Medical School for Lawyers: How To Conduct a Neurological Examination
Personal injury trial and other attorneys, who deal with medical legal issues, increasingly find that they need a solid understanding of the neurological system. In this program, Dr. Susan Pearson, a board certified neurologist will demonstrate and explain the complete neurological examination. Understanding clinical evaluation and diagnostic procedures used during a neurological examination will help you evaluate the medical evidence in your case. A basic understanding of the anatomy of the neurological system is essential.
The neurological systems major function is to process stimuli coming from the environment. It also integrates all functions of the body. The neurological system is divided into two major parts, the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and spinal cord. The brain consists of the cerebrum, brain stem and cerebellum. The left hemisphere controls language and the right controls non-verbal and perceptual functions.
The cord consists of 31 pairs of spinal nerves. There are 12 pairs of cranial nerves. The peripheral nervous system consists of the cranial and spinal nerve pairs as they emerge from the brain stem and spinal cord. The spinal cord conducts motor neurons away from the brain and sensory impulses toward the brain. Pain, pressure, temperature and crude touch sensations must cross the spinal cord to the opposite side of the body before sent into the brain.
Light touch, two point discrimination and vibration sensations ascend the spinal column on the same side of the body. Nerves are distributed in dermatomes which are skin areas supplied by a specific spinal nerve roots. Numbness or pain in specific dermatomes can pinpoint the nerve root involved. Because dermatome area is overlapped, sensory loss results only when a number of dermatomes are severely damaged. Attorneys with the assistance of medical professionals have to evaluate whether damage to the neurological system has been caused by traumatic injury.
Head injuries can result in skull fractures, diffuse axonal injury, brain contusions and increased intracranial pressure. Whiplash injuries can cause milder forms of acceleration, deceleration, sheer injury and surface contusions. Spinal cord injuries may cause paralysis, loss of sensation and loss of bladder and respiratory functioning below the injured or severed cord area. Pre-existing conditions such as congenital abnormalities, degenerative disease and neoplastic conditions complicate diagnosis and must be considered during an examination.
Dr. Pearson: Performing a complete neurological exam consists of several areas. First of all, the patient’s current complaint or chief complaint is elicited. And we take a history of present illness and afterwards information about the patient’s past medical history is noted. And it’s important to ascertain how that information might pertain to their current complaint. In doing the examination, a detailed mental status exam is performed and afterwards an elemental neurologic exam is performed.
Then with attention to the patient’s current complaints a directed neurologic exam may be carried out. Eliciting a thorough history of the present illness and past medical history is critical to an accurate diagnosis. It’s important to determine the onset of the complaint, its duration and frequency, any precipitating or alleviating factors, any associated symptoms or response to prior treatments.
Past medical history should focus on previous neurologic and traumatic conditions such as seizure disorder, stroke, migraine headache and prior history of head and neck trauma. The neurologic review system should focus on general health questions like sleep, weight changes and mood swings. After taking the patient’s history and eliciting their chief complaint, it’s important to do a mental status examination. If the patient’s complaints involve cognitive difficulties, it’s imperative that a detailed mental status exam be done.
The elemental neurological examination consists basically of a series of different types of tests to evaluate everything from head to foot in the nervous system. The first area that we concentrate on are the cranial nerves. Next I would move to the motor examination, which includes, para testing and reflex testing. After that a sensory examination is done which concentrates on evaluating the primary modalities of pinprick, light touch, joint positions [inaudible 00:04:51] as well as vibration. The cerebella examination is the next step and that is basically a test of co-ordination.
And finally, the last part of the elemental neurologic exam, is to do a balance and gate evaluation. I’m going to start with the cranial nerve exam. The first part of the cranial nerve exam is just to test the old factory nerve which is cranial nerve 1. And to do that, you just ask the patient to close their eyes. Can you close them for me? And just identify a scent placed under your nose. What do you smell there?
Dr. Pearson: Right. Okay. Second cranial nerve is the optic nerve which controls a person’s vision. So what I’ll ask the patient to do is first of all just look right at my nose and I’m going to test for visual field. The way that this is done is to have the patient concentrate on my nose as I check her periphery. I just want you to tell me which finger you see wiggling.
Dr. Pearson: Now which one?
