SURG351 - Neurosurgical Examination

Neurosurgical
Examination
Zain Alabedeen B. Jamjoom, M.D.
Professor & Consultant Neurosurgeon
Neurosurgical Examination
History
General Exam.
Neurological Examination
11/24/07
History

Extremely important!
Leads to diagnosis in up to 50% of cases.
Gives good information about speech and
mental status of the patient.
First let patient describe his complaint
spontaneously.
Clarify exactly what the patient means.
Avoid leading questions.
Initially all what the patient says is important.
11/24/07
History

11/24/07
Chief complaint
Past medical history
Social history
Toxin exposure
Family history
Systemic review
History cont.
Chief complaint:
What?
When?
How?
- sudden/gradual
Severity/extent
Time course:
progression/remission/relapse
Pattern: duration/frequency
Precipitating or relieving factors
Associated symptoms
Previous treatment & investigations
11/24/07
History cont.
Past medical history:
Previous illness, operation, trauma, etc.
Social history:
Marital status, employment, education, habits,

hobbies.
Toxin exposure:
Tobacco, alcohol, drugs, industrial toxins.
Family history:
Familial illness, consanguinity.
Systemic review:
11/24/07
Aim is to disclose other health problems that could

be relevant to present complaints
Examination
General
Examination
Higher cerebral functions
Cranial nerves
Reflexes
Motor system
Sensory system
Coordination & gait
Autonomic nervous system
11/24/07
Equipment

Ophthalmoscope
Bright flashlight
Visual acuity cards
Stethoscope
Bld. pressure cuff
Reflex hammer
Tuning forks (128 &
256 Hz)
11/24/07

Cotton-tipped swabs
Pins
Tape measure
Two test tubes
Bottles w. essences of
familiar odors
Assorted small objects
(coin, safety pin, sand
paper, key)
General Examination
Important
for detecting systemic

disease with neurological complications.
Metabolic disorders
Vascular disease
Neoplasm
Systemic infections
11/24/07
Higher
cerebral functions
Cranial nerves
Motor system
Reflexes
Sensation
Co-ordination
11/24/07
10
Higher Cerebral Functions

Speech
Orientation
Memory
Calculation
Abstract
thought
Spatial cognition
Apraxia
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11
Examination of Speech
Assess
spontaneous speech:
Fluency
Difficulty in finding the right words
Correct use of words
Voice level
Articulation
Test
understanding
Assess repetition
Word finding
Reading & writing
11/24/07
12
Speech Disorders
Dysphasia:
Disorders of understanding, thought

and word finding.
Dysphonia:
Disturbance of voice production.
Dysarthria:
Disturbance of articulation.
Dyslexia:
Impairment of reading
Dysgraphia: Impairment of writing
11/24/07
13
Dysphasia
Transcortical
sensory
aphasia
Sensory Wernickes
aphasia
area
Transcortical
motor
aphasia
Concept
area
Brocas
area
Arcuate facsiculus
Motor
aphasia
Conductive
aphasia
Hearing
11/24/07
Voice production
& articulation
14
Orientation
Time:
Date - Day - Month - Year - Season

Place:
Ward - Hospital - District - City - Country

Person:
Recognizing & naming relatives, etc.
11/24/07
15
Memory
Immediate
recall & attention:
Patient is requested to repeat after the

examiner a series of numbers in same order
and backwards. Normal 7 numbers forward
and 5 numbers backwards.
Short-term
memory:
Patient is requested to repeat 3 unrelated

nouns that were mentioned to him approx. 3
min. earlier.
Long-term
memory:
Test factual knowledge

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16
Calculation
Serial
subtraction of 7 from 100.

Doubling 3s.
Simple tasks:
Addition: 7 + 14
Subtraction: 23 8
Multiplication: 4 x 7
Division: 36 / 9
11/24/07
17
Abstract Thought
Tests
frontal lobe function

Tested by asking the patient to:
Explain simple common proverbs
Explain difference betw. pairs of objects
Estimate various things, e.g. distance
Riyadh-Mecca, weight of a camel, etc.
Useful
in frontal lobe lesions, dementia,

and psychiatric disorders.
11/24/07
18
Spatial Cognition
Disorders
of spatial cognition are

referred to as agnosias
Copy a simple shape (e.g. 5-pointed star)
Recognize faces of famous people
Identify his left side, hand and fingers
Identify with closed eyes common small
objects by hand (e.g. coin, paper clip, etc)
Tests
for parietal & occipital lobe

function. Useful in dementia
11/24/07
19
Apraxia
Inability
to perform a task when there

