11

3The Neurological Examination

Basic Principles of the Neurological				Examination of the Autonomic Nervous System . . .			39
Examination . . .	11			Neurologically Relevant Aspects of the General
Stance and Gait . .	. 13			Physical Examination . . .	39
Examination of the Head and Cranial Nerves . . .				16 Neuropsychological and Psychiatric Examination . . .			39
Examination of the Upper Limbs . . .			27	Special Considerations in the Neurological Examination
Examination of the Trunk . . .		36		of Infants and Young Children . . .		43
Examination of the Lower Limbs . . .			37

Basic Principles of the Neurological Examination

Neurological diseases can often be diagnosed based on a carefully elicited history in combination with the physical examination. In order to ensure completeness, the examining physician should examine all patients according to the same general scheme, making individual variations where required. One may either test the individual components of the nervous system in a particular sequence (cranial nerves, reflexes, and motor, sensory, and autonomic function), or else orient the examination along topographic lines (head, upper limbs, trunk, lower limbs). The presentation in this chapter is topographically organized.

Neurology stands by itself as an independent medical specialty and field of research. Most neurological illnesses affect only the nervous system. Nonetheless, general medical illnesses often manifest themselves with neurological symptoms and signs (cf. p. 120 ff.). The clinical neurological examination must therefore always include a general physical examination.

The practicing neurologist should indeed lay emphasis on the neurological aspects of the physical examination but cannot neglect its general aspects. Some of the basic principles of physical examination are listed below.

The examiner must talk to the patient, briefly explaining the purpose of individual steps in the examination where appropriate. This holds for patients of all ages, even more so for children.

In principle, the neurological examination should always be complete and should always be performed in the same sequence, though the examiner is free to use whatever sequence he or she prefers. The individual

components of the examination are listed in Table 3.1. In certain exceptional situations, a highly experienced clinician may choose to perform only a partial examination. This is generally to be avoided, however, as even the best neurologist can miss something important in this way. In addition, a thorough, methodical examination helps reassure the patient that the physician is competent and attentive.

Patients should be examined undressed, after being given clear instructions about which clothes to remove, usually everything but their underwear. The spine cannot be examined if the upper body remains clothed and, if the patient is wearing socks, sensation cannot be tested in the feet, and the Babinski reflex cannot be elicited.

As we have already stressed, the examination should always be systematic and complete; yet, the tentative diagnosis (or diagnoses) suggested by the history will direct the clinician to lay particular attention on certain aspects of the examination. There is no sense in the mechanical, unthinking performance of a rigidly identical examination on every patient.

As soon as possible after the examination is completed, the examiner should document the findings in writing. Global statements such as “Neuro unremarkable” are worthless. The findings can be summarized in an outline such as the one provided in Table 3.1. The main purpose of precise documentation is to enable the clinician to follow the development of a disease process from one examination to the next. It is also obviously indispensable for medicolegal reasons.

Moreover, certain findings should be quantified or numerically graded, particularly muscle strength (see Table 3.4, p. 30). Sensory disturbances should be documented precisely in terms of their topography and extent.

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The Neurological Examination

12	3 The Neurological Examination
		Table 3.1 The neurological examination
		Head and cranial nerves
		Head freely mobile	No meningismus
		Skull not tender to percussion	No bruits
		No supraor infraorbital point tenderness	No occipital point tenderness
		Carotid pulsations strong bilaterally, without bruits	Perioral reflexes not exaggerated
		Temporal artery pulsations strong bilaterally, without tenderness

ICoffee correctly identified by smell in both nostrils (spontaneously named/chosen from list)

II	Corrected visual acuity (distance): R	L
	Visual fields full to confrontation
	Optic discs normal bilaterally
III, IV, VI	Eye movements full and coordinated
	No pathological nystagmus
	Pupils equal, round, midsized, and symmetrical,
	with prompt reaction to light and convergence

VSensation in the face intact

	Corneal reflex symmetrically elicitable
	Masseter strong bilaterally
VII	Facial expression normal
	(both voluntary and involuntary movements)
VIII	Hearing subjectively normal
	Whisper heard at a distance of m (R ear), m (L ear)
	Weber not lateralized
IX, X	Palatal veil symmetrical at rest, elevates symmetrically
	Gag reflex intact
	Swallowing subjectively unimpaired
XI	Sternocleidomastoid strength full and symmetrical
XII	Tongue symmetrical, protrudes in the midline, freely
	mobile

