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Friday, July 19th, 2013

Neurologic Exam in Children

Neurologic Exam

• Components– General Assessment– Mental Status– Cranial Nerves– Motor– Sensation– Reflexes– Cerebellum– Gait

General Assessment

• Vital Signs • Developmental Stage• General inspection of Patient– Dysmorphic features– Appropriate size, weight, head circumference– Voluntary or purposeful movement– Posture

Physical Exam Findings

• Skin– Hypopigmented patches, facial hemangiomas,

café au lait spots, • Spine– Visualize spine, gluteal folds

• Head– Size, sutures, fontanel, swelling

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Mental Status• Orientation• Language • Memory

– Breakfast (short term)– Name of teacher/school (long term)– Counting or Alphabet

• Attention, Concentration, Executive Function, Calculations, Praxis– Spell world backwards– Serial 7s

• Level of Consciousness– One of the most important parts of the neuro exam– Glascow Coma Scale

• Mood, Thought Content

Infant Scale5. Coos, babbles4. Irritable cries3. Cries to pain2. Moans to pain1. No response

6. Spontaneous, purposeful movement5. Withdraws to touch4. Withdraws to pain3. Decorticate posture to pain (flexion)2. Decerebrate posture to pain (extension)1. No response

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Cranial Nerves

• Infants: mainly observational• I olfactory: rarely tested• II optic: – Visual acuity: infant reaching for objects, child

recognizing objects/letters/numbers– Visual fields: objects in the periphery– Pupillary light response: direct and consensual– Fundoscopy

Fundoscopy

Cranial Nerves

• III oculomotor: Superior/Inferior/Medial recti, inferior oblique, levator palpebrae superioris, autonomic muscles

Cranial Nerves

• IV trochlear: superior oblique, pulls down/in

Cranial Nerves

• VI abducens: lateral rectus, abducts

Corneal Light Reflex

Abnormal Eye Movements

• Nystagmus• Tonic horizontal deviation • Tonic downward gaze deviation• Unilateral dilated, poorly reactive pupil• Unilateral constricted pupil

Cranial Nerves

• V Trigeminal: – sensation of face, cornea, conjunctiva– Motor function of masseter, temporalis,

pterygoids (muscles of mastication)– Lacrimation, taste

Cranial Nerves

• VII facial: – Symmetry of nasolabial folds– Eyelid muscle strength– Ability to wrinkle forehead– Infants• Closes both eyes when crying• Look for symmetric suck, spillage to one side

(V, VII, IX, X, XII)– Taste

Cranial Nerves

• VII facial nerve palsy

Cranial Nerves

• VIII Vestibulocochlear:– Infants: alerting reponse to sound, localizes to

sound– Children: whisper number or letter– Older children: Webber and Rinne– Vestibular• Poor head control, truncal instability, gait ataxia, N/V,

nystagmus (horizontal)

Cranial Nerves• Weber Can detect – unilateral sensorineural (inner)– unilateral conductive (middle)

Weber without lateralization

Weber lateralizes left

Weber lateralizes right

Rinne both ears AC>BC Normal/bilateral sensorineural loss

Sensorineural loss in right

Sensorineural loss in left

Rinne left BC>AC Conductive loss in left

Combined loss : conductive and sensorineural loss in left

Rinne right BC>ACCombined loss : conductive and sensorineural loss in right

Conductive loss in right

Rinne both ears BC>AC Conductive loss in both ears

Combined loss in right and conductive loss on left

Combined loss in left and conductive loss on right

Cranial Nerves

• IX Glossopharyngeal and X Vagus: – Controls swallowing, soft palate movement, gag

reflex– Drooling, pooling saliva can be a sign of

dysfunction– Hoarseness can be a sign of CN X dysfunction– Dysarthria (IX, X and XII)

Cranial Nerves

• XI Spinal Accessory: trapezius and sternocleidomastoids– Elevation of shoulders, turning neck against resistance

• XII Hypoglossal: innervates the tongue– Tongue should be midline on protrusion– Deviation to affected side indicates palsy– Atrophy, fasiculations or oromotor apraxia can be a sign

of dysfunction or serious illness

Motor - Infants

• Passive Tone– <28 wga: limbs passively extended– 34 wga: flexion of knee/hip, extended UE– 40 wga: strong flexion in all four extremities

• Active Muscle Activity• Posture

Ballard Scale

Motor - Infants

• Active Muscle Activity– Symmetric, smooth, spontaneous movements (34 wga)

