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Neurological examination in equine practice, physiological findings and pathological disturbances are described. Because of the sizes of the horse the neurological examination is more difficult than in small animals. The examination of cerebrospinal fluid is a worthful completion and is able to refer to the etiology of a certain disease. The technique of the puncture of cerebrospinal fluid is described.
The essentials of the neurological examination are reviewed from the perspective of the emergency medicine practitioner. Important historical information to be obtained, as well as indications and techniques for individual components of the physical examination, are covered. Appropriate and concise methods for documenting the results of the neurological examination in the patient record are also discussed.
The neurologic examination in children requires an ability to communicate with the parents and child, a knowledge of developmental milestones, and an index of suspicion that encompasses multiple physiologic systems. Observation is the single most important skill. When coupled with the background knowledge to put these observations into their appropriate places, the diagnostic considerations can be dramatically reduced. The use of specialized testing may be minimized by a thorough history, physical examination, and review of prior evaluations. Most neurologic conditions have a slow course. If the diagnosis is not readily defined, a series of follow-up visits may give a clearer picture of the underlying process. Children are constantly changing. The examinations we perform must be infinitely flexible to accommodate this fact.
OBJECTIVE: To determine whether neurologic examination findings, results of CSF analysis, or age at the onset of seizures could be used to predict whether results of magnetic resonance imaging (MRI) would be normal or abnormal in dogs with seizures. DESIGN: Retrospective study. ANIMALS: 115 dogs. PROCEDURE: Information on results of neurologic examination, results of CSF analysis, age at the onset of seizures, and results of MRI was obtained from the medical records. RESULTS: Results of MRI were abnormal in 61 dogs and normal in 54. Sensitivity and specificity of neurologic examination alone were 77 (47/61) and 91% (49/54), respectively. Sensitivity and specificity of CSF analysis alone were 79 (48/61) and 69% (37/54), respectively. Results of MRI were abnormal for 12 of 28 (43%) dogs with abnormal CSF analysis results and normal neurologic examination results but for only 2 of 35 (6%) dogs with normal CSF analysis and normal neurologic examination results. Similarly, results of MRI were abnormal for 36 of 37 (97%) dogs with abnormal CSF analysis and abnormal neurologic examination results but for only 11 of 15 (73%) dogs with normal CSF analysis results and abnormal neurologic examination results. Age at the onset of seizures (< 6 vs > or = 6 years old) was not significantly associated with results of MRI. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that neurologic examination findings and results of CSF analysis are useful in predicting whether results of MRI will be abnormal in dogs examined because of seizures, but age at the onset of seizures is not.
The neurological examination is a challenge for both the physician as well as the patient. Its goal is the formation of a syndrome--but not the diagnosis--with the tools of the case history and the neurological examination, which are presented coarsely, weighted, ostentatious, and provocative at times.
OBJECTIVE: To determine whether neurologic examination techniques established for use on dogs and cats could be adapted for use on sea turtles. DESIGN: Prospective controlled observational study. ANIMALS: 4 healthy Green Turtles (Chelonia mydas), 1 healthy Kemp's ridley sea turtle (Lepidochelys kempi), and 6 Green Turtles suspected to have neurologic abnormalities. PROCEDURE: Neurologic examinations were performed while sea turtles were in and out of the water and in ventral and dorsal recumbency. Mentation, general activity, head and body posture, movement and coordination, thoracic and pelvic limb movement, strength and muscle tone, and tail movement were observed. Thoracic and pelvic limb flexor reflexes and nociception, righting response, cranial nerve reflexes, clasp and cloacal reflexes, and neck, dorsal scute, cloacal and tail nociception were tested. RESULTS: Results of neurologic evaluations were consistent for healthy sea turtles. Sea turtles suspected to have neurologic abnormalities had abnormal results. CLINICAL IMPLICATIONS: Many of the neurologic examination techniques used to evaluate dogs and cats can be adapted and used to evaluate sea turtles. A standardized neurologic examination should result in an accurate assessment of neurologic function in impaired sea turtles and should help in evaluating effects of rehabilitation efforts and suitability for return to their natural environment.