Language Unremarkable
Upper Limbs	right-handed	Left-handed
Bulk normal bilaterally
Tone normal bilaterally
Full mobility throughout
Raw strength normal in all muscle groups
Postural testing normal bilaterally, without sinking
Rapid alternating movements performed well bilaterally
No rebound phenomenon
Finger−nose test accurate bilaterally, no intention tremor
No finger tremor
Reflexes: Biceps reflex symmetrical, of medium strength
Triceps reflex symmetrical, of medium strength
Brachioradialis reflex symmetrical, of medium strength
Mayer reflex elicitable bilat		Hoffmann, Trömner not exaggerated bilat.
Sensation bilaterally intact to touch
Pain sensation bilaterally intact		Two-point discrimination 5 mm bilat.
Temperature sensation bilaterally intact
Position sense in the fingers bilaterally intact
Vibration sense bilaterally intact
Stereognosis prompt bilaterally		Coin recognition good bilaterally
Trunk
Spine unremarkable, without percussion tenderness anywhere
Sensation on trunk intact		“Saddle” sensation intact
Abdominal skin reflex symmetrically intact		Finger-to-floor distance: . . ./. . . cm
Cremaster reflex bilaterally present (males only)		Small Schober . . ./. . . cm
Lower limbs
Bulk normal bilaterally
Tone normal bilaterally
Full mobility throughout
Raw strength normal in all muscle groups, incl. plantar flexors
and dorsiflexors
Lasègue negative bilaterally		No nerve trunk tenderness
Postural testing (supine position) normal bilaterally, without sinking
Heel−knee−shin test accurate bilaterally
Reflexes: Quadriceps reflex symmetrical, of medium strength		Oppenheim negative bilaterally
Achilles’ reflex symmetrical, of medium strength

Babinski negative bilaterally

Gordon negative bilaterally

Continued

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Stance and Gait 13

Table 3.1 The neurological examination (continued)

Sensation bilaterally intact to touch

Pain sensation bilaterally intact

Temperature sensation bilaterally intact

Position sense in the toes bilaterally intact

Vibration sense bilaterally intact

Graphesthesia (number recognition) good on both legs

Stance and gait
Romberg negative (in various positions of the head)
Normal gait with normal accessory movements
Walks well on heels bilaterally	Walks well on tiptoes bilaterally
No unsteadiness in heel-to-toe walk
Mental status grossly unremarkable without further testing	General physical examination: blood pressure, pulse, heart,
	lungs, abdomen, lymph nodes, peripheral pulses

(Only those items marked with a check or plus sign + have been examined)

Stance and Gait

General remarks. Though stance and gait are listed at	in front of the other, at first while looking at the floor,
the bottom of Table 3.1, we in fact recommend testing	then while looking straight ahead, and finally while
these functions as the first step in the examination of	looking at the ceiling. Heel-to-toe walking should be
the undressed patient. Mere observation of the patient	possible under all of these conditions. Heel-to-toe walk-
in a standing position can reveal evidence of a disease	ing with the eyes closed is a more difficult task that
process, e. g., muscle atrophy, spinal deformities, and	many normal persons cannot perform.
winging of the scapula. The patient’s posture at rest may
be abnormal, e. g., the exaggerated lumbar lordosis of	The Romberg test (Fig. 3.1e) is a further test of equi-
muscular dystrophy (cf. Fig. 14.3, p. 266) or the stooped,	librium. The patient is asked to stand with the feet to-
rigid posture of the patient with Parkinson disease (cf.	gether and parallel and with eyes closed, for at least 20
Fig. 6.33, p. 128). Stance and gait are best examined with	seconds. This should be accomplished calmly and easily,
the patient barefoot; meaningful findings can be ob-	without any appreciable swaying. The test can be made
tained only if the patient has enough room to walk in.	more difficult by having the patient turn or incline the
The testing of stance and gait often provides important	head to one side. It can also be performed in combina-
clues to the type of disease process that is present. The	tion with positional testing of the arms (see below).
sequence of tests is shown in Fig. 3.1a−g. The most im-	The functions of the vestibular system (p. 201) and
portant features of gait are whether the patient can	cerebellum (p. 80) can be tested in a number of ways, in-
walk at normal speed and without limping. If the	cluding with the Unterberger step test (Fig. 3.1f). The
patient limps, then the pathological side is the side that	patient walks in place, with the eyes closed, raising the
bears weight for the shorter time. The examiner should	knee to the horizontal or above with each step. After 50
note the length of the patient’s steps, the manner in	steps, the patient should have rotated no more than 45°
which the feet are planted on and rolled off the ground,	from his or her original position. Larger rotations sug-
and the accompanying swinging of the arms. Some	gest disfunction of the vestibular apparatus on the side
characteristic disturbances of gait are described in Table	to which the patient has turned, or of the cerebellar
3.2.	hemisphere on that side. In the “star gait” test of Babin-
Walking on tiptoe and walking on the heels (Figs.	ski and Weil, the patient keeps the eyes closed and
	walks two steps forward and two steps back, repeatedly.
3.1b, c) let the clinician judge the strength of the calf	Disfunction of the vestibular system manifests itself as
muscles and the foot and toe extensors. If the plantar	involuntary turning to the side of the lesion. In blind
flexors are only mildly weak, the patient will still be able	walking, the patient first looks at the examiner, who is
to walk on tiptoe, but will not be able to raise himself or	standing some distance away, then closes the eyes, and
herself on tiptoe while standing on one leg, or hop re-	walks toward him or her. Vestibular lesions cause a de-
peatedly on one foot (10 times in succession).	viation to the side of the lesion.
The “tightrope walk” (heel-to-toe walk) (Fig. 3.1d) is a	A number of common gait abnormalities are il-
	lustrated in Fig. 3.2.
very sensitive test of equilibrium and gait stability. The
patient is instructed to place one foot firmly and directly

