Neurological exam - SA Flashcards
Can you have the same disease of a different localisation?
Yes
Does lesion size = CS severity?
No
Does CS severity = prognosis?
No
Does location (anatomy) = function?
Yes
What is using the loss of function to work out the location?
Neurolocalisation
How is the spinal cord divided?
- C1-C5
- C6-T2
- T3 - L3
- L4 - Cd
Where might a neurological lesion be located?
- BRAIN (forebrain, brainstem, cerebellum)
- SC
- Neuromuscular
2 aims of neuro exam
- neurologically normal or abnormal?
- localisation of lesion
Tools for neuro exam
- room
- chair
- yoga mat
- reflex hammer
- haemostats
- Q tips (corneal reflex)
- cotton balls
- penlight
- lens
State the 8 parts of the neuro exam
- mentation
- posture
- gait
- postural reactions
- spinal reflexes
- cranial nerves
- palpation
- nociception
Define mentation
- LEVEL of consciousness: alert, obtunded, stupor / semicoma, coma
- QUALITY of consciousness: appropriate, inappropriate (compulsion, dementia/ delerium)
What is assessed with posture?
- head
- limbs
- body
Outline head posture
- Tilt (roll) suggests vestibular disease
- Turn (yaw) suggests forebrain disease
Outline limb posture
- wide based stance - proprioceptive loss
- narrow based stance - weakness?
- decreased weight bearing - evidence of pain?
What are the 3 different body postures?
- decerebrate
- decerebellate
- Schiff-Scherrington
Control of gait = ?
requires integration of proprioceptive and motor systems
What is determined in gait analysis?
- normal or abnormal
- which limbs?
- paresis, ataxia, lame, combination?
Define paresis
- decreased voluntary movement
- can be UMN or LMN
- differentiation cannot be based on severity alone
- also assess postural reactions, spinal reflexes, mm tone
Features - UMN paresis
- MUSCLE TONE is normal to increased in limbs caudal to the lesions
- SPINAL REFLEXES are normal to increased in limbs caudal to the lesion
- STRIDE: length is normal to increased, spastic
+/- ATAXIA (sensory) - swaying/ floating gait, knuckling
Features - LMN paresis
- MUSCLE TONE is decreased in limbs with a reflex arc containing a lesion
- SPINAL REFLEXES are decreased to absent in limbs with a reflex containing the lesion
- STRIDE: length is normal to decreased, stiff, ‘bunny hopping’, +/- collapse
+/- ATAXIA (sensory) knuckling
3 types of ataxia
- sensory (proprioceptive)
- cerebellar
- vestibular
Describe sensory ataxia
= loss of sense of limb/ body position
- wide based stance
- increased stride length
- swaying/ floating gait
- knuckling
Describe cerebellar ataxia
= disorder of rate and range of movement
- hypermetria
- intention tremor
- postural tremor
- jerky movements
- (high step thoracic gait)
Describe vestibular ataxia
- UNILATERAL: falling/ leaning/ circling to one side, head tilt
- BILATERAL: wide excursions of the head, +/- head tilt, crouched posture
- strabismus nystagmus commonly
Outline the purpose of assessing postural reactions
= requires integration of proprioceptive and motor systems
- similar pathways to gait
- pathways are long (‘sensitive/ non-specific’, interpret with gait, spinal reflexes, mm tone)
List some possible postural reactions to teat
- paw positioning
- hopping
- wheelbarrowing
- hemiwalking (tactile, visual)
- extensor postural thrust
- always look for symmetry*
What does the biceps tendon reflex test?
Tendon reflex - musculocutaneous nn - C6-8
What does the triceps tendon reflex test?
Tendon reflex - radial nn - C7-T2
What does the patellar tendon reflex test?
Tendon reflex - Femoral nn - L4-6
What does the gastrocnemius tendon reflex test?
Tendon reflex - sciatic nn - L6-S2
Name 2 flexor (withdrawal) spinal reflexes
- thoracic limb
- pelvic limb
What does the thoracic limb withdrawal reflex test?
multiple nn - C6-T2
What does the pelvic limb withdrawal reflex test?
