Neurological Examination

Dr. Mahmoud Al Salhi

NEUROLOGICAL EXAMINATION
Cranial

nerves examination. Examination of old child. Examination of baby & toddlers. Cerebellar system

Neurological examination is so difficult !!!

Motor Cranial nerves sensory Upper limbs trunk reflexes

lower limbs

Gait

Mental status Tone

Power

Neurological examination of babies or toddler is the most difficult part !!!

Dont rush in to put baby on bed & undress him

Observe

Observe

Observe

Only when you have obtained as much information as possible from observation proceed to the remainder of examination

Start with observing the baby fully dressed on parents lap or while playing with toys in an enjoyable nonthreatening environment.

Observing what the baby choose to do is more instructive than their compliance with actions which you have requested them to carry out.

Pediatric-Neuro Exam 6 month Behavior.flv

General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head. Upper limbs. Trunk & back. Lower limbs. Reflexes.

GENERAL INSPECTION

State of consciousness :
Conscious. Irritable. Lethargic (sleepy , arousable by fine stimuli). Obtundation ( arousable by sever stimuli ). Stupor (unarousable but respond to pain). Coma (unarousable & unresponsive).

 Mentality

the patient's level of awareness and interaction with the environment. Can be assisted b observing the baby while interacting with parents or toys. Clues for retarded infant : Long periods without crying or interest in surroundings. Prolonged crying with no cause. Delayed speech. Delayed gross motor. Delayed fine motor.

 Handedness

It became obvious between age of 1.5-5 years. Hand preference in infants < 1.5 years (hemiplegic).

Coordination :
Offer the child an interesting play & observe : Does he reach out for it ? Is there is an intention tremor ? What sort of grasp ? Does he transfer objects between hands ?

If

Coordination is impaired , think of

Poor

visual acuity. Cerebellar disease (Ataxic CP). Sensory loss

Neuro exam 18 MonthBehavior-Mental Status Understanding.flv

General inspection : Cerebral functions. Coordination Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head. Upper limbs. Trunk & back. Lower limbs.

Reflexes.

 Overall

size & proportions of head/trunk/limbs :

 Dysmorphic

features:

 Posture

:
Frog like position :
Hip abducted & knee flexed in hypotonia

Erbs palsy
Shoulder adducted & internally rotated , elbow extended & wrist flexed

Torticollis
Abnormal posture of head towards one side

Opisthotonus:
Involuntary extension of neck with arching of back occurs in meningitis , tetanus or CP.

Scissoring of legs
Legs cross over each others in spastic diplegia

 Movement

: (observe gross & fine motor)

General Paucity. Asymmetry. Accessory movements.

Tics : repeated identical movement. Tremors : involuntary rhythmical alternating movements (resting or intentional). Titubation : tremor of head & neck. Athetoid : Slow involuntary writhing movements usually of proximal limbs. Chorea : rapid involuntary irregular movements usually of face & extremities. Convulsions

General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait Eyes & Cranial nerves. Head.

Upper limbs.
Trunk & back.

Lower limbs.
Reflexes.

HEAD Shape . Size (HC) . Fontanelles. Sutures. VP shunt. Look for tongue fasciculation.

HEAD

 Shape

Scaphocephaly
Head is long & narrow due to premature closure of sagittal suture

Trigonocephaly
Pointed forehead due to premature closure of metopic sutures

Plagiocephaly
Either frontal (unilateral closure of coronal suture) or occipital (Postural or unilateral closure of lambdoid suture)

Brachycephaly
Back of head is flat as in down syndrome or bilateral closure of coronal sutures.

Oxycephaly , Turricephaly or Acrocephaly.

Tower (tall) head due to premature bilateral closure of coronal sutures

 Head

circumference : Microcephaly Macrocephaly.

:

Fontanelles

Anterior (diamond shape). Posterior (triangular). Third (Normal Down syndrome).

Size. (Wide Narrow). Character : baby should be in setting position & calm. ( Normal tense bulging sunken ).

o o

Sutures. VP shunt.

General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head.

Upper limbs.
Trunk & back.

You can undress the baby to the nappy at this stage

Lower limbs.
Reflexes.

UPPER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power.
Sensation.

Reflexes.

UPPER LIMBS (MOTOR)

Posture & deformities :

CP

Claw hand
In radial nerve or lower plexus injury

Erbs palsy

Shoulder adducted , elbow & wrist flexed

Syndactyly

Polydactyly

Clinodactyly

Muscle bulk : Lost in LMNL , generalized wasting or disuse atrophy. Muscle fasciculation's : LMNL. Muscle tone :

Tone is resistance to passive movements. Always compare both sides.

Passively flex & extend the elbow & the wrist. Hold both wrists in your hands & shakes them quickly to & fro. Scarf Sign. Handling the child (Shoulder girdle). Head support. Always remember to distract the baby by speaking with him

Scarf Sign
The tone of the shoulder girdle is assessed by taking the baby's hand and pulling the hand to the opposite shoulder like a scarf. The hand should not go past the shoulder and the elbow should not cross the midline of the chest

neurology exam newbornabnormal Tone-Upper Extremity Tone.flv

joints

Hand shaking

Neuro exam 12 Month- Motor - Tone.flv

joints

Scarf sign

Neurology Exam, 3 Month Positions Vertical Suspension.flv

Handling (normal)

06Hipoton-a.MPG.flv

Handling (Hypotonia)

Medical Videos - Muscle Strength and Tone.flv

HYPOTONIA

Central.

Atonic cerebral palsy. Down syndrome. Hypothyroidism.

Cerebellar disease. Anterior horn cells. Peripheral nerves. Neuromuscular junction. Muscle.

