Neurological and orthopedic examination Flashcards
Neurological examination
Regular visit
Regular visit:
Specific anamnesis – ask specific questions
When the problem started, is it going worse/better/same, from where it started (legs, head etc), the first signs
Observation (hands off)
Palpation (hands on)
Localization
Differential diagnosis, diagnostic plan
Prognosis
Neurological examination
Emergency visit
Emergency visit:
Anamnesis as fast but as thoroughly as possible, same with examination.
Be alert when dealing with traumas
Localization
How bad is the condition?
Diagnostics vs stabilizing
Prognosis!
Differences between a regular and emergency neuro exam.
For an emergency, skip some more mundane anamnesis questions if possible. You can ask them later too.
Observational exam and full palpation exam are skipped in favor of localizing the emergent issue at hand.
No time to come up with a ddx list, you just go for the issue at hand and stabilize.
Torticollis
twisted neck/wryneck
Mental state can be classified as (4)
Normal
- Bright/quiet+ alert+ responsive (BAR/QAR)
Depressive
- conscious, but lethargic, not interested
Stuporous
- unconscious, reacts to strong stimuli, feels pain
Coma
- deep unconsciousness, does not respond, does not feel pain
Neuro Behaviors can be e.g. (7)
Disorientation
Moving in circles
Compulsive movements
Head pressing
Vocalizing
Loss of learnt behavior
Aggression
Head tilt as a neuro sign
Usually tilted towards lesion
Ddx Periferal/ central vestibular problem
Head turn as a neuro sign
+ body turn and circle movement
Usually towards lesion
Ddx Problem of brain, brainstem
Ventroflexation as a neuro sign
Head tilted down, can be til thorax
Ddx Myastenia gravis, thiamine/B1
deficiency, hypokalemia (e.g. aldosterone producing tumors of the adrenal gland)
Broad-base stance as a neuro sign
Balance problem
Ddx Central/peripheral vestibular system problem
Spinal curvature as a neuro sign, define:
Kyphosis
Lordosis
Scoliosis
Kyphosis- upward hump
Lordosis- downward concave
Scoliosis- laterally curved
Ddx Pain, malformation of the vertebrae, syringomyelia
What do you look for in regard to Movement (neuro exam)? (4)
We are looking for:
Limping
Ataxia, paresis
Which limb is affected?
Ambulatory/ non-ambulatory
Paresis vs Plegia
Paresis =
Neurological weakness
Partial paralysis - voluntary movement is partially preserved, as well as deep pain.
Plegia =
Paralysis, total loss of voluntary movement, deep pain might be preserved or might not be.
Ataxia, the unnormal coordination of movements, origin can be (3)
Spinal, vestibular or cerebellar
Monoparesis/-plegia:
one limb is affected
Paraparesis/-plegia:
front OR hind limbs
(“half” the body only)
Hemiparesis/-plegia:
limbs in one side
e.g. front and hind left limbs
Tetraparesis/-plegia:
all limbs affected
DDx: tetanus
Define:
Dysmetria
Hypermetria
Hypometria
Dysmetria – change in stepping pattern
Hypermetria – abnormally long steps, animal is lifting limbs unusually high)
Hypometria – tripping, short steps
Possible Involuntary movements in neuro cases (3)
Tremor
- Rhythmic trembling of antagonistic muscle groups.
Epileptic seizures:
- Focal – affect only part of body, animal is conscious.
- Generalized – all body, animal can be conscious or not.
Myoclonus
- Strong rhythmic contractions of a muscle or a muscle group
name and explain different types of Tremor (4)
Resting tremor – seen at resting
Intention tremor – if animal is focusing on something (food, toy).
Action tremor – seen during physical action
Generalized tremor – seen in epilepsy for example
Cranial nerves testing steps (3)
- Careful, you are very close to animals face, while testing for cranial nerves!