Dr. Pearson: We move up to the higher visual fields. So look right at my nose. Which is wiggling now?
Dr. Pearson: Now which?
Dr. Pearson: Good. And now which is wiggling?
Dr. Pearson: Okay. Now?
Dr. Pearson: And above?
Dr. Pearson: Good. Okay. The next thing to examine the cranial nerves 2 is just the pupillary reaction. So I have the patient look straight at my nose and shine the light in the eye to make sure that the pupils constrict briskly and equally. Visual acuity is then tested because that’s also part of cranial nerve 2. By having the patient just close one eye or cover one eye for me. And just look at this card and just read this line for me of numbers.
Patient: Four, two, eight, three, six, five.
Dr. Pearson: Good. Now the next… next eye. Same thing lower down?
Patient: Three, seven, four, two, five, six.
Dr. Pearson: And finally, I’ll check the patient’s optic disc with a fundoscopic examination with a… using an ophthalmoscope. Now look straight ahead for me. Okay. I’m just going to hone in right in on pupil and check. Check the optic disc and the margins of the disc. What we are looking for here is any evidence of hemorrhage in the retina. Sometimes this can occur as a result of whiplash or other types of mild brain injury. Most importantly the third, fourth and fifth cranial nerves are the areas that we concentrate on when we are looking for evidence of mild brain injury.
There we ask the patient to just move with my finger, move your eyeballs up and down, this way and across this way. Now, I’m going to bring my finger right into your nose. Often what you can see in a mild brain injury patient is some subtle abnormality of coordination of eye movement such that the eyes are no longer conjugate, which means if they move exactly together. If there is a little bit of nystagmus which is a bouncing movement of the eyes towards the end of gaze or even on spontaneous gaze, another indication of the mild brain or even more severe brain injury.
Cranial nerve 5 is a trigeminal nerve and that’s basically tested by having the patient report sensation to me. So I’ll check all three divisions; the upper, middle and lower just by light touch. Can you fee that? Feels the same on both sides? Here same?
Dr. Pearson: Now here is the same?
Dr. Pearson: And up here, all the same?
Dr. Pearson: Okay. The other way to test the trigeminal nerve or cranial nerve 5 is to just test the patient’s corneal reflex which is just a matter of taking a various slight wisp of cotton and putting it in the eye to see if there is a blink reflex. And that’s done on both sides. I’m just going to touch your eye with this cotton. Good. Cranial nerve stem is the nerve that controls motor to the face. So we ask the patient to grimace or smile and observe for symmetry of the face. Just close your eyes really tight, don’t let me open them, like you had soap in them. Really tight, squeeze hard. Good.
Over here? Good. Open your eyes, now just wrinkle your nose up. Good. Okay. Now the last thing, I will check on her lower cranial nerves. I’m going to have you open your mouth for me and check cranial nerves 9 and 10 which control the gag reflex and palate. So open wide and just say ah.
Dr. Pearson: And observe for symmetry of the palate as it elevates. To test the gag reflex again, you just touch the back of the throat. Open wide and say ah.
Dr. Pearson: Good. And stick your tongue out for me straight out. Cranial nerve 12 controls motor to the tongue. You observe for symmetry of the tongue in the midline as the person protrudes it.
The only other cranial nerve I haven’t tested yet is cranial nerve 8 and I’ll come back to that last. Basically that nerve is examined by checking the eardrum or tympanic membrane just with an otoscope looking inside the ear. Okay. And then we go round on this side as well. Just observing for any type of abnormality of the eardrum like purely a pus like discharge behind the eardrum. The hearing is grossly assessed by just a whispered voice. Asking the patient to tell you what the number is you whisper in their ear. What was that?
Dr. Pearson: Okay. Good. Then we do what’s called a Weber test which is just to use a tuning fork on top of the head and asking the patient to tell me whether or not she hears a tuning fork tone in both ears equally.
Patient: Both sides.
Dr. Pearson: Good. Okay. And that’s a test which measures what’s called the conductive hearing loss. If the Weber is abnormal then the tone will localize to one side of the head only. The other tuning fork test is called the rinne test. There we ask the patient to tell us where they hear the tone as it’s conducted through the bone and the back of the… behind the ear. And now do you hear the tone here?
Dr. Pearson: Is it louder in front?
