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