HYPERTONIA
Spasticity

Initial resistance to passive movements followed by sudden release (Clasp Knife). Due to UMNL (CP).

Rigidity

Constant resistance to passive movements such as (lead pipe) or (Cogwheel). Due to lesions in basal ganglia.

Clonus :

Rhythmic series of involuntary contractions evoked by stretching the muscle. May be normal :

Newborn (5 beats). Anxious babies.

May be Abnormal (UMNL ) :

Sustained. Asymmetrical.

Most commonly evoked at ankle joint.

Muscle Power :
Impossible to test formally in this age group. Power of hand muscles can be tested by :

The tightness with which the child will grip objects.

Power of flexor muscles of arms can be tested by :

Pulling the infant up by the arms from supine position , the infant with normal power will flex at the elbow to resist your pull..

Pediatric-Neuro Exam 6 month- Motor - Traction.flv

Sensation :
It is difficult to test in infants .

Application of painful stimuli should never be used in exams.

Sensation can be assisted through the assessment of coordination. Normal coordination requires normal sensation in hands.

UPPER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination.
Sensation. Reflexes.

Better to be tested at the end of examination

General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves.

Head.
Upper limbs. Trunk & back Lower limbs Reflexes.

General inspection : Cerebral functions. Coordination. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Gait. Eyes & Cranial nerves. Head.

Upper limbs.
Trunk & Back. Lower limbs. Reflexes.

TRUNK

All children > 1.5 y should be able to get up from supine position. , if not (Proximal weakness). All children > 10 m should be able to sit unsupported , if not ( Truncal weakness or ataxia). With the child sitting give a gentle sideways push against the shoulder , if the child falls sideways it indicates weakness of trunk. Hold the baby in the prone position by your hand & observe the axial tone.

Here the head drops much lower than one would expect, and the examiner has the sense that the infant could easily slip out of her hand without extra support

Pediatric-Neuro Exam 6 month Postural Reflexes Landau.flv

Hypotonia 5.flv

BACK

Expose the back. Inspect for:

Dural sinuses Swelling Tuft of hair Dimple. Pigmentation

Palpate : Run your finger quickly over the spinous processes to detect spina bifida occulta.

Newborn Examination of the back and feet.flv

General inspection : Cerebral functions. Size & proportions of head/trunk/limbs. Dysmorphic features. Posture. Movement. Eyes & Cranial nerves. Head. Upper limbs. Trunk & Back. Lower limbs. Reflexes.

LOWER LIMBS
Motor system Gait Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Sensation. Reflexes.

Gait :
Wide based gait

Normal in toddlers.

Cerebellar disease. Ataxic CP.

Spastic diplegia gait

Hip & knee semiflexed.

Legs are stiff & scissoring

Spastic diplegia gait

Abnormal Gait Exam - Diplegic Gait Demonstration.flv

Hemiplegic gait
Hip & knee are extended (straight leg). Leg move stiffly by circumduction. Arm swinging is limited on the affected side.

Waddling gait
subject sways from side to side. due to a lack of hip stabilization. In DDH & duchenne muscle dystrophy.

Hemiplegia gait

Abnormal Gait Exam - Hemiplegic Gait Demonstration.flv

Waddling gait

Abnormal Gait Exam Myopathic Gait Demonstration.flv

Bowed Legs
Normal in toddlers. If extreme : Rickets. Osteogenesis imperfecta. Achondroplasia.

Knock Knee
Rickets in preschool age.

Toe walking
May be normal. Spastic diplegia. Contractures.

Limp Gait where less time is spent bearing weight on one leg than on the other.
Examine legs for : Deformities. Scars. Joint swelling. Rashes. range of movements.

LOWER LIMBS
Motor system Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Gait. Sensation. Reflexes.

 Deformity

 Muscle

bulk .

Bilateral wasting Spina bifida. Werdings Hoffmann disease

Unilateral wasting Hemiplegia

Hemi hypertrophy Measure thigh & calf girth at fixed distances from knees

Bilateral calf hypertrophy

Duchenne muscle dystrophy

 Fasciculation

: Rarely seen in infants. Always associated with muscle wasting in LMNL.

Fasciculations

of lower leg muscles..flv

 Muscle

tone :

Lightly left each leg & flex it at knee & hip for few times & feel the amount of tone you have to overcome. Abduct each hip while the knee flexed & pelvis fixed by one hand.

Flick the knee joint off the bed :

Normal : flexion of knee & the heel remain in contact with mattress. Spasticity : Whole leg is jerked into the air & remains straight. Hypotonia : the legs will remain straight on bed.

Neuro exam 12 Month Motor Tone3.flv

 Clonus

Can be tested by sudden dorsiflexion of foot with the knee partially flexed.

Abnormal Motoric Exam - Tone - Lower extremity.flv

 Power

Passively flex the legs & observe how hard the infant pushes against you. The ability to stand up from lying position reflects good tone of pelvic girdle muscles. Can be partly gauged from the gait. Application of powerful stimuli to different sites (rarely used)

physical exam -Newborn Normal Tone - Lower Extremity Tone.flv

GOWERS SIGN

Gower's Sign.flv

 Coordination:

Normal gait obviously implies normal coordination.

More sensitive tests can be used as : Running. Hopping. Tackling stairs.

LOWER LIMBS
Motor system Gait Posture. Deformities. Muscle bulk. Muscle fasciculation. Tone. Clonus. Power. Coordination. Sensation. Reflexes.

Sensation :
It is difficult to test in infants .

Application of painful stimuli should never be used in exams.

Sensation can be assisted through the assessment of coordination. Normal coordination requires normal sensation in hands.

Thank you