Neurological examination

9/12, and persists!
3) Child with NeuroDisability
• Alertness • Examination tests depend on level of disability
• Speak to these children directly, introduce yourself – do they respond / react?
– OFC & plot on centile chart – Skeleton, spine, hands & feet (deformities) – Skin, genitalia, eyes
• • • • • • •
Position, Posture & Movement (Muscle bulk etc.) OFC, shape, sutures & fontanelle (? VP shunt?) Comment; (eyes; open/movements? feeding/sucking) Tone; position, fisting, head control, floppy? etc. Spinal Reflexes; knee jerk, clonus etc. Spine / Natal cleft Primitive Reflexes (* moro at end; it‟s upsetting)
2) Infant
• • • • Alertness Dysmorphism (as before) Position, Posture & Movement CN; Eyes - ? Fixing & following
• Face; smiling, crying? Symmetrical? • Bulbar; feeding & making sounds
Disappears at
2/12 4/12 4/12 4/12 4-6/12 4-8/12 until 1 yr old
Primitive Reflexes
• Brainstem-mrole • Disappear with Cortical Inhibition
• Examine relative to child‟s understanding • May need to improvise • Remember what your testing;
– Eyes (vision, movement, pupils) – Face – Hearing – Speech (making sounds) & Swallow
Upper limb Lower limb
4) Co-ordination, Gait, Cerebellar signs 5) Developmental 6) Higher functioning
Cognitive & Behavioural
1) 2) 3) 4)
Neonate Infant/toddler Child with Neuro-disability Older Child (age & ability - appropriate tests) [* that‟s the child‟s ability, not the examiners!*]
• Parachute reflex; support child‟s trunk & lower him/her
suddenly down towards bed/surface. Child will throw out arms to protect him/her-self appears ~
Neurological examination
Dr. D. Barry
Many Parts in Full Neuro Exam
1) Inspection – alertness/GCS
Dysmorphia (syndrome?)
2) Cranial Nerves 3) Peripheral Nerves
• Head-righting reflexes;
Horizontal suspension (extension of head, spine & legs) ~ 3-6/12 Vertical to horizontal position (? Knees flex & head corrects) ~ 6/12
• Examination texts/technique should be age-appropriate • CN II – XII > 5 years • ↑↓ with co-operation, sociability etc.
1) Neonate
• Alertness • Expose & observe • Dysmorphism; facies
May be asked…
• Examine this child‟s lower limbs • Examine this child‟s gait • Examine this patient‟s visual fields / eye movements / for squint • Demonstrate this child‟s reflexes • Examine this child for signs of cerebellar dysfunction
with toys etc.
Postural Reactions
As opposed to primitive reflexes which neonate is born with, these evolve early in infancy Many doctors include them together with primitive reflexes, but they have very different underlying significance
• Primitive Reactions & Postural Reactions • Peripheral; Tone, Reflexes • Developmental Milestones; gross motor, fine motor (co-ord) – what are they doing & watch them playing
*Many books vary on exactly when these reflexes are lost, so it can be confusing, therefore at least have general rule; most gone by 6/12 (with motor dev. & voluntary movement takes over), All gone by 1 year (roughly) & in general, they are lost in a Cephaol-caudal direction *
• • • •
Dysmorphic features (nb OFC) Position, Posture Movements & Muscle Bulk External Supports nb. (?Catheter/urine bag/ splints/ etc.)
• if in a wheelchair / sitting out; “ideally I‟d like to examine them in the bed esp for spinal & lower limb exam & expose”
– Any individual / isolated part of neuro exam
General Neuro Inspection
• Dysmorphic features
– – – – Facies OFC (eg. Macrocephaly, microcephaly), shape Skeleton, spine (eg. scoliosis, spina bifida), hands & feet Skin (eg. Neurocutaneous syndromes), genitalia & eyes
• • • •
Posture Movement Muscle bulk +/- fasciculations Supports eg glasses / hearing aids / wheelchair etc. etc. etc.
1) Cranial Nerves
• I - olfactory Eyes; vision & movements • II – optic – visual acuity, fields, fundoscopy, • III - oculomotor • IV – trochlear • VI – abducens (false localising) Face (motor & sensory) • V – facial; muscles of facial expression • VII – trigeminal; sensory to face (& tongue) • VIII – vestibule-cochlear; hearing Bulbar (speech & swallow) • IX – glossopharyngeal • X – vagal • XI – accessory • XII – hypoglossus
Eyes; CN II, III, IV, VI