Dr. Pearson: And that’s a normal test. Abnormal test will be the opposite. That it’s louder conducted by the bone than it is by the ear. The next part of the neurological exam consists of the motor testing examination. And we start by testing the muscles that are innovated still by cranial nerve. So cranial nerve 11 innovates two muscles. The trapezius muscle and the sternocleidomastoid muscle. So to test those we have the patient turn to the left, please? And hold your head right there. And don’t let me turn it back, hold hard and you can see that the right sternocleidomastoid muscle stands out.
The next thing I’ll ask her to do is shrug up your shoulders, hold them really hard, don’t let me push down. The next thing that I’m going to test is what’s called permeated drift. And this is a test which helps diagnose subtle motor deficits, often localized to the parietal lobe of the brain. So I’m going to have you hold your arms out in front of you, put your palms up like this and just keep your arms straight. Close your eyes and hold your arms right there. Just watch and observe for any drifting or subtle turning of the hands, which would localize to the opposite parietal lobe.
Okay. That’s fine. That’s a normal examination. The next thing we do is just go then to the arms and legs and test power in each of the different muscles.
Moderator: Strength testing requires that resistance be applied to the limb and graded accordingly. If a patient can move her limb in a full arc of motion against gravity, it’s graded 3 over 5. Four over 5 implies partial resistance and 5 over 5 implies normal strength resistance with maximal effort. Two over 5 indicates the patient can’t move the limb against gravity, with zero indicating no movement at all.
Dr. Pearson: So I start with the muscles at flex and abduct shoulders. Hold hard, don’t let me push down. Hold strong. Okay. Now, keep your arms straight, don’t let me bend, this is tricep muscle. Don’t let me bend your elbow, keep it straight. Hold your arm strong like this, don’t let me pull down. Bicep muscle, hold tight. And put your hands out like this so that we test wrist extensors now. Hold hard, don’t let me push down. Hold strong. Good. And now, I just want you to squeeze my fingers as tight as you can. Don’t let go. Hold strong. Good. This one over hear, squeeze hard. Good.
Now, we can do the same in the lower extremities by just asking the patient to lift your knee up and touch my hand. Hold strong here, the hip flexor muscle, hold strong. This one over here, pull tight. Good. Kick your leg out straight. Good. Hold strong, don’t let me push down. Good. This one here, this is your quadricep muscle. Hold strong. Now bend back for me. Pull back hard as you can, don’t let me pull it out, hamstrings, bend the knee. Hold tight. And bring the seat up for me, ankles is up strong, hold strong, dorsiflexion. And the big toe pull it up. Hold hard. Hold hard and point your toe down for me now. Point down. Good. Push down like you were stepping on the gas. Good.
The final part of the motor exam is to look at whether there’s rapid alternating movements which help again diagnose solo coordination defects. Just take your hands and turn them like this like you were screwing in a couple of light bulbs really rapidly. And you observe for symmetry of the motion to see if one side is slower than the other. The next part of the examination is to check the reflexes or deep tendon reflexes. This is basically what’s known as a simple spinal reflex so that when we tap on the muscle tendon, you’ll get a jerk in the segment of the arm or leg in which the tendons are attached.
The way that that is done by just having the patient relax in a very normal position and just tapping over for instance a bicep tendon. Okay. And we generally do the side to side to compare any differences. Now triceps is in the back of the elbow. The same on this side. And finally the brachioradialis. Good jerk there. Just relax. Finger jerks can also be tested in, particularly in cervical injuries where you are looking for the lower cranial, sorry, lower cervical nerves. The tendon jerks are important part of the motor examination because they are very objective findings. And they are localizable to certain nerve roots.
For instance the bicep jerk is localizable to the C5 nerve root. The tricep jerk is localized to the C7 nerve root. The brachioradialis jerk is innovated by the C6 nerve root. And the finger jerks are innovated by the lower cervical nerves and a higher thoracic nerve. So that would be the C8 nerve root. It’s important to assess the patient for differences between left and right in terms of strength. Subtle differences can mean many things. Most importantly when worrying about a neck injury or a spinal nerve root compression, a subtle weakness one side can be referable to compression of the spinal nerve root.
