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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

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coulditbe?Isitmorelikelytobesuperficial,inthecortex,ordeeperinthebrain?1Couldyourpatient havehadastroke?Atumor?Aninfection?Yoursubsequentevaluationcannowbegearedtowardfiguring thisout.
Themotorpathwaysconvergeastheydescend,fromthecortexdownintotheinternalcapsuleand brainstem.Youcanseethatitwouldrequireaverylargecorticallesionbutarelativelysmallinternal capsulelesiontoresultinface,armandlegweakness.
TheNeurologicExamination
Theneurologicexaminationistheprideandjoyofneurology.Thisisnotbecauseit’scomplicatedor becauseitrequiresabagfulloftools(apenlight,reflexhammer,tuningfork,safetypins,etc.)but becauseitworks:whenproperlyutilizedandperformed,theneurologicexaminationcantellyouthings thateventhemostmeticulouslyobtainedhistoryandhighest-resolutionMRIcannot.Intherightcontext,a downwarddriftofanextendedarmcanpromptemergentthrombolytictherapytodissolveabloodclot; subtleweaknessinneckflexioncanraiseredflagsfortheimpendingneedforintubation;adroppedreflex orasymmetricsmilecandramaticallychangeapatient’sdifferentialdiagnosis,management,and treatment.
Yes,theneurologicexaminationcanseemintimidating.Solet’swalkthroughit,onestepatatime.
Thecomponentsofacomprehensiveneurologicexaminationinclude:
1.  Mentalstatus: levelof consciousness, intellectual function, language, and praxis (praxis refers tothe cognitive abilityto perform learnedmotortasks,fromwritingtothrowingacurveball)
2. Cranialnerves:2to12(whynot1?Cranialnerve1istheolfactorynerve,andmostofthetimeyouwon’tneedtotestsmell)
3. Motorsyste m:bulk,tone,andstrength
4. Somatosensorysyste m:lighttouch,pain,temperature,vibration,andproprioception
5.  Reflexes : six common reflexes are tested: the brachioradialis, biceps, triceps, patellar, Achilles, and plantar (also known as the
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Babinskisign)
6. Coordination:rapidalternatingmovements,finger-nose-fingerandheel-to-shintesting
7. Gait:stance,balance,armswing,andabilitytoheel,toe,andtandemwalk
Nowlet’slookateachofthesesevendomainsindividually,stressingthewayeachisevaluatedduring yourneurologicexamination.We’veincludedjustenoughneuroanatomysothatyoucanunderstandthe contextandimportanceofeachexaminationfinding.Wereadilyadmit:itisalotofmaterial,sotakeyour time.Youdon’thavetomasteritallatonce,althoughyouarecertainlywelcometotry,andtherelevance ofmuchofittoneurologicdiagnosiswillbecomeapparenttoyouaswegothroughthevarious neurologicdisordersthatcomprisethebulkofthisbook.
MentalStatus
Thementalstatusexaminationtestsamultitudeofmentalcapacitiesandfunctions,butitisofteneasyto determinesomeone’smentalstatuswithinthefirstminuteofmeetingthem.Isyourpatientawakeandalert, acknowledgingyou,smilingappropriately?Canyourpatientholdacoherentconversation?Ifso,you’re likelygoodtogo.
However,thementalstatusexaminationcanbehighlynuancedanddetectsubtleabnormalitiesyou mightmissonfirstimpression.We’vesimplifieditheretoincludeonlythemostrelevantandclinically usefulcomponents.
1.  Levelofconsciousness. Youneedtorecognizethe termslistedbelow because you’ll hearthemused, butbeaware that,because therearenostandardized,agreed-upondefinitionsoftheseterms,thebestwaytodescribeapatient’slevelofconsciousnessissimplyto specifywhatyousee.Ifthepatientisgroggyandnotresponsivetovocalstimuli,forinstance,justsaythat.Everyoneusesanddefines thesetermsslightlydifferently,butherearesomeofthemorecommondefinitions:
a.
Awakeandalert:Normal.
b.
Lethargic:Groggy,butresponsivetovocalstimuli.
c.
Obtunded:Brieflyarousabletopainfulstimuli,thenfallsbacktosleep.
d.
Comatose:Unarousable.
2. Intellectualfunction.Afewsimpletestswillestablishapatient’scognitivefunction:
a.
Orientationtoperson,place,andtime.
b.
Attentionandconcentration.Thiscanbetestedbyaskingyourpatientstospelltheword“WORLD”backwardorsubtractserial 7’sfrom100.Youmusttakeeducationalbackgroundintoaccounthere.
c.
Memory. Test 3-item recall: Give your patients 3 wordsto remember, thenask them to repeat the words back to you after severalminutes. Morein-depthmemory andcognitive testing, suchas the Mini-Mental State Examination (MMSE) andthe MontrealCognitiveAssessment(MOCA),willbediscussedlater(seeChapter7).
3. Language.Thiscoversexpressionandcomprehension2:
a.
