Clinical skills

1. Special techniques:
 meningeal signs;
 lumbosacral radiculopathy
(straight leg raise),
 asterixis (floating tremor).
 Cutaneous or superficial
stimulation reflexes.

2. Meningeal signs
testing for these signs is important if you
suspect meningeal inflammation from
infection or subarachnoid haemorrhage.
1. Neck stiffness
2. Brudzinski’s Sign
3. Kerning’s Sign

3. PATHOGENESIS OF MENINGEAL SIGNS
 The basis for all meningeal signs is the patient’s natural rejection of any movement that stretches
the spinal nerves, all of which pass through the irritated subarachnoid space.
 Experiments with cadavers show that flexion of the neck pulls the spinal cord toward the head,
thus stretching the spinal nerves,
 Whereas flexion of the hips with the knees extended pulls on the sciatic nerve, thus displacing the
conus of the spinal cord downward toward the sacrum.
 Flexion of the hips with the knees flexed, in contrast, does not stretch the sciatic nerve.
 The mechanism of this sign is similar to the positive straight leg raise test.
 Irritation or compression of a lumbar or sacral nerve root or the sciatic nerve causes radicular or
sciatic pain radiating into the leg when the nerve is stretched by extending the leg.

4. PATHOGENESIS OF MENINGEAL SIGNS
 Inflammation in the subarachnoid space causes resistance to movement
 that stretches the spinal nerves (neck flexion),
 the femoral nerve (Brudzinski sign),
 and the sciatic nerve (Kernig sign).

5. NECK STIFFNESS
 Neck stiffness denotes involuntary resistance
to neck flexion, which the clinician perceives
when trying to bend the patient’s neck,
bringing the chin down to the chest.
 Occasionally, the aggravated extensor tone of
the neck and spine is so severe that the
patient’s entire spine is hyperextended,
leaving the torso of the supine patient
supported only by the occiput and the heels,
 an extreme posture called opisthotonos.

6. Opistotonus

7. Neck stiffness
 Neck stiffness with resistance to flexion
 is found in ∼84% of patients with acute
bacterial meningitis
 and 21% to 86% of patients with
subarachnoid haemorrhage.
 It is most reliably present in severe meningeal
inflammation, but its overall diagnostic
accuracy is low.
 When the neck is flexed, the
inflamed nerve roots and meninges of
the cervical region get stretched.
 This causes protective muscle spasm
manifesting as neck stiffness.
 .

8. The Kernig sign
 The Kernig sign was first described by Vladimir Kernig in 1882.
 with the patient’s hip and knee flexed, the Kernig sign is positive
when the patient resists extension of the knee.
 Kernig called this a “contracture” of the hamstrings because the
knee would not extend beyond 135 degrees (with the hip flexed),
even though the knee extended fully if the hip was first positioned
in the fully extended position .
 Kernig's sign represents similar phenomena involving the
distal spinal cord and related nerves
 Most clinicians perform this test in the supine patient, although
Kernig described the test being performed in the seated patient
 Kernig sign may appear in patients with sciatica and those with
subarachnoid or epidural haemorrhage or tumor of the cauda
equina.
 When present, should be symmetrical:
 Pain and increased resistance to knee extension are a positive
Kernig sign.

9. BRUDZINSKI SIGN
 Józef Brudzinski described several
meningeal signs between 1909 and
1916.
 In his most popular sign, flexion of the
supine patient’s neck causes the patient
to flex both the hips and the knees, thus
retracting the legs toward the chest
 Flexion of both the hips and knees is a
positive Brudzinski sign

10. Asterixis
Asterixis helps identify a metabolic
encephalopathy in patients whose mental
functions are impaired.
Ask the patient to “stop traffic” by ex- tending
both arms, with hands cocked up and fingers
spread. Watch for 1 to 2 minutes, coaxing the
patient as necessary to maintain this position.
https://www.youtube.com/watch?v=sEnp2ss8VoA
The exact cause of asterixis is not completely understood; however, it
may be caused by impaired function of the diencephalic motor centres,
which are brain centres that provide a feedback mechanism to
cortical motor areas for initiation and control of voluntary movements.

11. Asterixis

12. Radicular Low Back Pain
A radicular (nerve root) pain, usually superimposed on low
back pain. The sciatic pain is shooting and radiates down
one or both legs, usually to below the knee(s) in a
dermatomal distribution, often with associated numbness
and tingling and possibly local weakness. The pain is
usually worsened by spinal movement such as bending and
by sneezing, coughing, or straining.