Same is also true with reflexes. So that’s why we assess side to side. If the right bicep is weaker than the left, they are not quite as pronounced then that can be referable as well to a nerve root injury. Other ways in which you might see mild weakness on one side of the body would be with a brain injury affecting the cerebral cortex or the deeper structures on the opposite side of the body. Neck and render the patient mildly hemiparetic or weak on one side.
The sensory examination is probably the most subjective part of the entire neurological exam. But there are ways to sort of sort out, what is this subjective loss of sensation as opposed to what is objective. And often that requires just repetitive testing so that you are confident that the patient is reliably and consistently reporting each time.
Moderator: Sensory loss can be caused by a brain, spinal cord or peripheral nerve injury. Central causes usually include trauma, stroke or tumor. Sensation includes the four primary modalities of vibration, kinesthesia, light touch and pain. The primary modalities can be impaired in any of three ways. Unilaterally, across from the side of the brain injury, bilaterally, below the level of the cord in both spinal cord and spinal nerve root injuries and symmetrically in all four limbs in the case of hereditary ideologies.
Dr. Pearson: I’m going to start with light touch. And a couple of things that we do in terms of light touch evaluation is first of all to look for touch localization. So I ask the patient to close their eyes and just tell me where I touch you. Right side or left side?
Patient: Right side.
Dr. Pearson: And now we are?
Patient: Left side.
Dr. Pearson: How about now?
Dr. Pearson: Sometimes when a patient will extinguish or not report that they feel sensation on both sides of the body, it’s a subtle indication of parietal lobe dysfunction in the brain on the side opposite of where the sensation is not felt. The next thing I’m going to do is just test pinprick or pain sensation on both sides of the body. So tell me, does the pin feel the same on the right as it does on the left?
Dr. Pearson: Good. Okay. Again, another indication that the patient may have subtle impairments in parietal lobe dysfunction on the side opposite where the pain would not be felt. In her case, the pain is equal. I frequently ask the patient to tell me, as I come across your body does the pain… does the pain feel different?
Dr. Pearson: Or is it feel the same?
Patient: It feels the same.
Dr. Pearson: As I come across and the patient just at the midline begins to say that they feel numb, that’s frequently a curious finding in as much as one would expect that sensation isn’t strictly confined to the mid line of the body. So that as you come across you’d expect a little variance around the area of the mid line. But a patient who splits the mid line may be embellishing their examination. I’ll then check if I’m worried about cervical nerve injury, pinprick and a dermatomal distribution.
That means I check pinprick according to sensation as it’s innovated by the various nerve roots as they come out in the spinal cord. For instance, C5 or the neuro… 5th nerve root innovates this patch of skin in the shoulder. So I’ll test pinprick side to side. Does that feel about the same?
Dr. Pearson: Both sides. The same is done down in the lower dermatomes. C6 being along the thumb. It feels the same on both sides?
Dr. Pearson: C7 being about the middle across the wrist. Feels the same?
Dr. Pearson: And C8 is here and here.
Dr. Pearson: They all feel the same.
Dr. Pearson: Frequently I’ll then test between dermatomes just to make sure that the patient is reliably and consistently reporting the same sensation each time. Another aspect of the sensory examination is to check joint position sense. And the way that’s done is to have the patient close your eyes, and just tell me whether I move your finger up or down. Which way is it going?
Dr. Pearson: And now?
Dr. Pearson: And now?
Dr. Pearson: Good. Same on this side. Which way?
Dr. Pearson: Now?
Dr. Pearson: Now?
Dr. Pearson: Loss of joint position sense really implies injury to the spinal cord itself. And it’s not usually seen with nerve root impingement. It can be seen unilaterally or lost on one side of the body again if the opposite parietal lobe is injured. The final part of this sensory exam is the tuning fork for the vibration testing. And here I just ask the patient, tell me do you feel the tuning fork?
Dr. Pearson: Generally I’ll judge how long they can feel the tuning fork at the tip of their finger. Is it gone now or do you still feel it?
Patient: No. I still feel it.
Dr. Pearson: Gone now?
Dr. Pearson: Very good. Gone now?
Dr. Pearson: Okay. Good. Tell me when it goes away. Gone right?