Naming.Startwith “high-frequency” (easy) objects suchas “finger,” andprogress to “low-frequency”(moredifficult)objects suchas“nail.”
b.
Comprehension.Startwithsimpleone-stepcommands:“stickoutyourtongue,”or“closeyoureyes.”Progresstomorecomplex commandsthatrequireyourpatientsto“crossthemidline.”Forexample,askyourpatientto“takeyourlefthandandtouchyour rightear.”
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c.
Repetition.Askyourpatienttorepeataphrase:welike“it’sasunnydayinNewYorkCity,”and“noifs,andsorbuts.”
4.  Praxis. Praxis is thecognitive abilitytoperformlearnedmotortasks.Ask yourpatientstoshowyou howtheybrush their teethor combtheirhair.Iftheyareunabletodosodespitenormalmotorfunction,theyare“apraxic.”
Thementalstatusexaminationencompassesawidevarietyofcriticaldomains.
CranialNerves
CranialNerve(CN)Anatomy101Thiscangetcomplicated,andwewillbediggingdeeperintocranial nerveanatomyinChapter18,butfornowallyouneedtoknowisthatthecranialnerves(withthe exceptionofCN1and2,whicharisefromthenasalcavityandtheretina,respectively)originateinthe brainstem,thepartoftheCNSthatconnectsthecerebrumtothespinalcordandincludesthemidbrain, pons,andmedulla.Thecranialnervesareinvolvedinmostofthenoncognitivethingswedowithour head,fromseeing,smelling,hearing,andtastingtomovingoureyes,turningourhead,chewing,and swallowing.Eachnervecancontain,invaryingdegrees,sensory,motor,andautonomicfibers.
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Theentranceand/orexitofthecranialnervesintooroutofthebrainstem.Thesensoryfibersofthecranial nervesareafferents:theyenterthebrainstem(inotherwords,theyreceivesensoryinformationfromthe environmentandrelayittothebrainstem).Themotorfibersareefferents:theyexitthebrainstem(they receivemotorcommandsfromthebrainstemandrelaytheinstructionsouttothetargetmuscles).
Whenyoutestcranialnervefunction,alwaysgoinorder,2to12,soyoudon’tmissanything.
Funduscopy(CN2).Useyourophthalmoscopetovisualizetheopticdiscandsurroundingvessels.Visualacuity(CN2).Holdavisualacuitycard(calledaSnellenchart)approximatelyonefootin frontofyourpatient’s left eye with therighteyecovered. Then testtheothereye.Patients should weartheircontactsorglassesifneeded. Visualfields (CN2). Have your patientscover their lefteyewhile you coveryour own righteye (thisallowsyoutocomparetheirvisualfieldtoyours).Facethemdirectlyandtellthemtokeeptheir eyesonyournose.Quicklyflashsome fingers ineachvisualquadrantandaskthem totellyouthe numberoffingersthattheysee.Thentesttheothereye. Pupillary reflexes (CN2, CN3). Reduce thelightin the room as much as possible. Swing your penlightbackandforthseveraltimesbetweenyourpatient’seyes,assessingpupilsizeaswellasthe degreeandrateofconstriction. Extraocularmovements(CN3,4,6).Tellyourpatientstofollowyourindexfingerwiththeireyes
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whilekeepingtheirheadstill.Drawan“H”intheairtobringtheireyesup,down,andside-to-side. Assess for full andsymmetric eyemovements as well as eyelid drooping (ptosis) and nystagmus (rapid,involuntaryjerkingmovementsthatwillbediscussedinmoredetaillateron).We’llsortout the specific contributions of each of these three cranial nerves in Chapter 18 when it becomes important. Facialsensation(CN5).Lightlytouchbothsidesofyourpatient’sforehead,cheeks,andchin,and askiftheleftandrightsidesfeelthesame.You’retestingthefirst(V1),second(V2),andthird(V3) branchesofthefifthcranialnerve,respectively.Testingjawstrength(the“musclesofmastication”) byhavingpatientsopenandclosetheirjawagainstresistancealsoassessesV3. Facialmovements(CN7).Ask patients to close their eyestightly,raise their eyebrows, puffout their cheeks, and smile. You’re looking predominantly for symmetry. Facial weakness may be obviousatfirstglanceormayrequire“activation”—smiling,raisingeyebrows—tobeappreciated. Nasolabialfoldflatteningisasubtlesignofsmileweakness. Hearing(CN8).Rubyourfingerstogetherinfrontofyourpatient’sear.Eachearshouldbetested separately. Uvuladeviation(CN9,10). Ask your patient tosay“ahh” so you can assess the movementand positionofthepalateanduvula. Shouldershrugandneckturn(CN11):Haveyourpatientsturntheirheadallthewaytotheleft, placeyourhandontheleftsideoftheface,andaskthemtoresistyouasyoutryturningtheirheadto theright.Testbothsides.Askyourpatientstoshrugtheirshoulderswhileyouresistwithyourhands. Tonguemovements(CN12).Askyourpatientstostickouttheirtongueandmoveitsidetoside.To teststrength, ask themto push the tongue againstthecheekfrom inside themouthwhile you push againstitfromoutside.