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The Neurological Examination

14

3 The Neurological Examination

Fig. 3.1 Tests of stance and gait. a

a

b

c

d

Normal gait. Note normal step length

and arm swing. b Walking on tiptoes.

c Walking on heels. d Heel-to-toe

walking. One foot is placed precisely

in front of the other. e Romberg test

with eyes closed, combined with pos-

tural test of the upper limbs. f Unter-

berger step test: walking in place

with eyes closed. See text for inter-

pretation of results. g Babinski−Weil

test with “star gait” (marche en

étoile): the patient is asked to take

two steps forward and two steps

back, repeatedly, with eyes closed.

For interpretation, see text.

e

f

g

Table 3.2 Characteristic disturbances of gait

Designation	Abnormalities of gait	Causes, Remarks
Spastic gait (Fig. 3.2)	slow, stiff, with audible dragging of the soles of the	bilateral pyramidal tract lesion
	feet across the ground

Ataxic gait (Fig. 3.2)	uncoordinated, stamping, unsteady, deviating ir-
	regularly from a straight line; heel-to-toe walking
	impossible

cerebellar dysfunction, posterior column dysfunction, peripheral neuropathy

Spastic−ataxic gait (Fig. 3.2) combination of the two above disorders; jerky, stiff, most commonly seen in multiple sclerosis inharmonious gait

Dystonic gait	uncontrollable additional movements interfering
	with the normal course of gait
Hypokinetic gait	slow gait, stiff, bent posture, small steps, lack of ac-
(Figs. 3.2 and 6.33)	cessory arm movements; turning requires multiple
	small steps
Small-stepped gait	small steps, unsteady, resembles hypokinetic gait
(“marche à petits pas”)	but with more normal accessory movements

basal ganglionic disease causing choreoathetosis or dystonia

most commonly seen in Parkinson disease; similar picture in the lacunar state (cerebral microangiopathy, cf. p. 102)

“old person’s gait” most commonly seen in the lacunar state, i. e., multiple small infarcts in the basal ganglia and along the corticospinal tracts, generally caused by atherosclerosis; distinguishable from parkinsonian gait mainly by the different accompanying signs

Circumduction (Fig. 3.2)	increased tone in the extensors of the paretic leg,
	which comes forward in a gentle outward arc, with
	a strongly plantar-flexed foot; hardly any accom-
	panying movement of the flexed and adducted ipsi-
	lateral arm
Steppage gait	the advancing leg is raised high and then placed on
	the ground toe first, often with an audible slap

central (spastic) hemiparesis

unilateral: foot drop, e. g., in peroneal nerve palsy; bilateral: e. g., polyneuropathy or Steinert myotonic dystrophy

Continued

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Stance and Gait 15

Table 3.2 Characteristic disturbances of gait (continued)

Designation	Abnormalities of gait	Causes, Remarks
Hyperextended knee	with each step, the knee of the stationary leg is	prevents buckling of the knee when the knee exten-
(Fig. 3.2)	hyperextended	sors are weak—unilaterally, e. g., in quadriceps
		weakness due to a lesion of the femoral n.; bilater-
		ally, e. g., in muscular dystrophy
Hyperlordotic gait	exaggerated lumbar lordosis	e. g., in muscular dystrophy affecting the pelvic
(Fig. 14.3)		girdle, in boys with Duchenne muscular dystrophy
Trendelenburg gait	with each step, the pelvis tilts downward on the	severe hip abductor weakness—unilaterally, e. g., in
(Fig. 3.2)	side of the swinging leg	lesions of the superior gluteal n.; bilaterally, e. g., in
		muscular dystrophy affecting the pelvic girdle and
		in bilateral hip dislocation
Duchenne gait	with each step, the upper body tilts to the side	mild or moderate weakness of the hip abductors (as
(Figs. 3.2 and 14.3 b)	of the stationary leg	in Trendelenburg gait, but less severe), or as a pain-
		reducing maneuver in disorders of the hip joint
Fig. 3.2 Common gait
disturbances

Parkinsonian gait	Paraspastic gait	Spastic–atactic gait	gait with circumduction
			in a patient with right
			hemiparesis

Trendelenburg	Duchenne gait	Quadriceps weakness Steppage gait with
gait		foot drop

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The Neurological Examination