Dr. Pearson: And I test on myself to make sure that’s also the case and her sensation is pretty normal. Again abnormalities of vibration really relate either to a peripheral neuropathy because as the nerves are they supply the tips of the finger are injured distally at the tips or it can imply a spinal cord injury such that vibration is lost on that basis. It can also imply if it’s unilateral on one side, again, parietal lobe dysfunction on the other side of the body. The cerebella examination is a fairly straightforward test. Basically we are testing coordination in the patient’s limb segment.
So the first thing I’m going to have you do is take your finger and touch your nose. Okay. And now touch my finger. And just go back and forth between and as quick as you can. Quicker. Very good. Very good. Okay. Now with your other hand. What I’m trying to do is compare how symmetric and easily she performs this movement. Very good. Now, we’ll do the same in the legs. This is called the heel to shin test. You take your heel and just place it here in your sheen bone. Okay. And slide the leg down and up your left leg. Up and down like that a few times. That’s very good. Now the other leg please. Same thing. All the way to the ankle and all the way back up. Very good.
The purpose of cerebella testing is to ascertain whether or not a patient has an ataxia or incoordination of movement on one side of the body. The cerebellum is the area of the brain that controls this movement. And generally when a person has ataxia on one side of the body, it will localize to the cerebellum on the same side.
The next part of the neurological evaluation is to look at the patient’s station and gait. Station meaning just the ability to stand. I’m going to have you stand up now for me please. And come on over here. This part of the examination is important to look for subtle problems with balance, weakness and antalgic or painful gait and also to assess the patient’s ability to balance in the face of a peripheral neuropathy. Or weakness in one muscle of the leg or foot. First thing I’m going to have you do is just close your eyes. This is known as a Romberg test. And what we are observing for is the patient’s ability to just maintain this position without excessive swaying from the ankles. If you see that sway, it’s indicative potentially of a peripheral neuropathy or a loss of sensation in the legs and feet.
Okay. Open your eyes now. This time I want you to just put one foot right in front of the other. This is known as a tandem stand. Again you are narrowing the patient’s basic support and asking them to demonstrate just normal postural reactions. Abnormalities with this examination, part of the examination can implicate cerebella difficulty in the balance organ of the brain. Inner ear difficulty because it also is part of the balance system of the brain. Both can be injured in a whiplash or mild brain injury. Just hold your balance. Close your eyes now, and just keep your balance. Very good. Okay.
Put your feet apart and just relax for a minute. Okay. Now this time what I want you to do is just walk right towards me. Okay. And turn around for me. And go back the other way. And come on around now. When observing the baseline gait, you are just looking for asymmetry in gait so that there’s evidence of weakness in leg or a foot muscle, whether the patient is antalgic or has pain with their gait, as I said before. The next part of the examination is to look at stress gaits. And these are just various more difficult types of gait maneuvers. For instance, I will ask the patient to perform certain stress gaits such as walking on their toes and walking on their heels.
When you ask the patient to do this, this is also a way to determine whether or not they are embellishing other parts of their exam. If they didn’t do very well on the power testing part of the examination, this is another way to check whether or not that weakness they exhibited is really true. So for instance, if they are very weak on pulling their toes up, you will ask them to walk on their heels. And that requires a very strong amount of power in order to perform it. Another area of stress gait testing is to ask the patient to walk in tandem. Again, this is just heel-toe walking where the patient’s required to exert the best of their balance reaction in order to maintain the gait. Finally, we can ask the patient to hop on one foot or jump on both feet in order to look for any asymmetry which is indicative of mild spasticity, mild weakness or other type of balance problem that might not be obvious on a routine exam.
When a patient comes to your office complaining of low back pain or pain radiating down the leg, there are several items on the neurological examination that should be attended to. First of all an obvious history has to be taken in terms of the nature of the pain and where it’s exactly located in the back or leg. The neurological examination will essentially then consist of a motor exam and this is first of all directed towards the reflexes. So we will check the knee and ankle jerks in this patient. Just relax.
Looking for symmetry and any difference between the two. And then the ankle jerk is checked on side to side. I would also check the Babinski reflex looking for signs… sorry, of spasticity or… The reflexes are generally considered an objective sign of nerve root injury if they were asymmetry found between the sides. Generally what you see is a depressed tendon reflex when you have a nerve root compression. I’m going to have you lay back now and check your strength. And your legs out. First thing I’m going to do is just have you lift this leg straight up in the air for me and hold it up there. Nice and strong. Don’t let me push down.
