Pediatric Neurological Examination

Pertinent general examination

· Head and neck

o Head circumference – microcephaly vs. macrocephaly

o Fontanelles – open vs. closed, size, fullness

o Dysmorphisms, symmetry of head/face

o Skin lesions – congenital or rashes

o Cranial and neck bruits – carotid, vertebral, temporal, orbital

· Cardiovascular

o Heart sounds, murmurs

· Abdominal

o Hepatosplenomegaly

· Musculoskeletal

o Joint swelling

o Muscle bulk

o Spine – scoliosis, neural tube defects

· Integument

o Hair, skin

Mental status

· Consciousness

· Appearance

· Behaviour, including abnormal movements

· Language

o Expressive – aphasia vs. dysphasia

o Receptive

· Orientation

o Time, place, person

· Memory

o Bibliographical memory

o Short-term, long-term memory

Cranial nerves

· I – Olfactory nerve

· II – Optic nerve

o Pupils, acuity, colour (red), visual fields, fundoscopy

· III – Oculomotor nerve

o Medial rectus, superior rectus, inferior rectus – “down and out”

o Levator palpebrae superioris muscle

o Pupil constriction in accomodation

· IV – Trochlear nerve

o Superior oblique – “up and out”

· V – Trigeminal nerve (V1-3)

o Facial sensation – corneal reflex

o Motor: masseter, temporalis, medial pterygoid, lateral pterygoid, tensor veli palatini, mylohyoid, anterior belly digastric, tensor tympani

· VI – Abducens nerve

o Lateral rectus

· VII – Facial nerve

o Muscles of facial expression

· VIII – Vestibulocochlear nerve

· IX – Glossopharyngeal nerve

o Afferent portion of gag reflex

o Sensory posterior 1/3 of tongue, tonsils, pharynx, middle ear, carotid body

o Parasympathetic fibres to the parotid gland

o Motor fibres to stylopharyngeus muscle and the upper pharyngeal muscles.

· X – Vagus nerve

o Muscles of pharynx/larynx

o Parasympathetic innervation of all the organs except the suprarenal glands, from the neck down to the second segment of the transverse colon

· XI – Accessory nerve

o Spinal accessory – sternocleidoid muscle, trapezius muscle

o Cranial accessory – joins with vagus

· XII – Hypoglossal nerve

o Muscles of the tongue

Motor exam

· Bulk

o Compare left vs. right, distal vs. proximal, upper vs. lower limbs

· Tone

o Hypertonia, hypotonia, spasticity, dystonia

o Truncal and limb tone

· Strength

o Pronator drift – subtle arm weakness, proprioception

o Power gradations:

· 0/5 no muscle activation

· 1/5 ineffective muscle activation

· 2/5 gravity removed

· 3/5 against gravity (3+ slight resistance)

· 4/5 some resistance (4- and 4+ gradations)

· 5/5 full power

o Common muscles tested:

· Deltoid C5 Axillary n.

· Biceps C6 Musculocutaneous n.

· Brachioradialis C6 Radial n.

· Triceps C7 Radial n.

· Ext Carpi Ulnaris C7 Radial n.

· Ext Digitorum C7 Radial n.

· First Dorsal Interossious T1 Ulnar n.

· Abductor Pollicis Brevis T1 Median n.

· Psoas L1,2 Lumbosacral Plexus

· Tibialis Anterior L4,5 Deep Peroneal n.

· Ext Hallucis Longus L5 Deep Peroneal n.

· Ext Digitorum Brevis L5 Deep Peroneal n.

· Gastrocnemius S1 Tibial n.

· Hamstrings S1 Sciatic n.

· Reflexes

o Reflex gradations:

· 0 absent reflexes

· 1+ diminished reflexes, reinforcement

· 2+ normal reflexes

· 3+ increased reflexes

· 4+ increased reflexes with clonus

o Common reflexes tested:

· Brachioradialis C6

· Biceps C6

· Triceps C7

· Patellar L4

· Gastroc-soleus S1

o Plantar responses:

Babinski Chaddock Oppenheim

o Other reflexes:

Hoffman

o Abdominal reflexes

Sensory exam

· Spinothalamic - light touch and pin-prick

· Dorsal columns - vibration and proprioception

· Landmarks:

o C5 Deltoid area

o C6 Thumb

o C7 Index finger

o C8 Small finger

o T4-5 Nipple Line

o T10 Umbilicus

o L5 Great Toe

o S1 Lateral Foot

Coordination

· Dysmetria – finger-to-nose, heel-to-shin

· Dysdiadochokinesia – rapid alternating movements

· Influenced by strength

Gait

· Regular gait, running

· Toe walking – plantar flexion strength

· Heel walking – dorsiflexion strength

· Tandem gait – difficulty if wide-based gait