Sciatic nn - L6 - S2
What does the perineal spinal reflex test?
Pudendal nn (S1-3) - there should be a bilateral response to a unilateral stimulus
How do you do the cutaneous truni mm spinal reflex test?
pinch skin in lumbar region with haemostats (not cats!)
Interpretation - decreased/ absent spinal reflex
- lesion within reflex arc
- physical limitation of movement (joint fibrosis, mm contracture)
- excitement/ fear
- ‘spinal shock’
Interpretation - exaggerated spinal reflex
- lesion to UMN pathways cranial to the spinal cord segment tested (since UMN attenuates tone in reflex arc)
- excitement/ fear (increased SNS tone)
- ‘psuedohyperreflexia’ due to loss of antagonism form mm on other side of limb
List the cranial nn
1 olfactory 2 optic 3 occulomotor 4 trochlear 5 trigeminal 6 abducent 7 facial 8 vestibulocochlear 9 glossopharyngeal 10 vagus 11 accessory 12 hypoglossal
Which CN is tested in a vision test?
CN2 –> forebrain
Which CN is tested in a menace response?
CN2 –> forebrain –> cerebellum –> brainstem –> CN 7
Which CN is tested in a PLR?
CN 2 –> brainstem –> CN 3
both direct and indirect
Features of Horner’s syndrome
= sympathetic denervation of the orbit
- miosis
- ptosis
- enopthalmos
Which CNs give motor to the extraocular mm? 3
3 occulomotor
4 trochlear
6 abducent
What controls strabismus (eye position)?
CN 8 –> central vestibular/ brainstem –> CN 3, 4, 6 (i.e. same as nystagmus)
What controls nystagmus (eye movement)?
CN 8 –> central vestibular / brainstem –> CN 3, 4, 6 (i.e. same as strabismus)
What causes palpebral reflex?
CN 5 –> brainstem –> CN 7
What causes corneal relfex?
CN 5 –> brainstem –> CN 6 (globe reaction, any blinking is controlled by CN 7)
Function - trigeminal - CN 5
- motor to mm of mastication so signs of dysfunction include atrophy and inability to close jaw
Function - facial - CN 7
- motor to mm of facial expression
- signs of dysfunction: facial paresis/ paralysis, facial asymmetry
- palpebral reflex: 5 > brainstem > 7
- menace response: 2 > forebrain > cerebellum > brainstem > 7
- autonomic innervation of lacrimal glands (test with STT-1)
Function - vestibulocochlear nn (CN 8)
COCHLEAR: auditory
VESTIBULAR: signs of dysfunction: ataxia (vestibular), head tilt, strabismus, nystagmus (abnormal)
PHYSIOLOGIC NYSTAGMUS: 8 > brainstem > 3, 4 and 6
Describe the types of nystagmus
- PHYSIOLOGIC: normal, decreased/ absent
- SPONTANEOUS / PATHOLOGIC
- DIRECTION: horizontal, rotary, vertical, fast-phase
- CONJUGATE/ DYSCONJUGATE
- POSITIONAL: inducible
Function - vagus nn - CN10
- sensory and motor to pharynx
- gag reflex: CN9 and 10 –> brainstem –> CN 9 adn 10
Function - hypoglossal nn - CN 12
- motor to tongue
- signs of dysfunction: paresis/ paralysis of tongue, atrophy/ asymmetry of tongue, seen as deviation of tongue
What are the types of palpation?
- LIGHT: swelling, atrophy
- DEEP: pain
- LOCATION: head, spine, limbs
- determine if focal or diffuse
Define nociception
= conscious perception of pain
- receptors –> brain
- SUPERFICIAL: skin
- DEEP: bone (periosteum)
- test cutaneous autonomous zones as necessary
T/F: limb withdrawal does not equal pain perception
Ture
Name 3 different types of lesion to then use to work out ddx
- focal
- multifocal
- diffuse