Now hold it tight here, hold straight, hold the knee straight. That’s it. Good. I’m going to do the same thing on this side, hold strong for me, don’t let me push down. Hold strong here, testing the quadriceps muscles as well as the hip flexors here. Next, I want you to bring your ankles up towards your head, both together. And we’ll test for strength here. Hold these muscles strong. Each one of the muscles that I test correlates to a certain nerve root in the low back. For instance quadriceps muscles correlated to the L4 nerve root. The EHL or Extensor Hallucis Longus muscle in the toe. Pull your toes up please. Both toes.
This correlated to the L5 nerve root and those are quite strong. Now I’m going to have you point your toes down, point down, push the foot down like you were stepping on the gas. Good. And these are plantar flexor muscles. Push down. And these are correlated to the S1 nerve root. Weakness in any of these muscles could be the result of a nerve root compression. Now, when the patient complaints of pain down the leg in the dermatomal distribution, it’s important to check for irritation in the sciatic nerve. The straight leg raise test is a test of sciatic nerve irritation. Basically the maneuver is performed by just bringing the leg up as high as a patient can tolerate and asking for their report of pain. Does this bother you?
Dr. Pearson: Now it is a subjective test in a sense because it depends on the patient reliably reporting. Does it bother?
Dr. Pearson: Some patients will report pain in the hamstring muscle due to tightness there but that’s not the same as sciatic nerve irritation. Proceeding on with the sensory examination, a pinprick test is done according to dermatomal distribution. With each nerve root correlating just specific skin areas in the leg. For instance, in the upper leg, the L2 nerve root is high up in the thigh. So we test from side to side here. I’m sorry. That feels normal. And then L3 nerve root, side to side. Going down the leg, L4 is found on the inside or medial side of the leg and tested side to side. The L5 nerve root it supplies this area, so we test pinprick along that. And that feels equal on both sides. Right?
And finally the S1 nerve root really occupies the back and the lateral or outside border of the foot. So we check in the back of the leg or the lateral border of the foot for equal pinprick sensation. At times, the pinprick examination may not reveal sensory loss. But if the patient does complain of a shooting pain or numbness, or burning pain down the leg and the distribution of a dermatome, then one can still consider a pinched nerve or compressed nerve is ideology. Other diagnostic test that would be useful to elucidate this would be obviously an MRI of the lumbar spine which would help show compression of nerve root and disc protrusion.
A more dynamic electro physiologic test would be the EMG, which shows us those muscles that are innovated by nerves which are damaged. In other words, the muscle being supplied by a nerve root that’s been compressed will have abnormal potentials on the EMG.
Reflex sympathetic dystrophy which is also know as causalgia is a disorder that involves the autonomic nervous system and its effect on a limb. Generally a disorder is confined to a distal extremity such as the arm or the distal leg. It can follow any type of a trauma. Sometimes in rare instances it’s spontaneous but usually the trauma can be quite mild. Patients who’ve been in casts for a very long time may come up with this problem and may also follow a patient who’s had a stroke and has a paralyzed arm.
The examination basically consists of looking for what is known as basal motor or pseudo motor changes. And these are changes in skin color, skin temperature and tautness or shininess of the skin. Sometimes you may see loss of hair and basically it’s a fairly subjected examination by just testing the patient’s skin temperature side to side. You also look for the shininess or tautness of the skin. At times thermography can be used in an objective way as long as it’s used to just compare one side of the same patient to the other side of the same patient. There are no standards for thermography across a population. Thermography can be useful in addition in terms of serial examination of the same arm.
The other findings that you might see in reflex sympathetic dystrophy are swelling in the distal extremity. Particularly in the hand, the patient may have excessive tenderness to just even mild compression of the MCP or knuckle joints of the hand. There is no one diagnostic test to prove reflex sympathetic dystrophy. But one of the other supporting pieces of evidence that one might obtain in a patient where it’s suspected, it is a bone scan. And this can sometimes show abnormal uptake on the side of the reflex sympathetic dystrophy. In very late stages, patients may have bone loss or osteopenia on just a plain x-ray of the wrist, hand or feet.
