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Cervical Conundrum

Neurologic Examination

Results

Cognitive: alert and oriented in all realms. Speech clear and fluent. Responses appropriate. Readily follows complex commands.

Cerebellar Function

• Ataxia on tandem gait
• Drags right foot on neutral gait
• Romberg grossly positive
• No pronator drift
• No dysmetria on finger to nose testing
• Able to perform rapid alternating movements

Cranial nerves: trigeminal, glossopharyngeal, and facial nerves abnormal; remaining cranial nerves within normal limits.

Sensory examination: Diffusely decreased to light touch C2 through S1. Pain and temperature were decreased throughout the right side. Vibration sense absent throughout right side. Sensation significantly decreased right V1, V2 and V3.

Objectives

• Discuss the procedure for sensory testing
• Review the procedure and significance of cerebellar testing
• Review the procedure and significance of the cranial nerve examination

Sensory Examination

The sensory examination is one of the most difficult portions of the neurologic examination. Patient understanding and cooperation are essential. Patients who are fatigued, or tired may be unable to report accurate sensory changes, therefore providing an inadequate examination.

When performing the sensory examination, attention should be directed to technique. Assure that the patient is relaxed and comfortable. Light touch sensation is tested by brushing the skin lightly, along the dermatome, with the fingertip or a soft brush. Pinprick is tested using a sharp object, such as a safety pin. Lightly tap the pin on the surface of the skin along the dermatome line. Always discard the safety pin after each use: never reuse on another patient. Care is taken to apply equal pressure to all surfaces tested.

Paresthesias or dysesthesias generally suggest a lesion arising from the sensory pathway or spinal cord. The patient may complain of tingling, or "pins and needles," or numb sensation. Record the dermatome which is affected, as well as symmetry of sensation.

Light touch, pain and temperature comprise the cutaneous sensory exam, while position, motion, vibration, and pressure-pain comprise the proprioceptive portion.

Cerebellar Examination

Cerebellar lesions generally result in alteration in fluidity of motion; therefore, cerebellar functions are tested to assess coordination of movements. Several tests are used to assess coordination. Finger to nose testing is performed by having the patient touch the index finger, followed by touching his/her nose with a rapid motion. Inability to fluidly touch the finger of the examiner indicates dysmetria.

Romberg is a test to determine proprioception and balance. Have the patient stand, with feet together, and close his/her eyes while holding the arms and hands outward with palms up. Observe the patient for sway of motion or inability to maintain posture. If the patient exhibits an inability to maintain posture, this is considered a positive Romberg. This would imply a problem with vestibular function or proprioception. A cerebellar lesion should be considered in any patient who exhibits a positive Romberg with the eyes open.

Coordination and fluidity of motion are tested with rapid alternating movements (RAM). With the patient sitting comfortably, ask him/her to pronate and supinate the palm of the hand on their knee in rapid succession. Testing the lower extremities can be performed by asking the patient to rapidly tap the foot on the ground. Remember to test each limb individually. Slowness in movement or inability to perform this task may indicate a cerebellar lesion, proprioception disturbance, or hemiparesis.

Gait is also controlled by the cerebellum, and should always be included in the cerebellar testing. Observe the patient for fluidity of movement and arm swing while walking. Tandem gait is tested by having the patient walk heel-to-toe. Patients who loose balance while performing tandem testing are considered ataxic. Ataxia can also be noted on neutral gait by simply observing the patient while walking and turning around.

Cranial Nerve Examiation

There are 12 cranial nerves, each with specific purpose and function. During the neurologic examination, each cranial nerve should be tested. When afferent fibers are involved, sensory deficits are present. Motor impairments are present when efferent fibers are damaged.

CN I: Olfactory (afferent) is tested with common smells such as coffee, soap, or alcohol. Avoid the use of ammonia when testing the sense of smell, as this may stimulate the nerve endings of the trigeminal nerve. Always test each nare individually. When testing the olfactory nerve, assure that there is no airway obstruction which would inhibit the patient's ability to discriminate the odors being used. Take into account that the sense of smell normally declines over age; therefore smell may be naturally decreased in the elderly population. Olfactory agnosia is the inability to smell.

CN II: Optic (afferent) is tested by first inspecting the eyes and eyelids for symmetry. Inspect the palpebral fissures for size, position and symmetry. Test visual fields and central visual acuity (Snellen and Rosenbaum charts).

CN III, IV and VI: Oculomotor, Trochlear and Abducent (efferent) are tested together. Measure pupil size and reaction to light and accommodation. Keep in mind that approximately 15% of the normal population have anisocoria as a normal pupillary variant. Test vertical and lateral gaze by having the patient follow your finger or a penlight in all visual fields. Nystagmus on far lateral gaze may be a normal variant.

CN V: Trigeminal (afferent and efferent) tests facial sensation. The face is tested in three regions: V1, V2 and V3. The corneal reflex, which is dependent on both the 5th and 7th cranial nerves, is also tested. Mastication is the motor component of the trigeminal nerve, and is tested by asking the patient to clench the jaw.

CN VII: Facial nerve (afferent and efferent) is tested by assessing symmetry of the facial muscles by asking the patient to smile. Also note eye blinking and if the patient is able to completely close the eyelid. Symmetry of the nasolabial fold and speech fluency and articulation are also tested under the facial nerve. Taste on the anterior 2/3 of the tongue is tested by applying a small amount of sugar, salt or lemon to each side of the tongue individually.

CN VIII: Vestibulocochlear (afferent) tests the patient's ability to hear properly. Most hearing intact patients should hear finger rub at 20-24 inches from the ear. It is important to discriminate conductive (wax or blocked canal) from sensorineural hearing loss. The tuning fork is used to test the Rinne, which distinguishes conductive loss, from Weber which detects sensorineural hearing loss.

CN IX and X: Glossopharyngeal and Vagus (afferent and efferent) tests the gag response, as well as movement of the palate. This is an unpleasant test which is done by examining the pharynx with a tongue blade. Depressing the tongue at the posterior pharynx elicits a gag response in the person with a normally functioning cranial nerve. As the gag reflex occurs, observe the palate, which should rise symmetrically. If the cranial nerve is abnormal on one side, the palate will rise to the normal side. Also note elevation and symmetry of the uvula. Unilateral lesions usually result in deviation of the uvula away from the affected side. Movements of the tongue are also tested under the control of this nerve. Gently stroking the side of the tongue with a tongue blade or q-tip will determine sensory changes. When examining the tongue, check also for fasciculations or tongue deviation.

CN XI: Spinal Accessory (efferent) innervates the sternocleidomastoid and trapezius muscles. The function of the nerve is tested by asking the patient to turn the face to the opposite side to resistance of the examiner. The trapezius muscle is tested in the same fashion by asking the patient to shrug the shoulders to resistance. Observe and palpate the muscles at rest to detect any asymmetry in bulk or contour.

CN XII: Hypoglossal (efferent) is tested by observing the tongue at rest. Note mass and contour of the tongue. Ask the patient to protrude the tongue and note deviations or fasciculations. If a unilateral nerve is involved, the tongue will deviate toward the side of involvement. Some patients with nerve lesions will also exhibit difficulty with repetitive sounds such as "la la la la."