Hi, I'm Dr. Nick De Pompa one of the board-certified
veterinary neurologists here at Southeast Veterinary Neurology of Miami.
I'm here with Lola Beth Anne and Jackie and
we're gonna show you all of the steps to a comprehensive neurologic exam.
Prior to the neurologic examination a thorough history and general physical
examination should be performed. The purpose of the neurologic examination is to determine
where in the nervous system the problem is located and to determine the severity of
the symptoms. The examination is unlikely to definitively prove the cause of the symptoms.
The neurologic examination can be broken up into 6 simple steps. Evaluation of mentation,
gait & posture, the cranial nerves, the postural reactions,
the spinal cord reflexes, and finally evaluation of nociception (if appropriate).
Each portion of the exam should be performed, in order to properly localize the problem.
While gathering the history it is important to watch the patient
as they engage with their environment. This will provide a sense of their mentation,
as well as provide insight into the patient's gait and posture.
Here we are looking for any weakness, ataxia/incoordination, or lameness.
Additionally, we should evaluate the pattern of the gait – ensuring that the patient is
not walking in circles or getting caught in corners, etc.
Here as we watch Lola walk, we can see that she walks in a straight line, her foot placement is
appropriate, she is not scuffing or crossing her limbs. Additionally, she does not appear
off-balance or lame. Her head carriage is high. Her neck, back, and tail posture are normal.
The next step is to evaluate the cranial nerves. Initially, start by looking for facial symmetry
both visually and via palpation. Here you can see that her eyes,
eye lids, nostrils, commissures of the lips and muscles of mastication are all symmetric.
There is no inappropriate tilting or turning of her head. Then, go through the cranial nerves
in a systematic fashion. The palpebral reflex is generated by gently tapping around the eye
resulting in closure of the eyelids. The menace response is generated by creating
a ‘menacing’ gesture towards the face, also resulting in closure of the eyelids.
The eyes are evaluated to ensure that there are no abnormal eye movements (such as a nystagmus),
or abnormal eye placement (such as a strabismus) and that a normal physiologic nystagmus is
present when the head is rotated into different positions. The pupils are evaluated for symmetry
and then the direct and indirect pupillary light reflex is evaluated using a bright light source.
Proprioception is evaluated though a series of tests to
evaluate the patient’s awareness of where the limbs are in space.
This can be evaluated through proprioceptive positioning and hopping as seen here.
The spinal cord reflexes are best evaluated with the patient resting
in lateral recumbency. The withdrawal and patella reflexes are the most fundamental
and should be evaluated in all patients.
The cutaneous trunci reflex is most helpful in patients with thoracolumbar spinal cord problems.
Next, the patient should be evaluated for spinal muscle symmetry
and for spinal pain. It is best to start away from the suspected source of pain
and gradually make your way toward the area of interest. The entire spine should be palpated
as well as performing a gentle range of motion of the cervical spine and tail.
The final step is to evaluate for nociception or “feeling” or sometimes called "deep pain”. If the patient has
voluntary motor function then this does not need to be performed. If any limb lacks voluntary motor
function, then this evaluation of nociception must be performed. This test is looking for a
voluntary or conscious response from the patient indicating that they felt the noxious stimuli
that has been applied to the affected limb.
The withdrawal reflex where the limb is pulled up toward the body
does not indicate that deep pain is present as
that is a local reflex.
The patient must look back or vocalize or
otherwise indicate that they consciously felt the stimulus.
I hope you found this video to be useful.
Consider to download our free neuro exam form which will allow you to
be systematic during your examination.
In general, performing the examination in a systematic fashion doing it the same
way every time, will yield the most information.