If necessary, use a muzzle, and/or do the tests from behind the animal or skip them! - Look at the animals face: notice the pupils, face balance, mannerisms.
- Resume with testing the following:
Menace reaction
Pupillary light reflex
Strabismus/nystagmus
Palpebral reflex
Corneal reflex
Head and facial sensitivity
Swallowing, movement of tongue
Menace reflex
The menace response is one of three forms of blink reflex. It includes the reflexive blinking that occurs specifically in response to the rapid approach of an object.
Pupillary light reflex (direct, indirect)
Directing a strong light into the eye, we expect pupil constriction.
Direct: e.g. Right direct pupillary reflex is the right pupil’s response to light entering the right eye, the ipsilateral eye.
Indirect: e.g. Right consensual pupillary reflex is the right pupil’s indirect response to light entering the left eye, the contralateral eye.
Optic nerve (II CN), oculomotor nerve (III CN), additionally retina, optic junction, tract, brainstem, iris muscles.
Not a vision test! Animal can be blind and still have this reflex intact.
Mydriasis, miosis, anisocoria are useful terms.
Nystagmus
Physiological nystagmus (normal)
- Stabilizes the image on the retina when the head moves
- Vestibular cochlear nerve (VIII CN), oculomotor nerve (III CN),
trochlear nerve (IV CN),
abductor nerve (VI CN),
additionally eye muscles.
Pathological nystagmus
- Horizontal, vertical, rotary, pendular
- For evaluation, turn the animal on its back as well
- “Fast phase”-direction often away from the lesion.
Palpebral reflex
A gentle touch in the inner and outer corner of the eye, we expect the eye to close.
Trigeminal nerve (V CN),
facial nerve (VII CN), plus sensory receptors in the skin around the eyes, brain stem, eyelid muscles.
In case of deficiency, it is important to evaluate other findings related to V and VII CN.
- Facial paralysis, corneal reflex, facial and nasal mucosa sensitivity.
Corneal reflex
Very gentle touch of the eyeball, we expect the eye to close.
Only test if the palpebral reflex is incomplete!
Trigeminal nerve (V CN),
facial nerve (VII CN),
abductor nerve (VI CN),
plus corneal sensory receptors, brainstem.
Sensitivity of the mucous membrane of the face and nose is also part of the cranial nerve exam. Explain.
A gentle slide over the face, with a finger or with the help of an instrument, expect movement/reaction of the skin of the face and nose area.
Facial sensitivity V CN, VII CN;
nose sensitivity V CN.
Swallowing, tongue movement is also part of the cranial nerve exam. Explain.
With the help of instruments, we check whether the animal swallows, whether the jaw tone and tongue movement are normal.
Important if there is a history of difficulties with eating/drinking/swallowing, or other pathologies related to the mouth.
Swallowing reflex IX CN, X CN;
jaw tone V CN,
tongue mobility XII CN.
After cranial nerve exam - what do we examine next?
Postural reactions
- Help identify dysfunctions, asymmetries.
- Mostly upper motor neuron problems (recognizing position of limbs in space).
If the animal’s condition permits, all exercises and limbs should be performed, regardless of the complaint.
- Proprioceptive positioning
Describe some postural reactions (5)
(these Help identify dysfunctions, asymmetries. Mostly upper motoneuron problem (recognizing position of limbs in space))
Wheelbarrowing (with/without neck extension)
Extensor postural thrust
Hopping
Hemistanding/ hemiwalking
Placing reaction (visual & tactile)
Spinal reflexes exam
Using a reflex hammer you distinguish between upper and lower motor neuron type lesions.
UMN lesions may involve reflexes that are be exaggerated (hypermetria).
LMN lesions may involve reflexes that are diminished or absent (hypometria).
Scale -2, -1, 0, +1, +2
(0 = normal, negative are missing wholly or partially, positive grading refers to hypermetria).
