Neuro 101: Neurological Examination

The Neurological Examination

The eight steps:

1. Mental status examination
2. Cranial nerve examination
3. Motor examination
4. Reflex examination
5. Special reflex examination
6. Sensory examination
7. Cerebellar examination
8. Gait and station examination

Mental status examination

Assess:

• Appearance and mood
• Higher cortical functions:
  • Speech
  • Attention
  • Orientation
  • Memory
  • Calculation
  • Perception and praxis

Aphasia refers to a dysfunction of language, either production and/or comprehension.
Dysarthria refers to a dysfunction of the mechanical process of speech production, while language processing remains normal.
Neglect is typically due to a non-dominant hemisphere injury (usually the right side) and leads to neglect of the opposite side of the body. This may involve the visual field, sensory input, or body awareness (asomatognosia). Individuals may extinguish stimuli from the left side when both sides are stimulated simultaneously.

Cranial nerve examination

Group cranial nerve testing by function:

• Smell – CN I
• Eye movements and vision – CN II, III, IV, VI
• Facial movement and sensation – CN V, VII
• Hearing and balance – CN VIII
• Oromandibular function and sensation – CN IX, X, XII
• Sternocleidomastoid and trapezius muscles – CN XI

Motor examination

Differentiate between upper motor neuron (UMN) and lower motor neuron (LMN) lesions.

Upper motor neuron signs:

• Hypertonicity
• Hyperreflexia
• Babinski response (extensor plantar)
• Clonus

Lower motor neuron signs:

• Flaccid tone
• Muscle wasting and atrophy
• Hyporeflexia
• Fasciculations

Test muscle strength using the Medical Research Council (MRC) grading system.

The Medical Research Council grading system remains the standard, but research has shown that there are difficulties with inter-observer reliability. An alternative method with simpler criteria has been proposed.

• 0 = Paralysis
• 1 = Severe weakness
• 2 = Slight weakness
• 3 = Normal strength

Reflex examination

Reflexes help distinguish UMN from LMN lesions.

• UMN: Brisk reflexes
• LMN: Diminished or absent reflexes

Elicit reflexes by tapping the tendon and observing for muscle contraction.

Special reflex examination

Plantar reflex:
Gently stroke the sole from heel to toe and observe the big toe’s response.

• Downward movement = normal (flexor response)
• Upward movement = abnormal (Babinski/extensor response) → indicates UMN lesion or corticospinal tract involvement.

Other reflexes

• Chaddock sign – alternative/complementary test to the Babinski reflex to test the integrity of the corticospinal tract.
• Oppenheim reflex – a pathologic reflex that indicates a loss of cortical inhibition and is associated with upper motor neuron lesions
• Beevor sign – Upward movement of the umbilicus with truncal flexion from a supine position, associated with a spinal cord lesion between the levels of T10 and T12

Sensory examination

Cutaneous sensibilities:

• Pinprick
• Temperature
• Light touch
• Vibration
• Proprioception

Cortical sensibilities:

• Two-point discrimination
• Graphesthesia
• Stereognosis
• Double simultaneous stimulation

Start sensory testing in areas of suspected loss and work towards regions of normal sensation.

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Cerebellar examination

Pronator drift:
Push the patient’s arms down gently. A delay in return or bouncing suggests cerebellar dysfunction.

Coordination:

• Observe for ataxia during gait or limb testing.
• Test upper limbs with finger-to-nose-to-finger.
• Test lower limbs with heel-to-shin.
• Tone is generally decreased in cerebellar disease.

Gait and station examination

Gait assessment:

• Symmetry
• Pain
• Stooping
• Circumduction
• Hip hiking
• Steppage
• Speed
• Step width

Common gait patterns:

• Parkinsonian gait: Festinating, hesitant, stop-start motion
• Ataxic gait: Uncoordinated, veering due to sensory or cerebellar dysfunction
• Apraxic gait: Appears as if the patient has forgotten how to walk; seen with frontal lobe lesions or normal pressure hydrocephalus
• Hemiplegic gait: Swinging of one leg, commonly post-stroke

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Clinical Neurology Essentials

• Coni R. Neuro 101: Neurological Examination. LITFL
• Coni R. Neuro 101: Cerebral Hemispheres. LITFL
• Coni R. Neuro 101: Cerebellum and Basal Ganglia. LITFL
• Coni R. Neuro 101: Brainstem. LITFL
• Coni R. Neuro 101: Cranial Nerves. LITFL
• Coni R. Neuro 101: Spinal Cord. LITFL
• Coni R. Neuro 101: Peripheral Nervous System. LITFL

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References

Further reading

• Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 8e 2021
• Campbell WW. DeJong’s The Neurologic Examination. 8e 2019
• Fuller G. Neurological Examination Made Easy. 6e 2019
• Kiernan J. Barr’s The Human Nervous System: An Anatomical Viewpoint. 10e 2015
• O’Brien M. Aids to the Examination of the Peripheral Nervous System. 6e 2023
• Patten JP. Neurological Differential Diagnosis. 2e 1996
• Waxman SG. Correlative Neuroanatomy. 23e 1996