Randa M. Albusoul

Neurological Assessment

Anatomy

The nervous system can be divided into:

Central Nervous System (CNS)

Peripheral Nervous System (PNS)

# CNS includes brain and spinal cord

#PNS includes 12 pairs of Cranial Nerves (CN) and

31 pairs of spinal nerves.

The brain consists of:

•Cerebrum: vast network f interconnecting neurons.

Nerve cell = cell body and axon.

Brain tissue may be gray or white matter.

Gray matter (neuronal cell bodies)

White matter: (neuronal axons).

•Why cerebral cortex is gray?

Because it lacks myelin

•Hemisphere: is a half of the cerebrum.

•Each hemisphere has 4 lobes.

•Each lobe mediate specific function.

•Frontal lobe:

personality, behavior,

emotions, and

intellectual function.

•Contains Broca’s area

that mediates motor

speech; when injured

lead to expressive

aphasia; person cannot

talk.

•Parietal lobe: primary center for sensation.

•Occipital lobe: primarily visual receptor center.

•Temporal lobe: primarily auditory reception center.

•It also contains Wernicke’s area for language

comprehension (receptive aphasia: hear sounds but

have no meaning for him).

•Basal Ganglia: movement. Example; Arm and leg

swinging during movement.

•Thalamus: processes sensory impulses and relays

them to the cerebral cortex.

•Hypothalamus: maintain homeostasis, regulates

temperature, heart rate, blood pressure, sleep

center, emotional behavior, pituitary gland

regulator.

•Cerebellum: voluntary movements, equilibrium,

and muscle tone.

•Brain Stem: midbrain, pons, medulla (has vital

autonomic centers: respiratory, heart, gastro).

Spinal Cord:

•Long structure that connect the

brain with the spinal nerves.

•It can mediates reflexes.

•Ends at 1st or 2nd lumber

vertebra.

Pathways of the

CNS:

Sensory pathways:

•There are sensory

receptors in skin,

mucosa, muscles,

tendons, and

viscera..

•The brain monitor

the organ sensation,

position, function…

•Sensation travels in the afferent fibers in the

peripheral nerve then posterior root then spinal cord.

•Then there are two methods to go to the brain:

Spinothalamic tract for sensation of pain, temp, and

touch; from the posterior root these sensations travel

in the second sensory neuron to the opposite side and

ascend up the spinothalamic tract to the thalamus there

fibers synapse with a third sensory neuron that carry

them to sensory cortex.

Posterior columns: these fibers conduct the sensation

of position, vibration, and localized touch.

•From the posterior root by the same side proceed at

the medulla synapse with the second neuron and then

cross, then thalamus then synapse and proceed to the

sensory cortex.

Sensation of position: proprioception; without looking

you know where your body parts are in space and in

relation to each other.

Sensation of vibration: feeling vibrating objects.

Localized touch: stereognosis; without looking you

can identify familiar objects by touch.

Note that LT cerebral cortex receives sensory info

from and controls motor function to the RT side of the

body and visa verse this is called crossed

representation.

Motor Pathways:

Pyramidal tract

(corticospinal):

•Motor cortex then brain

stem, then (a) cross to the

opposite side pass down in

the lateral column; (b)

anterior column of the

spinal cord.

•For voluntary skilled,

discrete, purposeful

movements such as writing.

Extrapyramidal tracts: include motor fibers that

originate in motor cortex, basal ganglia, brain stem,

and spinal cord; this is lower more primitive motor

system that maintain muscle tone and control body

movements such as walking.

The PNS:

The Cranial Nerves (CN): emerge from cranium;

CN I and II from the brain.

CN III to XII fro diencephalon and the brainstem.

The peripheral nerves:

•31 nerve; 8 cervical, 12 thoracic, 5 lumbar, 5 sacral,

1 coccygeal.

•Each nerve has an anterior root containing motor

fibers, and posterior root containing sensory fiber.

•The anterior and posterior roots merge together to

form spinal nerve.

Reflexes: involuntary mechanism that permit a quick

reaction to painful or damaging situation.

Types of reflexes:

• deep tendon reflex.

•Superficial reflexes: such as corneal reflex and

abdominal reflex.

•Visceral reflexes (organic): pupillary response to light

and accommodation.

•Pathologic (abnormal) reflexes: such as Babinski’s

reflex.

Reflex arc:

Sensory stimulus,

posterior root, spinal cord,

synapse with a motor

neuron in the anterior

horn, anterior root,

muscle.

Dermatomes:

•Band of skin that is innervated by the sensory root

of a single spinal nerve

•Help to localize the lesion to a specific spinal cord

segment.

