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

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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Neurology Library: Headache – Treatment

• Coni R. Neuro 101: Neurological Examination. LITFL

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

Publications

• Aydogdu I, Ertekin C, Tarlaci S, Turman B, Kiylioglu N, Secil Y. Dysphagia in lateral medullary infarction (Wallenberg’s syndrome): an acute disconnection syndrome in premotor neurons related to swallowing activity? Stroke. 2001 Sep;32(9):2081-7
• Beh SC, Greenberg BM, Frohman T, Frohman EM. Transverse myelitis. Neurol Clin. 2013 Feb;31(1):79-138. doi: 10.1016/j.ncl.2012.09.008
• Biousse V, Newman NJ. Ischemic Optic Neuropathies. N Engl J Med. 2015 Jun 18;372(25):2428-36.
• Boller F. Strokes and behavior: disorders of higher cortical functions following cerebral disease. Disorders of language and related function. Stroke. 1981 Jul-Aug;12(4):532-4.
• Brust JC, Shafer SQ, Richter RW, Bruun B. Aphasia in acute stroke. Stroke. 1976 Mar-Apr;7(2):167-74
• Carrera E, Michel P, Bogousslavsky J. Anteromedian, central, and posterolateral infarcts of the thalamus: three variant types. Stroke. 2004 Dec;35(12):2826-31.
• Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91
• Davidovic L, Ilic N. Spinal cord ischemia after aortic surgery. J Cardiovasc Surg (Torino). 2014 Dec;55(6):741-57.
• Erro R, Stamelou M. The Motor Syndrome of Parkinson’s Disease. Int Rev Neurobiol. 2017;132:25-32.
• Fama ME, Turkeltaub PE. Treatment of poststroke aphasia: current practice and new directions. Semin Neurol. 2014 Nov;34(5):504-13
• Fanciulli A, Wenning GK. Multiple-system atrophy. N Engl J Med. 2015 Jan 15;372(3):249-63. 
• Flanigan RM, DiGiovanni BF. Peripheral nerve entrapments of the lower leg, ankle, and foot. Foot Ankle Clin. 2011 Jun;16(2):255-74
• Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10.
• Kelly PJ, Stein J, Shafqat S, Eskey C, Doherty D, Chang Y, Kurina A, Furie KL. Functional recovery after rehabilitation for cerebellar stroke. Stroke. 2001 Feb;32(2):530-4.
• Kwong Yew K, Abdul Halim S, Liza-Sharmini AT, Tharakan J. Recurrent bilateral occipital infarct with cortical blindness and anton syndrome. Case Rep Ophthalmol Med. 2014;2014:795837.
• Li K, Malhotra PA. Spatial neglect. Pract Neurol. 2015 Oct;15(5):333-9. doi: 10.1136/practneurol-2015-001115. Epub 2015
• Limthongthang R, Bachoura A, Songcharoen P, Osterman AL. Adult brachial plexus injury: evaluation and management. Orthop Clin North Am. 2013 Oct;44(4):591-603.
• Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010 Jan 15;81(2):147-55
• O TM. Medical Management of Acute Facial Paralysis. Otolaryngol Clin North Am. 2018 Dec;51(6):1051-1075
• Patterson JR, Grabois M. Locked-in syndrome: a review of 139 cases. Stroke. 1986 Jul-Aug;17(4):758-64
• Rees RN, Noyce AJ, Schrag A. The prodromes of Parkinson’s disease. Eur J Neurosci. 2019 Feb;49(3):320-327.
• Rusconi E. Gerstmann syndrome: historic and current perspectives. Handb Clin Neurol. 2018;151:395-411.
• Tepper SJ. Cranial Neuralgias. Continuum (Minneap Minn). 2018 Aug;24(4, Headache):1157-1178.
• Waqar M, Vohra AH. Dissociated sensory loss and muscle wasting in a young male with headaches: syringomyelia with type 1 Arnold-Chiari malformation. BMJ Case Rep. 2013
• Watson JC, Dyck PJ. Peripheral Neuropathy: A Practical Approach to Diagnosis and Symptom Management. Mayo Clin Proc. 2015 Jul;90(7):940-51