When a patient comes into my office complaining of headache, neck pain, arm or hand weakness following a cervical whiplash injury, I do a directed examination to look for evidence of nerve root compression and cervical muscle strain. In order to check for cervical strain, or soft tissue injury after whiplash injury, I initially look at the patient’s range of motion in the head and neck. That’s just done by having the patient bend forward as far as they can go, looking up and checking all planes of motion. Turn your head to the side and back to the side. And now bend your ear this way and bend your ear the other way. The concepts here is that you are looking for asymmetry of movement from side to side which might indicate excessive muscle strain or pain on one side of the spine versus the other.
The next thing that I do is palpate the muscles of the cervical spine on either side and into the high thoracic area looking for muscle spasm. This is graded in a fairly subjective fashion, generally one plus, two plus or three plus. And finally in patients who are complaining of head pain or headache, I’ll look for painful sites where the nerve supplying the muscles and the skin of the scalp will exit from the skull. That’s called the greater occipital nerve and can sometimes be very tender and be this source of severe headache.
This is an example of an MRI of the neck. This film show a sagittal view or mid-line cut through the neck. And what it demonstrates is a herniated disc at the level of C4-5. The spinal cord comes down through the canal and you can see where the spinal cord has an indentation into it due to an extruded disc segment.
Severe whiplash injuries can cause acceleration, deceleration injuries to the brain. These create a sheer stress or sheer injury to the axons that interconnect different parts of the brain. For instance, connections between the frontal lobe and other parts of the brain may be disrupted causing things like loss of consciousness or feelings of confusion after the injury. It’s important in these cases to do a detailed mental status evaluation. Neuro-physiological testing can provide detailed evaluations of various cognitive domains such as attention, concentration, long-term memory, new learning, reasoning skills and abstraction skills.
This test can be subjective if the patient is not consistent in their reporting, but it is important to document over time the patient’s response. As a result you can then demonstrate some consistency on serial examinations in particular for those patients who have complaints of concentration or other cognitive impairments. I’m going to ask you to remember a few things for me, a speedy Cadillac, a white rose and Market Street. Can you say those three things?
Patient: Speedy Cadillac, a white rose, Market Street.
Dr. Pearson: Very good. Okay. This time what I want you to do is just start at 40 and count backwards by three till you get down to zero or one. Just do your best.
Patient: Forty, 37, 34, 31, 28, 25, 22, 18.
Dr. Pearson: Keep going. Hang in there.
Patient: Fifteen, 12, 9, 6, 3, that’s it.
Dr. Pearson: Good job. Can you remember those three things that I gave you to remember?
Patient: A speedy Cadillac, a white rose and a market street.
Dr. Pearson: Very good. This time what I want you to try to do is start with the months of the year and say them in reverse order for me. So you start with December and go around backwards so you get up to January. Go ahead.
Patient: December, November, October, September, August, July, June, May, April, March, February, January.
Dr. Pearson: Good. If I ask you what does it mean when someone says, “The grass is always greener on the other side of the fence.” What would you say?
Patient: It means that things are always better somewhere else.
Dr. Pearson: And an apple and a horse, do you see anyway in which those two things could be similar?
Patient: They’re both found in the outside.
Dr. Pearson: Okay. Abnormal responses on test of higher cognitive functioning like abstraction or problem solving can indicate the need for further testing with nerve physiological test batteries and MRI. An MRI can be a useful test if it shows a positive finding as in the case of contusion or blood along the surface of the brain. In the case of severe sheer injury or axon injury, one might see high signal intensities in the deep substance of the brain. This is an example of an MRI of the brain in a severely injured patient, which demonstrates several types of injuries that can occur in the brain with trauma.
In this gentleman’s case, he suffered an epidural hematoma which cause compression of the left side of the brain. In addition he suffered a cortical contusion which highlights as a very bright spot here in the frontal region of the brain. And finally, because of the diffused axonal injury or sheer injury to the axons of the brain, you’ll see very small tiny punctate lesions that highlight on this sequence. However in many cases, particularly in milder brain injury the MRI can be negative. If that’s the case, it’s not a supporting piece of information and one has to go on and do an objective neuro physiological test battery.
Moderator: An understanding of a neurological examination including patient history, screening, clinical evaluation and diagnostic tests can enhance your practice and assist you in evaluating personal injury claims. This video program was designed to introduce you to the complete neurological examination.