The Neurosurgical ExamChristopher P. Demers, MD, FAANSBoard Certified Neurological SurgeonManaging Partner, Sierra Neurosurgery Group, Reno, NVAssistant Professor, Univ. of NV SOMMedical Director of Neurosurgery, Renown RMC

The Physical Exam Examine the Patient!!!

This is a really big topic

Only he aspects relevant to common neurosurgical outpatient problems will be discussed

General Principles Do it the same way every time Tailor the exam to to pathology Examine the Patient!!!

The Physical Exam General Principles: M-C-M-C-R-S-G Mental Status

Cranial Nerves

Motor

Coordination

Reflexes

Sensory

Gait

Mental Status In the office setting, Folstein MMSE

You can get all the mental status information you need from a basic interview

Mental Status Language Testing: Dominant F/T/P lobes Broca’s dysphasia Expressive Often can understand just fine Can’t produce speech- a motor

deficit Wernicke’s dysphasia Receptive dysphasia / Word Salad Motor works fine Producing understandable speech

a problem Most have a component of both

Cranial Nerves A Whirlwind Tour in 3 minutes

CN 1: Olfactory Easy to disrupt traumatically

Almost never tested clinically

The only sensory input to bypass the thalamus- direct link to limbic system

CN 2: Optic Visual Acuity Fields

Look for APD Afferent Pupillary

Defect) CN 2 and 3 Aka Marcus Gunn

Pupil Swinging Flashlight

Test

Macular vision both MCA and

PCA blood supply ?evolutionary

advantage

CN 2: Optic Patterns of Visual Field Deficits

CN 3: Oculomotor All eye muscles

except for 2 LPS (levator

palpebrae superioris) Superior Rectus Medial rectus Inferior Oblique Inferior Rectus

Controls Pupillary constriction Parasympathetic

Fibers on Surface of Nerve

CN 3: Oculomotor CN 3 Palsy Lower pic Unable to open eye LPS palsy

Upper Pic Pupillary dilation Down and out CN 6 and CN 4 still working CN 3 is not

CN 4: Trochlear

Superior Oblique only

Very difficult to test clinically

Depresses, abducts eye

Intorts (medial rotation of top of globe)

CN 5: Trigeminal Motor to… My Ass Meets The Toilet Mylohyoid Anterior Belly of Digastric Masticators Tensor Tympani Tensor Veli Palatini

Sensory to the Face and part of TM

CN 6: Abducens Only 1 muscle- Lateral rectus

Controls lateral gaze

The 2nd longest intracranial course

Prone to pressure-related damage

CNs 3-6: Cavernous Sinus

CN 7: Facial Much more Complex- multiple components

Parts to Remember Motor to muscles of facial expression (not mastication) Taste to anterior 2/3 of tongue

CN 7: Facial

CN 8: Vestibulo-Cochlear Hearing and Balance

CN 9: Glossopharyngeal

CN 10: Vagus Voice, visceral sensory, sensory to

throat

CN 11: Spinal Accessory Trapezius, Sternocleidomastoid motor function

CN 12: Hypoglossal Tongue Movement Each side controls sticking out tongue on same side This pt has a Left CN 12 palsy

CN 7-12 Anatomy

Motor Exam 90% of fibers are crossed To arms and legs

10% stay ipsilateral To postural muscles

0-5 Grading scale 5=normal 4=against gravity but not normal 3=against gravity only 2=some mvt but not against gravity 1=flicker in muscle, but no mvt 0=no action

Motor Exam

Motor Exam Look for… Bulk Tone Fasciculations Atrophy

Myotomes:Cervical

Myotomes: Lumbar Cerebellum-controlled

Ipsilateral to location in cerebellum

Test with finger to nose, and rapid alternating hands

Coordination

Reflexes 0=absent

1=hypoactive

2=normal

3=hyperactive

4=severely hyperactive extension to adjacent

muscles

Reflexes Upper Motor Neuron Lesion Hyperactive Reflexes Lack of descending inhibition Clonus Babinsky Hoffman’s

Lower Motor Neuron Lesion Hypoactive Reflexes Inhibition of the sensory input

to the reflex arc

Sensory Multiple

sensory Modalities Muscle Stretch Light touch Vibration Pressure Pinprick Deep Pain Temperature

Sensory: Homunculus

Sensory Anterolateral

System

Pain/Temperature Sensation

Fibers cross immediately in spinal cord

Bare wires

Slow conduction velocity

Sensory Dorsal Column/

Med. Lemniscus Proprioception Light Touch Pinprick

Fibers Cross in Nuclei in brain stem

Heavily Myelinated

Fast conduction

Sensory Dermatomes Sensory Romberg Test Visual and Proprioceptive input keeps us upright Visual input can compensate for proprioceptive

deficit Stand with feet together, close eyes. Positive Romberg: Closing eyes induces postural

instability Postural Instability with eyes open suggest cerebellar

ataxia.

Sensory Dermatomes

Gait Antalgic- pain related

Ataxic- cerebellar or proprioception deficits

Thank You! References Haines Neuroanatomy

Sandoz Cranial Nerves

Youmann’s Neurosurgery

Aids to the Examination of the Peripheral Nervous System