13. Lasegue test
 If the patient has noted low back pain that
radiates down the leg, check straight leg
raising on each side in turn. The patient should
be lying supine. Raise the patient’s
 relaxed and straightened leg until pain occurs.
Then dorsiflex the foot.
 Record the degree of elevation at which pain
occurs, the quality and distribution of the pain,
and the effects of dorsiflexion. Tightness and
mild dis- comfort in the hamstrings with these
maneuvers are common and do not indicate
radicular pain.

14. SUPERFICIAL REFLEXES
1. CORNEAL AND CONJUNCTIVAL REFLEX
2. PHARYNGEAL REFLEX
3. PALATAL REFLEX
4. ABDOMINAL Reflex

15. The superficial reflex-abdominal reflexes
Use an orange stick, lightly scratch the abdominal wall.
Watch the abdominal wall; this should contract on the same side.
• Afferents: segmental sensory
• Efferent: segmental motor nerves
• Roots: above the umbilicus, T8–T9; below the umbilicus, T10–T11.
Abdominal reflex is absent:
1. obesity,
2. previous abdominal operations
3. or frequent pregnancy, age,
4. a pyramidal tract involvement above that level
5. or a peripheral nerve abnormality.

16. SUPERFICIAL REFLEXES
 PLANTAR REFLEX:
 Scratch over the outer edge of sole cause
plantar flexion and adduction of all toes and
dorsiflexion and inversion of foot.( L5,S1)
 Anal REFLEX( S4-S5)

17. Deep reflexes

18. Which reflexes do we test?
 Use the whole length of the patella
hammer; let the hammer swing.
 Ensure the patient is relaxed.
 Avoid tension
 Reflexes can be graded:
 0 = absent,
 ± = present only with
reinforcement
 1+ = present but depressed ,
 2+ = normal ,
 3+ = increased,
 4+ = clonus.

19. How to remember the root numbers?
 The root values for the reflexes
can be recalled by counting from
the ankle upwards.
 Reflex man illustration makes it
easy to remember

20. Testing and root innervation of major
muscles
 Upper extremity Muscle Testing Major nerve .root level
 Deltoid Abduction of upper arm C5
 Biceps Supinated arm flexion C6
 Triceps Extending forearm C7
 Extensor carpi muscles Extend wrist C6, C7
 Hand intrinsic muscles Hand grasp C 8, T1
 Lower extremity
 iliopsoas Hip flexion L2
 Quadriceps femoris Leg extension L3, L4
 Hamstring muscles Leg flexion S1
 Gastrocnemius Foot extension S1
 Tibialis anterior and Foot and toe L5, S1
 toe extensors dorsiflexion

21. Deep reflexes
 JAW JERK: 5TH CRANIAL NV NUCLEI
 BICEPS JERK: C5,6

22. Biceps reflex
 Place the patient's hands on his abdomen.
 Place your index finger on the biceps tendon;
 swing the hammer on to your finger while
watching the biceps muscle.
 Nerve: musculocutaneous nerve
 Root: C5, (C6).

24. Deep reflexes
 TRICEPS JERK: C6,7
 SUPINATOR JERK: C5,6

26. Triceps reflex
 Draw the arm across the chest,
holding the wrist with the elbow at
90 degrees.
 Strike the triceps tendon directly with
the patella hammer; watch the
muscle.
 Nerve: radial nerve
 Root: C7

27. Deep reflexes
 KNEE JERK: L2,3,4( knee extension)
 ANKLE JERK: S1,2(the foot is dorsiflexed)

28. Knee reflex
 Place the arm under the knee
so that the knee is at 90
degrees.
 Strike the knee below the
patella; watch the quadriceps
muscle response
 Nerve : femoral nerve
 Root : L3–L4.

29. Ankle reflex
 Hold the patient's foot at 90 degrees with a
medial malleolus facing the ceiling.
 The knee should be flexed and lying to the
side.
 Strike the Achilles tendon directly.
 Watch the muscles of the calf
 Nerve : tibial nerve
 Root : S1–S2.

31.  https://www.youtube.com/watch?v=ke5EsXMXPHo
 https://www.youtube.com/watch?v=euNPB3OjrdM
 https://www.youtube.com/watch?v=LdAD9GNv8FI
https://www.youtube.com/watch?v=v4FyZydgHs0