Medicare recently announced the adoption of minimum documentation criteria for the neurologic examination. These criteria are added to existing standards for the history and medical decision-making. These criteria will be used in compliance audits by Medicare and other payors. Given the current federal initiative to eliminate fraud in the Medicare program, all neurologists need to comply with these standards. These criteria are for documentation only. Neurologic standards of care require a more complex and diverse examination pertinent to the problem(s) under consideration. Further guidance as to the content of a neurologic evaluation is outlined in the article "Practice guidelines: Neurologic evaluation" (Neurology 1990; 40: 871). The level of history and examination required for specific services is defined in the American Medical Association current procedural terminology book. Documentation standards for examination of children are not yet defined.
We performed a routine neurologic examination on 200 patients who were reexamined by a second physician under three different conditions: (1) reexamination of only one item, (2) complete reexamination without knowledge of the patient's history and complaints, and (3) complete reexamination with such knowledge. We used changes in reliability as an index of the effect of additional information on basic data collection. Additional information increased reliability, indicating that diagnostic hypotheses obtained mainly from the history improve the examiner's precision. When a complete reexamination was performed with knowledge of the patient's history, reliability was substantial (kappa > 0.6). More experienced examiners do not perform the examination more reliably, but do utilize the patient's history differently.
This study examined the role of cranial sonography and neurological examination in the prediction of developmental progress during the first 19 months of life in extremely preterm infants. Forty-seven infants with mean birth weight 993 +/- 197 g and gestational age 27.9 +/- 1.9 weeks were studied. Each infant was classified as normal, suspect, or abnormal using cranial sonography and a structured neurological examination. Developmental outcome was assessed using the Infant Neurological International Battery (INFANIB) at 4, 8, and 14 months and the Rockford Infant Developmental Evaluation Skills (RIDES) at 19 months. Sonographic classification was the best predictor of outcome through 14 months, F(2.72) = 12.4, p < .001. The neurological examination predicted performance only at 4 months. No infant classified as normal on both examinations was abnormal on follow-up. Infants with suspect or abnormal neurological examinations had normal outcomes if their sonographic findings were normal.
We determined the accuracy of neurologic examination and the history of a previous neurologic event in detecting clinical evidence of a magnetic resonance imaging (MRI)-diagnosed cerebral infarction in 30 children with sickle cell hemoglobinopathy. Each patient had an MRI of the brain, neurologic examination, chart review, and psychometric evaluation. Seventeen children (57%) had MRI evidence of cerebral infarction based on demonstration of parenchymal abnormalities in a vascular distribution. Among the 17 children with MRI evidence of cerebral infarction, only 12 (71%) had an abnormal neurologic examination, and 11 (65%) had a history of a prior neurologic event. In contrast, among the 13 children with normal MRIs, 12 (92%) had normal neurologic examinations, and no child had a previous history of a neurologic event. Multiple, bilateral, heterogeneous cerebral infarctions frequently occur without overt neurologic signs or symptoms in children with sickle cell hemoglobinopathy. Previous studies that relied on a focal neurologic examination or a history of a neurologic event to identify cerebral infarctions in patients with sickle cell hemoglobinopathy most likely underrepresented the true frequency of cerebral infarctions in this population. Future prospective studies of cerebral infarctions in children with sickle cell hemoglobinopathy should include MRIs for identification and classification, rather than neurologic examination or clinical history alone.
PURPOSE: To evaluate flow velocity measurements in the middle cerebral artery (MCA) and/or neurologic examination for detection of cerebral infarction in sickle cell disease (SCD). MATERIALS AND METHODS: Twenty-four pediatric patients aged 6 1/2-17 years with SCD underwent magnetic resonance (MR) imaging, MR angiography, neurologic examination, and transcranial Doppler ultrasonography (US). Transcranial Doppler studies were evaluated for maximum flow velocity in the right and left MCAs. Combinations of cut-off values were used to determine the sensitivity and specificity of transcranial Doppler US for detection of infarction. RESULTS: Neurologic examination had 58% sensitivity and 92% specificity for cerebral infarction. Maximal flow velocity > 200 cm/sec or < 100 cm/sec (including no flow) helped identify nine of 12 patients with infarcts proved at MR imaging, with only one false-positive result (sensitivity, 75%; specificity 92%). The combination of neurologic examination and transcranial Doppler US produced 92% sensitivity and 83% specificity for cerebral infarction. CONCLUSION: The combination of transcranial Doppler US and neurologic examination has potential as a screening technique for infarction in SCD.