is no weakness, incoordination or
movement disorder to prevent it.
Perform an imaginary task (e.g. open a
door, comb the hair, etc)
Use simple common tools to perform a
task ( e.g. a key to open a door etc)
Tests
for parietal and pre-motor frontal

lobe function. Useful in dementia.
11/24/07
20
Cranial Nerves
Olfactory
Facial
Optic
Vestibulotrochlear
Oculomotor
Glossopharyngeal
Trochlear
Vagus
Trigeminal
Accessory
Abducent
Hypoglossus
11/24/07
21
Olfactory Nerve
Examination:
Nasal passage must be free
Close other nostril and both eyes
Test with 2-3 different familiar odors, e.g. coffee,
vanilla, etc (sufficient pauses in between)
Findings:
Normosmia: Patient can smell & name different
odors equally in both nostrils
Hyposmia / Anosmia: Reduced or lost smell sense
in one or both nostrils
Parosmia: Different odors smell the same, but
distorted and unpleasant
11/24/07
22
Optic Nerve
Examination:
Snellen chart for distant vision testing

Jaeger type cards for near vision testing
Ophthalmoscope
Torch
Four
1
2
3
4
11/24/07
components:
Pupils (shared with 3rd CN)

Visual acuity
Visual fields
Fundus
23
Optic Nerve:
Visual Acuity
Monocular examination
Bed side testing:
Blind
Light perception
Recognizes gross hand movements
Able to counts fingers
Able to read regular printed text
For
precise quantitative testing

assessment by ophthalmologist is
required (incl. distant & near vision)
11/24/07
24
Optic Nerve:
Visual Acuity
11/24/07
25
Optic Nerve:
Visual Fields
Most
important test for locating a lesion

in visual pathways
Bedside examination by confrontation
Perimetry:
Goldman perimeter for peripheral visual
fields
Bjerrum screen for central area
11/24/07
26
Optic Nerve:
Visual
Field
Defects
11/24/07
27
Optic Nerve:
Funduscopy
Examination:
A good ophthalmoscope
A large pupil
A still field
Abnormalities:
Optic disc: Papilledema, optic atrophy

Retina: Hemorrhage, exudates, pigmentn.
Vessels: Lumen variability, thin arteries,v
enous compression, emboli, atheroma
11/24/07
28
Optic Nerve:
Pathological
Funduscopic
Findings
Papilledema
Normal
11/24/07
Atrophy
29
Oculomotor, Trochlear,
Abducens Nerves
Examination
involves:
Eyelid
Pupils
Ocular movements
11/24/07
30
Oculomotor, Trochlear, Abducens Nerves
The Eyelids
Examination:
Note position of eyelid in relation to iris
Compare width of palpebral fissure
Abnormalities:
Ptosis: hanging eyelid
Oculomotor:
Sympathetic: Horner syndrome
Neuro-muscular: Myasthenia gravis
Lid retraction, lid lag

Exophthalmos: unilateral, bilateral
Enophthalmos: Horners syndrome
11/24/07
31
The Pupils
Examination:
Inspection: size, shape, symmetry
Reaction to light: Prompt, sluggish, absent,
symmetry
Accommodation reaction
Abnormalities:
Miosis: sympathicus lesion
Mydriasis: parasympathicus lesion
Argyll Robertson Pupil: small, irregular pupil, not
reacting to light but to accommodation
Myotonic pupil: in young females, unilaterally
dilated pupil with failure to react, associated with
areflexia
11/24/07
32
Horners Syndrome
Ptosis
Miosis
Enophthalmus
11/24/07
33
Ocular Movements
11/24/07
34
Examination of Ocular Movements
11/24/07
35
Oculomotor Nerve Palsy
11/24/07
36
Trochlear Nerve Palsy
11/24/07
37
Abducens Nerve Palsy
11/24/07
38
Nystagmus
Involuntary
slow eye drift in one

direction with a fast correction in the
opposite direction
Direction of nystagmus is described
after the fast phase
Causes:
Physiological
Peripheral labyrinthine
Central vestibular connections
Retinal
11/24/07
39
Nystagmus
End-point
N. (physiologic)
Symmetric lateral N. (toxic-metabolic)
Asymmetric lateral N. (one side > the
other) (labyrinthine or central)
Dysconjugate N. (one eye > the other)
(always central)
Vertical or rotatory N. (usually central)
11/24/07
40
Trigeminal Nerve
Functions:
Sensation of face,
anterior scalp, eye,
and anterior 2/3 of
tongue
Motor innervation of
muscle of mastication
11/24/07
41
Trigeminal Nerve
Examination:
Facial sensation
Mastication muscles
Jaw reflex
Left
trigeminal
lesion
Corneal reflex
11/24/07
42
Facial Nerve
Functions:
Innervation of the
facial expression
muscles
The intermediate
nerve carries:
Secretory fibers to
lacrimal and salivary
glands
Sensation fiber of
taste from anterior
2/3 of tongue
11/24/07
43
Facial Nerve Examination:
11/24/07
44
Facial Nerve Palsy:

Upper motor neuron

type: forehead
spared
Lower motor neuron

type: all branches
affected
11/24/07
45
Vestibulo-cochlear nerve
Functions:
Vestibular nerve
Balance
Cochlear nerve
Hearing
11/24/07
46
Examination of Hearing
11/24/07
47
Test of Vestibular Function

Provocation Tests of Nystagmus
1. Positional
2. Caloric
3. Rotational test
11/24/07
48
Glossopharyngeal & Vagus Nerves

Functions:
Common
sensation from pharynx,

tonsils, soft palate & post. 1/3 of tongue
Taste sense from post. 1/3 of tongue
(glossopharyngeus)
Motor supply of palatal & pharyngeal
muscles
Motor supply to vocal cord (vagus)
11/24/07
49
Glossopharyngeal & Vagus Nerves

Examination:

Inspection of soft
palate
Testing for the
gag reflex
Assessment of
swallowing
Assessment of
vocal cord
11/24/07
50
Accessory Nerve
11/24/07
51
Hypoglossal nerve

Motor supply of the

tongue
Observe for:
Atrophy
Deviation
Fibrillation
General: size, color,
texture
Test:
Unilateral weakness
Repetitive movements
11/24/07
52
The Motor System

Normal movement depends on:
Intact muscles
Intact innervation
Intact bones & joints
Intact coordination
11/24/07
53
The Motor System

Examination:
Inspection:

Posture
Movements: voluntary & involuntary
Limb/joint anomalies/deformities
Muscle wasting
Abnormal muscle bulk
Spontaneous contractions
Palpation
Measurements
Testing of muscle tone
Testing of muscle power
11/24/07
54
Muscle Examination:
Abnormalities
Muscle
atrophy:
General
Proximal vs. distal
With vs. without facial involvement
Symmetrical vs. asymmetrical
Abnormal
muscle bulk:
Hypertrophy
Pseudohypertrophy
Spontaneous
contractions:
Fasciculation, fibrillation
11/24/07
55
Muscle Examination:
Testing of Muscle Tone

Technique:
Patient must be relaxed
Arms: pronation/supination, rolling hand around
wrist
Legs: Rolling straight leg from side to side, rapid
passive lifting of knee, flexing/dorsiflexing of foots
Abnormalities:
Flaccidity
Spasticity
Rigidity & cogwheel rigidity
11/24/07
56
Muscle Examination:
Testing of Muscle Power

Medical
Research Council Scale:

0 = no movement
1 = flicker
2 = moves with gravity eliminated
3 = moves against gravity only
4 = moves against resistance
5 = normal power
11/24/07
57
Muscle Examination:
Testing of Muscle Power

Pronator test:
Ask patient to hold his arms out in front with palms
upwards and to close his eyes
Findings:
One arm pronates and drifts downwards: unilateral
arm weakness
Both arms drift downwards: bilateral weakness
Arm rises: cerebellar disease
Arm moves up and down: impaired position sense
11/24/07
58
Muscle Examination:
Testing of Arm Power

Movement
Muscle
Nerve
Root
Shoulder abduction
Deltoid
Axillary
C5
Elbow flexion
Biceps brachii
Musculocutaneous
C5,6
Elbow extension
Triceps
Radial
C6,7,8
Finger extension
Extensor digit.
Radial, post. interos
C7,8
Finger flexion
Flexor digit.
Median + Ulnar
C8
Finger abduction
1st dorsal
interosseous
Ulnar
T1
Finger adduction
2nd palmar
interosseous
Ulnar
T1
Thumb abduction
Abduct poll brev
Median
T1
Push arms against wall
Serratus anterior
Thoracicus longus
C5,6,7
11/24/07
59
Muscle Examination:
Testing of Leg Power