Forelimb & Hind limb reflexes
(these are the most important)
Perineal reflex
Bulbo/vulvourethral reflex
Panniculus reflex
Spinal reflexes - Front limbs (2)
Flexor e. withdrawal reflex (C6-T2)
- Toe pinch followed by reflex flexor muscle contraction, limb withdrawal.
Extensor carpi radialis (C7-T2)
- A blow to the belly of the muscle, followed by a wrist extension.
Spinal reflexes - Hind limbs (3)
Flexor e. withdrawal reflex (L4-L6, L6-S2)
- Toe pinch followed by hip, knee and heel flexion.
Patellar reflex (L4-L6)
- Impact on the straight ligament of the patella, followed by contraction of the quadriceps muscle, and extension of the limb.
- Tibialis cranialis (L6-S1)
Impact on the proximal part of the cranial tibialis muscle, followed by heel flexion.
Spinal reflexes - Panniculus reflex
Gentle pinches on the trunk skin, on both sides, using an instrument, we wait for a skin movement reaction.
The m. cutaneus trunci tightens and moves the skin of the trunk.
Extends to the Th2-L4/L5 joint.
Very good for localizing damage to the thoracolumbar region.
An individual may be missing this reflex! Note: Dachshunds!
Spinal reflexes - Perineal reflex
Stimulating the anal region with the help of an instrument or while taking the temperature, we expect the contraction of the anal sphincter, the bending of the tail.
For evaluation of the caudal nerves of the tail, pubic nerve, S1-Cd5 of the spinal cord.
Hyperesthesia or hypoesthesia
for Superficial pain (as opposed to deep):
increased sensitivity = Hyperesthesia, decreased sensitivity = hypoesthesia
To evaluate deep pain, we
squeeze the toe on top of the bone with our fingers or clamp.
Expect a reaction: head turn, vocalization, bite test + limb bending (flexor reflex).
If the equivalent is only the bending of the limb, then the deep pain is missing!
This is only done if necessary. Do not press hard on a healthy dog, perform the test only in case of doubt.
A very good prognostic indicator for damage to the spinal cord and peripheral nerves!
The spinal cord has 2 thicker areas:
cervical and lumbar intumescence, where the nerves of the limbs begin.
A spinal cord segment does not always correspond to a
vertebra.
The spinal cord is divided into 4 functional areas:
- cranial cervical C1-C5
- cervicothoracic C6-Th2 intumescence
- thoracolumbar Th3-L3
- lumbosacral L4-S3 intumescence
explain LMN (lower motoneuron)
direct innervation of muscles.
Damage in LMN causes flaccid paresis/plegia.
explain UMN (upper motoneuron)
originates from brain, controls LMN.
Damage in UMN causes mostly spastic paresia/plegia.
Lesion localization in C1-C5, may include:
spastic tetraparesis; spinal reflexes normal/+
Lesion localization in C6-T2, may include:
tetraparesis; FL -/normal ja HL +/normal
FL = front limb
HL = hindlimb
Lesion localization in T3-L3, may include:
paraparesis, HL +/normal
Lesion localization in L4-S3, may include:
paraparesis, HL -/absent
review this table
review this table
VITAMIN D - our differentials
What does each letter stand for?
V - vascular
I – inflammatory (immune-mediated/infectious)
T – trauma/toxic
A – anomaly
M - metabolic
I - idiopathic
N – neoplastic/nutritional
D - degenerative
Orthopedic examination,
Regular visit
Accurate medical history
Feeding/keeping
Housing conditions, sporting, previous treatments.
The beginning of the problem, the course.
Ortho vs neuro vs other issue
Observation
Palpation
Manipulation
Localization
Differential list, presumptive diagnosis.
The prognosis?
Orthopedic examination,
Emergency visit
Fast anamnesis + as thorough a general examination as possible.
Important especially in case of trauma (fractures).
Localization?
X-ray vs stabilization
Prognosis!
Differences between regular and emergency ortho exams.