– Small amplitude, choeo-athetoid movements of hands are normal

– Jitteriness, tremulousness can occur, but should not be sustained

– Reflexes – stepping reflex– Head Control– Vertical and Ventral Suspension

Motor - Infants

• Hypotonia– Most common motor abnormality– Hypotonia + preserved mobility + hyperreflexia• Central nervous system origin (Down Syndrome)

– Hypotonia + weakness + areflexia• Anterior horn cell disorder• Peripheral nerve or peripheral muscle disorder

Motor - Infants

• Hypertonia– Less common than hypotonia– Pyramidal tract dysfunction– Passive movement of the muscle resistance– Associated with hypoxic-ischemic lesions– Difficulty determining spasticity vs. rigidity

• Spasticity (meaning to draw or tug) involuntary, velocity-dependent, increased muscle tone that results in resistance to movement

• Rigidity - Involuntary, bidirectional, non – velocity-dependent resistance to movement

Motor - Infants

• Opisthotonus– Arching of the neck and trunk– Decreased cortical inhibition– Associated with bilirubin encephalopathy, tetanus,

TBI, CP, meningeal irritation/increased ICP

Motor - Children

• Observe them at play• Muscle tone– Resistance felt upon passive movement– Hypotonia = decreased resistence + hyperextension– Hypertonia• Spasticity (clasp knife) pyramidal• Rigidity (lead pipe or cog-wheel feel) extrapyramidal

Motor - Children

• Weakness or Strength – Grades• 0/5: no muscle movement at all• 1/5: visible/palpable contraction, but No Movement• 2/5: movement with gravity eliminated• 3/5: movement against gravity• 4/5: movement against gravity and some externally

applied resistance• 5/5: movement against gravity and full resistance

Motor - Children

• Distal Weakness– Can be symmetric or asymmetric– Seen in peripheral myopathies

• Proximal Weakness– Usually symmetric– Seen in myopathyies– Gower’s sign

Motor - Children

• Pronator Drift– extend UE with palms up, eyes closed– UMN weakness• Arm pronates and falls, can pulls elbow down and in

– Cerebellar disease• One arm rises up or oscillates

UMN vs LMN

• Spasticity +/- weakness

• Stiffness +/- mild atrophy

• Increased Reflexes/Tone• Spontaneous clonus• Spontaneous spasms• Gait– Slow, stiff, difficult to turn– Heavy legs

• Weakness– Foot drop, difficulty w/ stairs

• Decreased Reflexes/Tone• Muscle atrophy• Fasciculations• Cramps• Gait– Steppage, waddling

LMN signs

• http://www.uptodate.com/contents/clinical-features-of-amyotrophic-lateral-sclerosis-and-other-forms-of-motor-neuron-disease?detectedLanguage=en&source=search_result&search=upper+motor+neuron&selectedTitle=1%7E150&provider=noProvider#H11

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Sensation

Sensation• Child– Vibration (128 or 256 Hz tuning fork)– Proprioception (Romberg)– Light Touch (cotton swab)– Temperature and Pin Prick – Two point discrimination, stereognosis, graphesthesia

• Infant – difficult to assess– Perioral tactile stimulation rooting reflex– Spinal cord lesion

• Only time pin prick testing is useful in infants

Romberg Sign

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Reflexes - Infant

Other reflexes

• Babinski reflex• Abdominal reflex• Cremasteric reflex• Perianal reflex

Reflexes - Children

• Jaw – tap chin with mouth slightly open• Biceps – with elbow flexed, tap at antecubital

fossa • Brachioradialsis - tap above the wrist, on

radial aspect flexion of elbow• Patellar – tap quadriceps tendon below patella extension of knee

• Ankle (Achilles)

Reflexes - Children

• Absent or diminished– Can be loss of sensory fibers – Can be loss of muscle stretch reflex arc

• Exaggerated – Clonus– Knee jerk contralateral hip muscle and plantar

foot flexion

Reflexes

• Grading– 0 absent – 1 Decreased (Hypoactive)– 2 normal– 3 Increased (Hyperactive)– 4 Clonus

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Cerebellar

• Dysmetria: Difficulty regulating rate and range of muscle contraction– Nystagmus– Intention tremor– Scanning speech– Truncal or gait ataxia– Rebound phenomenon

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Gait

• Assess gait, heel walking, toe walking and tandem gait

• Circumduction (spasticity, hemiparesis)• Broad-based, ataxic (cerebellar)• High-steppage gait (peripheral neuropathy)• Waddling gait (myopathy, DMD)

Noon Conference