How to perform stress-free neurological exam

Question 1

Minimising stress in neuro exam

Answer 1

Avoid eye contact
Minimise prolonged handling
Avoid forced restrain
make maximum use of observation in all parts of exam

Question 2

Signs of forebrain lesion

Answer 2

Mentation and behaviour changes

Seizures

Proprioceptive deficits (contralateral)

Menace deficit, central blindness (contralateral)

Circling (towards lesion), not common

Gait often normal

Can get hemi-neglect syndrome

Question 3

Signs of brainstem lesion

Answer 3

Proprioceptive or vestibular ataxia

Paresis: tetra or hemi (ipsilateral)

Mentation change: ascending reticular activating system

Cranial nerve deficits: ipsilateral

Circling (vestibular)

Question 4

Signs of cerebellar lesion

Answer 4

Head tremor - intention tremor

Dysmetria/hypermetria and ataxia

No paresis

Menace deficit (ipsilateral): no blindness

Vestibular/paradoxical vestibular signs

Relatively common cause is Neospora

Question 5

Where is movement of the limbs generated

Answer 5

Brain

Question 6

What would UMN signs in front and back legs signify?

Answer 6

Lesion C1-5

Question 7

What would UMN signs in back legs and LMN in front legs signify?

Answer 7

Lesion C6-T2

Question 8

Lower moton neuron signs

Answer 8

Paresis or paralysis

Reflexes absent or reduced

Mucsle tone reduced

Muscle atrophy severe, early - neurogenic

Question 9

Upper motor neuron signs

Answer 9

Paresis or paralysis

Normal or increased reflexes

Normal or increased muscle tone

Muscle atrophy late, mild - disuse

Question 10

C1-C5 injury

Answer 10

Thoracic limbs: UMN
Pelvic limbs: UMN

Question 11

C6-T2 lesion

Answer 11

Thoracic limbs: LMN
Pelvic limbs: UMN

Question 12

T3-L3 lesion

Answer 12

Thoracic limbs: Normal
Pelvic limbs: UMN

Question 13

L4-S3 lesion

Answer 13

Thoracic limbs: Normal
Pelvic limbs: LMN

Question 14

Paresis/plegia: C1-C5

Answer 14

‘Floating’ thoracic limb gait

Tetraparesis/plegia

Ataxia all limbs

Postural reaction deficits all limbs

Spinal reflexes normal in all limbs

Neck pain

Horner’s syndrome

Possible urinary retention (UMN bladder)

Question 15

Paresis/plegia: C6-T2 spine

Answer 15

‘Two engine’ gait - pathognomonic (unless significant pain in both front legs, but not postural reaction deficits)

Tetraparesis/plegia

PR (postural reaction) deficits all limbs

Neck pain

Reduced spinal reflexes/absent F/L’s (front legs), normal H/L’s

Muscle atrophy and reduced tone F/L’s

Horner’s syndrome

Cutaneous trunci may be absent

UMN bladder

Question 16

Paresis/plegia: T3-L3 spine

Answer 16

Paraparesis/plegia

Ataxia pelvic limbs only

PR deficits pelvic limbs only

Spinal reflexes normal all limbs

Thoracolumbar Pain

Cutaneous trunci reflex interruption

Urinary retention (UMN bladder)

Schiff-Sherrington phenomenon

Question 17

Paresis/plegia: L4-S3 spine

Answer 17

Paraparesis/plegia > ataxia

PR deficits (pelvic limbs)

Lumbosacral pain

Spinal reflexes ↓/absent pelvic limbs

Muscle atrophy and reduced tone pelvic limbs

Perineal reflex ↓/absent

Tail movements ↓/absent

Urinary incontinence (LMN bladder)

Question 18

Spinal shock

Answer 18

Reflexes in pelvic limbs are absent even if T3-L3 lesion (so should be normal).

Can mean you incorrectly localise to L4-S3, look for cutaneous trunci cut off.

Spinal shock causes this, it is temporary and doesn’t impact prognosis.

Question 19

Myelomalacia

Answer 19

PMM (progressive).

Usually occurs in acute, severe thoracolumbar lesions e.g. intravertebral disc extrusion.

Chain of events that leads to necrosis of the spinal cord in both directions.

It is irreversible so usually euthanasia is the only option as it can cause respiratory muscles to stop working.

Cutaneous trunci may creep cranially so monitor daily, LMN in hind limbs, forelimb signs, loss of tone in abdominal muscles etc.

If they cant hold themselves in a sitting position that is a bad sign.

Question 20

Schiff-sherrington reflex

Answer 20

rigidly extended limbs when lying down, border cells knocked out meaning disinhibition to extensor tone in front legs, but standing everything else works fine.

Doesn’t tell you anything about prognosis.

T3-L3 thoracolumbar lesion.