A battery of quantitative neurological tests was used in a multicenter clinical trial to compare ACTH with placebo for the treatment of patients with multiple sclerosis in acute exacerbation. Since the battery of tests was administered in ten centers by physical therapists, it was critical that the examiners were well trained and remained so. Results of experiments showed that physical therapists could be successfully trained to administer the tests in a uniform fashion and remained trained for three years, the duration of the clinical trial. The fact that physical therapists are not taught tell-tale side effects of a treatment, and hence do not perceive these as do the physician examiners, introduces another level of objectivity into neurological clinical trials.
To compare the reliability of neurological examination performed by telemedicine and face to face, a junior doctor examined 23 patients face to face, these examinations being witnessed either by one or by two telemedicine observers using a telemedicine video-link at 384 kbit/s. The gold standard was a face-to-face examination from a panel of six consultant neurologists. Power, deep tendon reflexes, plantar responses, coordination, sensation, eye movements, facial strength, tongue movements, sitting balance and gait were studied. Seventeen patients satisfied the inclusion criteria, and a total of 1,084 matched pairs of observations were made. The reliability of the telemedicine examination ranged from fair to moderate for deep tendon reflexes, coordination and eye movement, to near perfect for plantar responses. Overall, examination by telemedicine compared favourably with face-to-face examination. Telemedicine examination was more sensitive in detecting abnormalities than face-to-face examination for all the neurological tests studied and more specific for all but one (plantar responses). The study showed that neurological examination using telemedicine is at least as good as face-to-face examination performed by a junior doctor.
OBJECTIVES: The objectives of this study were to determine, first, whether an early neurologic examination could predict a persistent abnormal neonatal neurologic state comparable to the amplitude-integrated electroencephalography (a-EEG) and, second, whether a combination of the 2 methods would further enhance early identification of high-risk infants. METHODS: Fifty term infants were enrolled prospectively when they had evidence of intrapartum distress, Apgar score <or=5 at 5 minutes, or cord arterial pH <or=7.00 and were admitted to intensive care. Each enrolled infant underwent an early neurologic examination using a modified Sarnat staging system (stages 2 and 3 were regarded as abnormal) and a blinded simultaneous a-EEG measurement. Predictive values were calculated for a short-term abnormal outcome defined as persistent moderate to severe encephalopathy beyond 5 days. RESULTS: An abnormal short-term outcome was present in 14 (28%) of 50 infants. The neurologic examination was performed at 5 +/- 3 hours after delivery. A short-term abnormal outcome occurred in 9 (53%) of 17 infants with initial stage 2 and in both infants with initial stage 3 encephalopathy. In addition, 13 infants manifested features of both stage 1s and 2 and post hoc were classified (S1-2). Three of the latter infants (23%) developed an abnormal short-term outcome. The a-EEG was abnormal in 15 (30%) infants, 11 (73%) of whom developed an abnormal outcome. An abnormal a-EEG was more specific (89% vs 78%), had a greater positive predictive value (73% vs 58%), and had similar sensitivity (79% vs 78%) and negative predictive value (90% vs 91%) when compared with an abnormal early neurologic examination. A combination of abnormalities had the highest specificity (94%) and positive predictive value (85%). CONCLUSION: The combination of the a-EEG and the neurologic examination shortly after birth enhances the ability to identify high-risk infants and limits the number of infants who would be falsely identified compared with either evaluation alone.