Subjective Data

Common symptoms

Headache

Dizziness or vertigo

Weakness

Numbness or loss of sensation

Loss of consciousness

Seizure

Tremors

Difficult swallowing

Difficult speaking

Objective Data

1) Mental status and level of Consciousness.

Is the pt oriented to time, place, and person?

2) CN:

*Olfactory (I) (S): test sense of smell.

*Optic (II) (S): test visual acuity and fields (by

confrontation).

*Oculomotor (III), Trochlear (IV), Abducens (VI) (M):

Pupils size, reflex, accommodation, & upper lid

movement (III) & asses extra ocular movement.

*Trigeminal (V) (M/S):

•Assess the muscles, jaw

clenching for temporal and

masseter, lateral jaw movement

for lateral pterygoids.

•Assess all three devision of

the nerve (ophthalmic,

maxillary, and mandibular).

Compare between sharp and

dull or hot and cold sensations

in each side.

•Corneal reflex: make the pt look up and away

from you. Touch the cornea by cotton, the

normal reaction is blinking, the sensory of this

reflex is carried by CN (V), and the motor by

CN (VII).

*Facial (VII) (M/S):

•M / facial expression during movements; smile, close

eyes then open, frown, lift eyebrows, show teeth, puff

cheeks, close mouth.

•S / taste (sugar, salt, sour, bitter) on the anterior two

third of the tongue.

*Acoustic (VIII) (S): hearing acuity; whisper, Weber,

Rinne.

*Glossopharyngeal (IX) & Vagus (X) (M/S):

M / uvula (in midline) & soft

palate rise, positive gag reflex

(CN X),

S / taste on posterior 1/3 of the

tongue (salty, sweet, sour, bitter)

CN (IX).

*Spinal accessory (XI) (M): assess the muscles,

shoulder shrug (trapezius), turn head to each side

against your hand (sternomastoid).

*Hypoglossal (XII) (M):

Ask the pt to protrude the tongue, look for

symmetry/midline, ask pt to talk (CN V, VII, X, XII).

3) The motor system:

Coordination requires muscle strength, cerebellar

system, vestibular system, and sensory system

(position sense).

•Assess rapid alternating movement:

Ask the pt to strike one hand on the thigh,

raise the hand, turn it over, and then strike

the back of the hand down n the same place.

Point-to-point movements:

•Finger to nose; smooth & accurate movement; move

your finger, or fix it and make the pt close her eyes.

•Heel to shin: moves heel in a straight line down the

shin.

•Gait:

Assess pts walking across the room (posture,

balance, swinging of the arms..).

Walk heel-to-toe in a straight line.

Walk on the toes.

Hop in place.

Do a shadow knee bend.

Rise from a sitting position.

•Stance:

Romberg test:

ask the person to stand up with feet

together and arms at sides, close eyes.

Maintain posture & balance with slight

swaying.

Pronator drift:

4) The sensory system:

To evaluate the sensory system, test the

following:

●Pain and temperature (spinothalamic tracts)

●Position and vibration (posterior columns)

●Light touch (both spinothalamic and posterior)

●Discriminative sensations, which depend on

some of the above sensations but also involve the

cortex.

*compare symmetrical areas and proximal and

distal areas.

*vary the pace of your testing.

*Map out the boundaries.

•Pain: you can use broken tongue blade and cotton

swap.

•Show the pt both sensations before closing his eyes.

•Use lightest pressure needed.

•If pain assessment is normal no need for temperature

assessment.

•Light touch: see if the pt feel the touch and can

compare between sides.

•Vibration: if he can feel it and when it stops.

•Proprioception: up and down.

•Discriminative sensation:

•Stereognosis:

•Graphesthesia: number identification.

•Two point discrimination:

•Find minimal distance in

different body parts.

•Point localization.

•Extinction; simultaneously

stimulate corresponding

areas on both sides

of the body and ask where

the pt feel it.

5) Dermatomes:

Assess dermatomes of the pt, some landmarks may

be:

C3: Front of the neck

T4: Nipples

T10: Umbilicus

L1: Inguinal

6) Tendon reflexes:

•Encourage the pt to relax before beginning the

procedure.

•In documentation, follow the following grading

scale:

The knee reflex (Patellar Reflex) (L2, L3, L4):

•The pt may be sitting or lying but knee should be

flexed.

•Tap the patellar tendon below the paterlla.

•Note contraction of the quadriceps with extension

of the knee.

The Plantar response (L5,S1):

•Stroke the foot from the heel moving up toward the

small toe to the ball of the foot, curving medially

across the ball.

•The normal response is a downward contraction of

the toes, called the plantar response.

•The abnormal response is called Babinski response.

Plantar response Babinski response