient rubber without a weighted centre The Pins Mapping pins, kept sharp, with rounded white heads, can also be used for confrontation tests of the visual fields The Tuning Fork Though a fork vibrating at 128(C°) 1s usually recommended, the author finds vibration better appreciated using forks at 256(C!) providing they do not have an expanded foot 5LQUIPMENT 7 The ‘Iwo-Point Discriminator Often incorrectly called by deslers an acsthestameter, this must hive blunt points Draughtsman’s dividers are of no use Besides tts primary purpose, 14s an excellent sstrument for testing diplopia, ocular move ment, abdominal and plantar reflexes, and im traum tic cases, one prong can be inserted under a plister case to test the plantar reflex, a not uncommon problem to be faced The Stethoscope This shoukt have a bell end, preferably covered by a rubber ring which allows it to fit more closely to skull or cyeball when listentbg for an intracranial brunt Homatropine This should be available always, used rirely, but without hesitation if a fundus cannot otherwise be seen and the patient ss not elderly Tests of Smell and Taste See under appropriite section im Cranial Nerves Titr Examination Coucn Too iittle attention is pud to this prece of equipment {t should be stuble and covered with a warm material which is securely fixed so that the patients nether slip, nor fear that they are going to, for this results in maintained muscular tension The headpiece should be adjustable to allow the paticnt to be slightly Propped up, and the couch should be neither so fugh that one cannot reach over the obese patient’s stomach, nor so low that the examination has to be carned out on one’s knees It should be so placed that the examiner neither stands in hus own bght, nor has the patient directly facing a bright Irght that cannot be occluded, and it should be possible to walk round each side of the patient casily There should be a movable step under the couch to assist the small, the spastic and the elderly to get on and off THLE PATIENT Above all, one needs a patrent who 1s undressed, preferably completely, or at most wearing only short underpants The examer who 1s content B8 NEURGLOGICAL EXAMINATION with shirtsleeves and socks will sooner or later miss diagnostic physical signs Long pants, guaranteed to defeat adequate examination of the lower lhmbs in men, should be removed, for if rolled up above the knee they serve merely as an efficient tourniquet In women, brassiéres and corsets will often conceal a primary carcinoma of the breast, a distended bladder, or anill-conceived pregnancy, any of which may havea profound bearing on the diagnosis In conclusion, there 1s no doubt that in emergencies one may be able to improvise almost everything that 1s needed for a complete neurological examination, but nothing will ever replace a good ophthalmoscopeCHAPTER 3 The History An accurate tnd detailed history 1s the supremely smportant part of the Investigation of a neurological problem By the teme the history 1s complete, the physician should be three quarters of the way towards the diagnosts, and if he 1s not, then there as something wrong with the way in which tt has been taken Experience of consultations his shown that this ts almost invariably the weakest part in the presentation of a chimeal problem The modes of onset and progression of symptoms are ill-defined, the terms used are vagueand woolly, and items of unhelpful information often predominate instead of the sital facts The art of taking a good neurological history hes in paying partitular attention to certain important points ‘The Age of the Patient Surprisingly enough, this 1s often omitted from verbal case reports, butat influences the management of the problem more than almost any other single factor There1s generally a fairly high degree of correlation between age and the most probable diagnosts For example, at the age of 20, a very rapidly developing brain stem Iesion 1s most hkely to be due to demyclinative disease whereas in the 60s it ts probably due to basilar artery deficiency A cerebellar tumour below the age of 12 15 probably a medulloblastoma, in the late teens or carly twenties, often an astrocytoma or ependymom1, between 35 and 50, usually a haeman gioblastoma, while Inter on a metastasis becomes likely Record the year of birth in the cise notes, for records have a habit of perpetuating the age at which the pitient first attended Clarifying the Symptoms It must be made absolutely clear what the patient means by his descnption of hts symptoms By all means put it down in his own words first, but do net be content with that The term ‘giddiness’ may mean to some, 910 NEUROLOGICAL EXAMINATION rotational vertigo, to others a sense of instability, ataxia of gait, distur- bance of vision, loss of contact with surroundings, nausea, or the term may be used as a socially acceptable description of a full-scale epileptic convulsion ‘Black-outs’ may mean loss of consciousness, loss of vision, loss of memory, or just loss of confidence By explaiming to the patient the great importance of the doctor knowing as well as he does what he means by the terms he uses, and if necessary giving illustrations of the way im which different people mean different things, these points can be clarified by careful msistence Having reached this stage, the patient must then be forced to be precise about the nature, position and duration of his symptoms Do not be satisfied with generalisations and vague gestures A note such as ‘the patient complains of continuous pain in the right side of the face’ 1s of yery httle practical value ‘Continuous* may mean truly continuous or frequently repeated A pain in the nght side of the face lasting con- tinuously all day 1s not trigermnal neuralgia, but attacks of paim, each lasting a few seconds but repeated every few minutes throughout the day, may very well be, yet it 18 likely that either will be described as ‘continuous ’ The patient should clanfy the word ‘pain ? Many use this word as the easiest in their vocabulary to describe some quite different sensation, such as tingling or even numbness The character of the pain 1s umportant, whether it 1s aching, shooting, burning, searing, ete , and the patient should be asked to give an honest assessment of its severity Adjectives such as ‘agonising’ slip off the tongue too easily Finally, and stitl taking the same example, the patient must be made to indicate with his forefinger the exact part of the face affected Often by this method he may clearly trace out a sensory dermatome or the distribution of a penpheral nerve ‘The Mode of Onset and Progression of the Symptoms Most patients, if made to realise how important it 13, will be able to say whether a symptom developed abruptly or gradually As vascular accidents form so large a part of neurological work, this distinction 18 vital It1s still amazing how many patients with subarachnoid haemor- thages are admitted to fever hospnals with a diagnosis of *meningitss” because the dramatic onset of the headache and neck stiffness 1s not appreciated Ifthe patient 1s persistently vague in this respect, they should be asked to compare the onset with either a clap of the hands or a gradually nsing movement of the hand Inthe same way, the progression must be clanfied, whether tt has been steadily ‘Worsening, worsenmg in 2