During an emergency exam you won’t have time for a detailed anamnesis before treating the patient (you can fill in the gaps in info later).
Instead of observing, palpating, manipulating you strive to just simply localize and stabilize whereas with a regular visit you will also complete a ddx list.
Observation in orthopedic examination. What sort of things are you looking for/at? (8)
Anatomical peculiarities
Posture
Hypermobility of the joints
Shape and placement of limbs
Getting up and starting to move.
Difficulty getting up from a lying/sitting position?
Limp, ataxia, dysmetria, tipping, weird standing positions and other peculiarities.
Abnormal weight bearing - pain.
Palpation ja manipulation in an ortho exam.
Be systematic!
Palpate each limb from the tip of the nail to the spine.
Palpate the muscles, joints, and long bones.
Leave the problem spot for last.
Assess for symmetry, swelling, pain, tightness, range of motion, crepitation, instability, luxation/subluxation.
Palpate the vertebrae one by one.
Carefully palpate, stretch and bend the neck.
Don’t forget to palpate the head area as well.
If necessary, the animal can be upright, on its side, or lying down during the examination.
Palpation & manipulation of the front limb
Digits and their position, extension and flexion one by one.
Be sure to check the nails & nail beds, so as not to miss a foreign body/an excessively long claw, etc.
The wrist, its extension, flexion and lateral movement. Ulna and fibula.
The elbow joint, its extension and flexion, range.
Humerus. Shoulder joint, its bending, extension, approximation, removal - NB! Fix the scapula! Scapula, acromion.
Be sure to compare the muscle tone and symmetry of the limbs by palpating the full length of both limbs at the same time.
Palpation & manipulation of the hind limb
Digits and their position, extension and flexion one by one. Be sure to check the nails & nail beds. Metatarsal area.
The hock joint, its extension, flexion and lateral mobility.
Hamstring: knee extended, heel bent.
Collateral ligaments: short in flexion, long in extension.
Tibia and fibula. Knee joint, its extension, bending, patella position.
Symmetry should be assessed on a standing animal. During manipulation, assess the presence of swelling, crepitation, and pain in the area of the straight ligament of the patella.
Hip extension, flexion, rotation, subluxation/luxation. Iliac crest, ischiatic tuberosity, greater trochanter.
During the assessment, hold the knee joint with one hand, the other hand is placed on the greater trochanter - extension, bending, approximation, removal, rotation.
Patellar luxation exam
Examination in lateral recumbency or standing.
Medial luxation – hold stifle in extension, turn digits medially, slightly press patella also medially .
Lateral luxation – hold stifle slightly in flexion, turn digits laterally, slightly press patella also laterally.
Can be unilateral or bilateral.
Symptoms: lameness, lifting hind leg occasionally up when walking, sometimes not using hind leg at all.
If bilateral high-grade problem, walking may be difficult or impossible for the animal. Muscle atrophy of hind legs.
Cranial cruciate ligament rupture exam.
Sudden onset of lameness/ non-bearing at first; may become persistent lameness later.
Swelling and pain at first; stiffness and periarticular thickness later.
Small dogs & cats may have symptoms only in acute stage (or sometimes not at all).
Drawer movement/test – abnormal cranial movement of the tibia in relation to the femur.
Painful to the patient – be careful, use muzzle if needed. Inward rotation of the tibia increased. Harder to detect without previous experience palpating this.
NB! Fixate the femur and move only tibia!
Don’t twist randomly - You don’t want to be the cause of CCLR!
Grading patellar luxation.
Grade 1: The patella is loose, but stays in the correct place normally. It will dislocate if forced, but immediately returns when released. Can be asymptomatic, no treatment is needed usually.
Grade 2: The patella occasionally dislocates when dog is moving, but usually returns by itself. Mild symptoms.
Grade 3: The patella is permanently dislocated, can be pushed back into place, but slips out again.
Grade 4: The patella is permanently dislocated and is impossible to push back into place.
