The Neurologic Exam

1
The Neurologic Exam
2
Goal is to answer the following

• Do the clinical signs observed refer to a nervous
  system lesion?
• What is the location of the lesion within the
  nervous system?
• What are the differentials for a lesion at this
  location?

3
History

• Invaluable
• Do not get tunnel vision
• Listen to the owner, but draw your own
  conclusions
• What is the chief complaint?

4
Observations
5
Observe the patient without touching

• Mental status
• normal
• confusion
• depression/obtunded
• stupor
• coma
• Behavior
• Body posture and head position
• Gait

6
Cranial Nerve Examination
7
Twelve Cranial Nerves

• I - Olfactory
• II - Optic
• III - Oculomotor
• IV - Trochlear
• V - Trigeminal
• VI - Abducens
• VII - Facial
• VIII - Vestibulocochlear
• IX - Glossopharyngeal
• X - Vagus
• XI - Accessory
• XII - Hypoglossal

8
II
III-IV
V
VI-IX
X-XII
9
Vision
10
Menance Response

• Afferent is optic nerve (II)
• Efferent is facial nerve (VII)
• Response NOT reflex
• cerebral process

11
Pupillary Light Reflex

• Afferent is optic nerve (II)
• Efferent is oculomotor nerve (III)
• Direct and Indirect
• Use a GOOD light source

12
Ocular Position

• Afferent is vestibular system
• Efferent is the nerves to extra-ocular musclses
• oculomotor nerve (III)
• troclear nerve (IV)
• abducens nerve (VI)

13
Palpebral Reflex

• Afferent is trigeminal (V)
• Efferent is facial (VII)
• Neuromuscular disease may affect this reflex

14
Trigeminal Nerve

• Efferent to muscles of mastication
• Sensation to face
• Disease processes
• trigeminal neuritis
• trigeminal nerve sheath tumor

15
Vestibulocochlear Nerve

• Dysequilibrium
• Head tilt
• Nystagmus
• Hearing loss
• Vertigo
• Owners may report seizures

16
Swallowing/Gag Reflex

• Afferent is glossopharyngeal (IX) and/or the
  vagus (X) nerve
• Efferent is glossopharyngeal (IX) and vagus (X)
  nerves

17
Accessory Nerve

• Cervical musculature
• Rarely if ever identified as being compromised

18
Hypoglossal Nerve

• Efferent to tongue musculature
• Loss of innervation leads to crenulated tongue on
  affected side

19
Gait Evaluation
20
Evaluation of Gait

• Normal gait requires intact function of the
  following
• brainstem
• cerebellum
• spinal cord
• sensory peripheral nerves
• motor peripheral nerves
• neuromuscular junction
• muscles

21
Evaluation of Gait

• Ataxia
• proprioceptive or sensory
• vestibular
• cerebellar
• Paresis/Plegia
• tetraparesis/tetraplegia
• paraparesis/paraplegia
• monoparesis/monoplegia
• hemiparesis/hemiplegia
• Lameness

22
Postural Reaction Testing
23
Postural Reaction Testing

• Proprioceptive placing
• Hopping reaction
• Placing response
• Wheelbarrowing

24
Spinal Reflexes
25
The Reflex Arc
26
Spinal Reflexes

• Thoracic Limb Reflexes
• Biceps (C6 - C8)
• Triceps (C7 - T2)
• Extensor carpi (C7 - T2)
• Withdrawal (C7 - T2)

• Pelvic Limb Reflexes
• Patellar (L4 - L5)
• Gastrocnemius (L6 - S2)
• Cranial tibial (L6 - S2)
• Sciatic (L6 - S2)
• Withdrawal (L6 - S2)

27
Thoracic Limb Reflexes
Biceps
Triceps
Extensor carpi
28
Pelvic Limb Reflexes
Patella
29
Pelvic Limb Reflexes
Cranial tibial
Gastrocnemius
All reflexes are testing L6 - S1
Sciatic
Withdrawal
30
Perineal Reflex
Do a rectal exam
Testing S1 - S3
31
Cutaneous Trunci Reflex
32
Pain Evaluation
33
Evaluation of Pain

• Always do last
• Palpation of vertebral column and all joints
• Deep pain perception

34
Localize the Lesion
35
Localization