Movement
Muscle
Nerve
Root
Hip flextion
Iliopsoas
Lumbosacral plexus
L1,2
Hip extension
Gluteus maximus
Inferior gluteal
L5, S1
Hip adduction
Adductors
Obturator
L2,3
Knee extension
Quadriceps femor
Femoral
L3,4
Knee flexion
Hamstrings
Sciatic
L5, S1
Foot dorsiflexion
Tibialis anterior
Peroneus profundus
L4,5
Foot plantarflexion
Gastrocnemius
Posterior tibial
S1
Foot eversion
Peron long/brev
Peroneus superficialis
L5, S1
Big toe extension
Exten halluc long
Peroneus profundus
L5
11/24/07
60
Involuntary Movements
Tremor
Chorea
Dystonia
Myoclonic
11/24/07
jerk
61
Reflexes
Tendon
reflexes
Cutaneous reflexes
Other (non-physiological) reflexes
11/24/07
62
Tendon Reflexes
Reflex
Biceps
Brachioradial
Triceps
Knee
Ankle
11/24/07
Nerve
Musculocuteneous
Radial
Radial
Femoral
Tibial
Root
C5,6
C6,5
C7
L3,4
S1,2
63
Cutaneous Reflexes
Abdominal
reflexes:
Segmental sensory and motor nerves

Above umbilicus: T8-T9
Below umbilicus: T10-T11
Cremasteric
reflex:
Segmental sensory and motor nerves

Upper lumbar roots
Anal
reflex:
Sacral nerves and roots

11/24/07
64
Reflexes
Plantar
responses:
Normal: flexion of all toes

Abnormal: Extension of big toe and flexion
and fanning of other toes (Babinski sign)
Hoffman
sign:
Tapping on flexor side of finger tip elicits

brisk flexion of thumb and fingers
11/24/07
65
Clonus
Repetitive
muscle contractions after

sudden stretch of muscle
Sustained or un-sustained
Common cloni: Foot, patella
Indicated UMN-lesion
11/24/07
66
Sensation
Light
touch
Pain & temperature
Vibration
Position
Cortical
11/24/07
67
Coordination
Testing
of balance:
In sitting
In standing: Romberg test
Rapid
alternating movements:
Dysdiadochokinesis
Targeting
tests:
Finger-to-nose test
Heel-to-shin test
11/24/07
68
Gait:
Hemiplegic gait
Shuffling gait
Ataxic gait
High stepping gait
Waddling gait
11/24/07
Upper motor neuron

(Stroke, MS)
Extrapyramidal disorder
(Parkinson disease)
Cerebellar lesion
(MS, Tumor)
Drop foot
(L5 root compression,
Peroneal nerve palsy)
Pelvic girdl muscle weakness
(Proximal myopathy,
Congenital hip dislocations)
69
References
Essential Neurosurgery
By Andew H. Kaye,
3rd Edition, Blackwell Publishing.
Neurology and Neurosurgery Illustrated
By Kenneth W. Lindsay and Ian Bone,
3rd Edition, Churchill Livingstone.
Neurological Examination Made Easy
By Geraint Fuller,
2nd Edition, Churchill Livingstone.
Diagnosis in Color Neurology
By Malcolm Parsons and Micheal Johnson,
Mosby.
11/24/07
70

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Neurosurgical

Previous illness, operation, trauma, etc.

Marital status, employment, education, habits,

Tobacco, alcohol, drugs, industrial toxins.

Familial illness, consanguinity.

Aim is to disclose other health problems that could

for detecting systemic

Higher Cerebral Functions

Disorders of understanding, thought

Date - Day - Month - Year - Season

Ward - Hospital - District - City - Country

Recognizing & naming relatives, etc.

recall & attention:

Patient is requested to repeat after the

Patient is requested to repeat 3 unrelated

Test factual knowledge

subtraction of 7 from 100.

frontal lobe function

in frontal lobe lesions, dementia,

of spatial cognition are

for parietal & occipital lobe

to perform a task when there

for parietal and pre-motor frontal

Snellen chart for distant vision testing

Pupils (shared with 3rd CN)

precise quantitative testing

important test for locating a lesion

Optic disc: Papilledema, optic atrophy

Oculomotor, Trochlear, Abducens Nerves

Lid retraction, lid lag

Oculomotor, Trochlear, Abducens Nerves

Oculomotor, Trochlear, Abducens Nerves

Oculomotor, Trochlear, Abducens Nerves

Examination of Ocular Movements

Oculomotor Nerve Palsy

Trochlear Nerve Palsy

Abducens Nerve Palsy

slow eye drift in one

Facial Nerve Examination:

Facial Nerve Palsy:

Upper motor neuron

Lower motor neuron

Test of Vestibular Function

Glossopharyngeal & Vagus Nerves

sensation from pharynx,

Glossopharyngeal & Vagus Nerves

Motor supply of the

The Motor System

The Motor System

Testing of Muscle Tone

Testing of Muscle Power

Research Council Scale:

Testing of Muscle Power

Testing of Arm Power

Radial, post. interos

Abduct poll brev

Push arms against wall

Testing of Leg Power

Big toe extension

Exten halluc long

Segmental sensory and motor nerves

Segmental sensory and motor nerves

Sacral nerves and roots

Normal: flexion of all toes