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UsingaSnellencharttoevaluatecranialnerve2.
Whathappened,youmayask,tocranialnerve1?Thatistheolfactorynerve,anditisoftenunnecessary toevaluateit.Ifyouthinkitisrelevant—forexample,inapatientwithsuspectedCOVID-19(lossof smell—anosmia—isacommoncomplicationofthisdisease)—youcanusewhateverstimulusyoucan find(welikestrongcoffee!)totestonenostrilatatime.
TheMotorSystem
MotorSystemAnatomy101Thecorticospinaltractisthemajormotorpathway,responsiblefor voluntarymovementofthelimbsandbody.Thefibersoriginateinthemotorcortex(whichislocated withintheprecentralgyrusofthebrain—seethefigurebelow)anddescendthroughthesubcorticalwhite matter(includingthecoronaradiata),theinternalcapsule,andbrainstem.Theydecussate(orcross)inthe medullaatthemedullarypyramids,rightwherethebrainstemmeetsthespinalcord;thisiswhytheleft sideofthebraincontrolsmovementontherightsideofthebody,andviceversa.
Theseneurons,theuppermotorneurons,continuetodescendthroughthecord(onthecontralateral sidefromtheirsiteoforigin)inthelateralcorticospinaltract.Theysynapsejustbeforetheyleavethe cordonlowermotorneurons(alsocalledanteriorhorncells),whichexitthecordandtraveltotheir targetmuscles.
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Thecentralsulcusdividesthefrontalandparietallobes.Thegyrusjustanteriortoitiscalledtheprecentral gyrusandfunctionsastheprimarymotorcortex;thegyrusjustposteriortoitiscalledthepostcentral gyrusandfunctionsastheprimarysensorycortex.
Box1.4ThePyramidalTracts
You’llhearthetermpyramidaltractusedasasynonymforthecorticospinaltract,butinfact therearetwopyramidaltracts:(1)thecorticospinaltract—asjustdiscussed,theseare uppermotorneuronsthatoriginateinthemotorcortexandterminateonlowermotorneurons inthespinalcordand(2)thecorticobulbartract—theseuppermotorneuronsalsooriginate inthemotorcortexbutterminateinthebrainstemonthemotornucleiofthecranialnerves.
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A second motor system, the extrapyramidal system, runs outside the medullary pyramids (hence extrapyramidal) and includes neurons within the basal ganglia and cerebellum, among other
locations.Unliketheneuronsofthepyramidalsystem,theseneuronssynapseallovertheplaceand are important for indirect, largely involuntary, modulation, coordination, and regulation of movements. Lesions of the extrapyramidal system therefore result in abnormal, dysregulated movements.Dopaminedepletionwithinthebasalganglia,forinstance,asinParkinsondisease,can
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resultintremorandbradykinesia(slownessofmovement).Antipsychoticmedications(whichactas dopamine receptor antagonists) canalso cause extrapyramidal symptoms, including parkinsonism, dystonia (abnormal posturing that’s often associated with repetitive twisting movements), and akathisia(amovementdisordercharacterizedbyrestlessnessandinabilitytositstill).Wewillgetto allofthisinChapter13.
Box1.5UpperandLowerMotorNeurons
Damagealongthemotorpathwaysproducesdifferenttypesofdeficitsdependingupon whetherupperorlowermotorneuronsareinvolved.Itisthereforeimportantforlocalization toknowthedifference:
Uppermotorneurons(UMNs)includeallneuronsthatruninthemotorpathwaysabove the lower motor neurons. These include the neurons in the corticospinal and corticobulbartracts.ClassicfindingsofUMNdamageincludeweakness,increasedtone andspasticity,hyperreflexia,andupgoingtoes(akatheBabinskisign;seepage28). Lowermotorneurons(LMNs)arethefinalnervesinthemotorpathwaysthatinnervate (viatheneuromuscularjunction)themuscles.Theseincludetheanteriorhorncellsinthe spinalcordandthecranialnerveswithmotorcomponents(i.e.,allofthecranialnerves except 1, 2, and 8). Like UMN disease, LMN disease presents with weakness, but unlike UMN disease it can also cause muscle atrophy, decreased muscle tone, hyporeflexia,andfasciculations(ormuscletwitching).
LowerMotorNeuronDeficit UpperMotorNeuronDeficit
Hyporeflexia Hyperreflexia Markedmuscleatrophy Lesssignificantatrophy Musclefasciculationsandfibrillations Fasciculationsandfibrillationsarenotseen Decreasedtone(musclesareflaccid) Increasedtone(musclesarespastic) AbsentBabinskisign PresentBabinskisign
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Upperandlowermotorneurons.Damagetooneortheothercancauseverydifferentsymptoms.
Themotorsystemiscomplicated,butfornowthisisprettymuchallyouneedtoknowtounderstand whatyouaredoingandwhyyouaredoingitduringyourneurologicexamination.Wewillgetintomore detaillaterwhenitbecomesimportanttodigabitdeeper.
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