Clinical assessment of a neurosurgical patient

Question 1

3 different patients you may need to assess?

Answer 1

• Obtuded patient
• Confused/disphasic patient
• Awake patient

Question 2

How to assess an obtuded patient

Answer 2

Via an independent witness 
-ABC 
-GCS 
Eye movement 
Verbal response
Motor movement
-Pupils - herniation (shown in image)

-Cerebral perfusion: CPP= MAP-ICP
Cerebral perfusion pressure= mean arterial pressure- intracranial pressure

-Cerebral herniation

Question 3

How to assess a confused patient

Answer 3

History from a patient

• Observation: posturing, focal movement, eye movement
• Assess speech
• Mini mental score

Question 4

How to assess an awake patient

Answer 4

From patient

• Assess CRANIUM
• Assess spinal cord
• Assess periphery

Question 5

What are the functions of the frontal lobe

Answer 5

• Voluntary control of movement -
• Saccadic eye movement
• Bladder control
• Gait
• Speech
• Higher functions: RIO

Question 6

What does RIO stand for?

Answer 6

Restraint, initiative, order

Question 7

Examination of Frontal lobe

Answer 7

• Inspection
• Saccadic eye movements
• Problems with speech
• Problems with reflexes
• Pyrimidal signs
• Neurophysiology

Question 8

What is looked out for during inspection of the frontal lobe

Answer 8

• Abulia : indecisiveness
• Urinary catheter
• Decordinate posture
• Magnetic gait

Question 9

What are the pyrimidal signs looked out for in examination of the frontal lobe

Answer 9

UMN weakness, altered tone, altered reflexes

Pronator drift

Question 10

Which are the cortexes examined In neurophysiology of the frontal cortex?

Answer 10

• Orbito-frontal cortex
• Anterior cingulate/ supplementary motor cortex
• Dorso-lateral pre-frontal cortex

Question 11

What does the orbit-frontal cortex control?

How is it tested

Answer 11

• Controls restraint
• mediates empathetic, social and civil behaviour
• Can be tested via the troop test
• Can be tested via the GO/ NO-GO tests

Question 12

What does the Dorso-lateral pre-frontal cortex control?

Answer 12

• Controls order
• Integrates sensory information with ordering of tasks in sequential order in response to a variety of environmental factors

Question 13

What does the anterior cingulate cortex control?

Answer 13

Control initiative 
Lack motivation?
Apathy? 
Abulia?
Depression?

Question 14

What is decordinate posture?

Answer 14

Stiff posture- extended legs, bent arms

Question 15

What are the functions of the parietal lobe|?

Answer 15

Somatosensory area
Multimodality 
Visuospatial co-ordination 
Language 
Numeracy

Question 16

How to assess speech

Answer 16

• Ensure the patient can hear and that their first language is English
• Test fluency- reflected in Broca’s
• Normal aphasia
• Test repetition
• 3 step command to test Wernicke’s- assess comprehension of speech
• Baby hippopotamus- test cerebellar function
• Test orophacial movement: ppp, mmm,
• Test reading
• Test writing

Question 17

What are cortical signs of parietal damage?

Answer 17

• Inability to distinguish between two distinct points
• Astereoagnosia
• Dysgraphethesia
• Sensory inattention

Question 18

What is astereoagnosia?

Answer 18

Inability to recognise an item exclusively based on touch without other sensory information such as visual

Question 19

What is dysgraphethesia

Answer 19

Inability to recognise writing just based on touch

Question 20

Gertsman’s syndrome?

Answer 20

On dominant side
Patient presents with:
-Dyscalculia 
-Finger anomia : Inability to distinguish between numbers written on hand 
-Left and right disorientation 
-Agraphia

Question 21

What are the temporal lobe functions

Answer 21

• Processing auditory information
• Language
• Emotion (amygdala)
• Declarative long-term memory
• Visual field

Question 22

What are the symptoms to test for cerebellum damage

Answer 22

Dysdiacokinesia : inability to perform rapid movements
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
Past Pointing : patient asked to point at moving object with eyes open and then closed

Question 23

Characters of radiculopathy

Answer 23

Damage to the nerve root

• unilateral
• myotome damage- weakness
• Dermatome damage- sensory pain

Question 24

Characters of myelopathy

Answer 24

Damage to the spinal cord

• Bilateral
• Motor and sensory
• UMN below lesion
• At cervical/ thoracic level
• Long tract damage symptoms such as clonu, upgoing plantar, Hoffman sign

Question 25

Diseases which affect the Spinal cord?

Answer 25

• Radiculopathy
• Myelopathy
• Peripheral neuropathy
• Peripheral nerve damage
• Damage to cerebellum/higher up..