AIM: To underscore the importance of the pediatric neurological examination for the diagnosis, treatment and prognosis of nervous system disorders in children. For that, we reviewed the research carried out by our group in the past 40 years. DEVELOPMENT: Knowing the semiology of neurological development is essential for the neurological, psychological and motor follow-up of children. On their own, neuroimaging techniques are not sufficient to predict the long-term neurological and psychomotor consequences of perinatal events. On the other hand, the neurological examination is a sensitive method with good prognostic value, which facilitates a timely and appropriate treatment intervention. This observation has been confirmed by our research focused on the neurological examination, including the study of the developmental neurological examination in preschoolers, assessment of the psychological and neurological maturity in school age children, development of preterm-born school age children, limb-trunk coordination in premature newborns and their development, relationship between higher brain function, learning to read and write and improving the diagnosis of attention deficit/hyperactivity disorder in school children, neurological disorders in newborns, birth trauma, jaw opening reflex to appendicular compression, parachute and lateral propping reactions in newborns, neurological and psychomotor development at 6 months of corrected age in premature babies with neonatal crises and/or intracranial hemorrhage, and neurological examination in healthy newborns. CONCLUSIONS: The neuropediatrician must be aware of the importance of a comprehensive neurological history and consistent semiology to be able to request and correctly evaluate the results of ancillary tests, and thus make adequate treatment decisions.
In lieu of traditional training of examiners to identify cerebral palsy on a neurologic examination at age 1 year, we proposed an alternative approach using a multimedia training video and CD-ROM we developed after a two-step validation process. We hypothesized that use of CD-ROM interactive training will lead to reliable and valid performance of the neurologic examination by both pediatric neurologists and nonpediatric neurologists. All examiners were asked to take one of six interobserver variability tests found on the CD-ROM on two occasions. In the first interobserver variability evaluation, 89% (531 of 594) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the two items that had a 60% correct rate, the correct response rate rose to 93% (114 of 123). In the second interobserver variability evaluation, 88% (493 of 560) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the four items that had a 70% correct rate, the correct response rate rose to 96% (104 of 108). Interactive CD-ROM examination training is an efficient and cost-effective means of training both neurologists and non-neurologists to perform structured neurologic examinations in 1-year-old children. It provides an effective means to evaluate interobserver variability, offers a route for feedback, and creates an opportunity to reevaluate variability, both immediately and at periodic intervals.
OBJECTIVE: The Prechtl method of qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurologic outcome in fetuses, preterm infants, and term infants. The aim of this study was to compare the results of this new technique with those of traditional neurologic examination and of cranial ultrasonography in preterm infants. METHODS: Serial videotape recordings (with off-line assessment of GMs), ultrasound examination of the brain, and neurologic examinations were performed from birth until about 6 months of corrected age, on a group of 66 preterm infants whose gestational age ranged from 26 to 36 weeks (mean 30.7 weeks). The agreement between the two techniques and their predictive power, with respect to the neurologic outcome at 2 years of corrected age, were evaluated for five different age groups from preterm age to 65 weeks of postmenstrual age. RESULTS: Overall agreement of the neurologic and GM findings was 80.3% and strongly age related (lower during the preterm and term periods and higher thereafter). At all ages the results of GM observation correlated highly with neurologic outcome; they showed higher sensitivity and specificity than the neurologic examination. This held true in particular before term age, when poor neurologic responses might be related to transient complications, and at term age, mainly because of infants with normal neurologic examination results but unfavorable outcome. During the preterm period the ultrasound results showed a better specificity and a lower sensitivity to outcome than GM findings. CONCLUSIONS: The results of this study indicate that quality assessment of GMs should be added to traditional neurologic assessment, neuroimaging, and other tests of preterm infants for diagnostic and prognostic purposes.
Neurological examination and magnetic resonance imaging were performed in the neonatal period in 58 full-term infants who presented with hypoxic-ischaemic encephalopathy. The aim of this study was to evaluate the patterns of neurological abnormalities and their correlation to brain lesions on MRI. The prognostic value of the neurological examination performed at different times in the neonatal period was also evaluated. Our results showed that specific clinical patterns can be observed in infants with HIE and these can be related to the pattern of lesion on brain MRI. In particular, while infants with normal MRI or minimal changes tend to show only minor tone abnormalities after the first week of life, infants with more severe lesions such as basal ganglia lesions show persistent and diffuse neurological abnormalities. Infants with white matter changes but intact basal ganglia show a different clinical pattern with improved sucking reflex and behaviour and less severe tone abnormalities. Our results also suggested that the neurological examination performed after the second week of life is a reliable indicator of outcome in these infants.