Sensory system examination

Sensory system examination
Dr.A.P.P.Pavani
PG in medicine

OVERVIEW
 Introduction
 Anatomy of sensation
 Examination
 Sensory localisation---patterns of sensory loss

INTRODUCTION
 Sensory examination is the most difficult and tedious part of neurologic
examination.
 Requires great concentration and cooperation from the patient and from the
examiner.
 Inconsistency in patient’s replies may be due to fatigue, poor co-operation,
dementia or undue suggestibility.
 Examination needs to be goal directed; otherwise tends to be fruitless or
misleading.
 Sensory loss is of far greater importance in some conditions than in others
as in suspected syringomyelia , or in searching for the level of a lesion
causing a paraplegia, or in delineating a peripheral nerve lesion.

COMBINED OR CORTICAL SENSATIONSPRIMARY SENSATIONS
MODALITIES OF SENSATIONS TO BE
TESTED
EXTROCEPTIVE PROPRIOCEPTIVE

PRIMARY SENSATIONS
1.Extroceptive sensations:
Derived from sources outside the body
 Light touch
 Pain
 Temperature
2.Proprioceptive sensations:
Derived from body itself
 Sense of position and passive movement
 Vibration
 Deep pressure pain

COMBINED AND CORTICAL SENSATIONS
Require synthesis and interpretation of primary modalities by the
sensory association area in the parietal lobe.
 Stereognosis
 Two point discrimination
 Graphaesthesia
 Barognosis
 Localisation of touch(topognosis)

ANATOMY OF SENSATION
POST CENTRAL CORTEX
THALAMUS
FIBRE TRACTS
DORSAL HORN OF SPINAL CORD
SENSORY AFFERENTS
SENSORY RECEPTORS

Sensory receptors are of two general types:
EXTEROCEPTORS
 Those in the skin, mediating superficial sensation.
 Skin receptors are particularly numerous and transduce four types of
sensory experience: warmth, cold, touch, and pain.
PROPRIOCEPTORS
 Those in the deeper somatic structures.
 Proprioceptors inform us of the position of our body or parts of our
body; of the force, direction, and range of movement of the joints
(kinesthetic sense); and a sense of pressure, both painful and painless.

LOCATION AND MORPHOLOGY OF MECHANORECEPTORS IN HAIRY
AND HAIRLESS SKIN OF THE HUMAN HAND

SPINOTHALAMIC PATHWAY OR ANTEROLATERAL SYSTEM
• The polysynaptic projections of the smaller fibers (unmyelinated and
small myelinated), which subserve mainly nociception, itch, temperature
sensibility, and touch, cross and ascend in the opposite anterior
and lateral columns of the spinal cord, through the brainstem, to the
ventral posterolateral (VPL) nucleus of the thalamus and ultimately
project to the postcentral gyrus of the parietal cortex.

POSTERIOR COLUMN–MEDIAL LEMNISCAL PATHWAY
 The larger fibers,which subserve tactile and position sense and
kinesthesia, project rostrally in the posterior and posterolateral columns
on the same side of the spinal cord and make their first synapse in the
gracile or cuneate nucleus of the lower medulla.
 Axons of second-order neurons decussate and ascend in the medial
lemniscus located medially in the medulla and in the tegmentum of the pons
and midbrain and synapse in the VPL nucleus of thalamus.
 Third-order neurons project to parietal cortex as well as to other cortical
areas.

 Although the fiber types and functions that make up the spinothalamic
and lemniscal systems are relatively well known, many other fibers,
particularly those associated with touch, pressure, and position sense,
ascend in a diffusely distributed pattern both ipsilaterally and
contralaterally in the anterolateral quadrants of the spinal cord.
 This explains why a complete lesion of the posterior columns of the spinal
cord may be associated with little sensory deficit on examination.

TRANSVERSE SECTION THROUGH THE SPINAL CORD, COMPOSITE
REPRESENTATION, ILLUSTRATING THE PRINCIPAL ASCENDING (LEFT) AND
DESCENDING (RIGHT) PATHWAYS..

THE "SENSORY HOMUNCULUS," OR CORTICAL REPRESENTATION OF
SENSATION IN THE POSTCENTRAL GYRUS

SYMPTOMS
• Before proceeding to sensory testing, the physician should question
patients about their symptoms.
• Abnormal sensory symptoms can be divided into two categories:
 Positive symptoms.
 Negative symptoms.

SYMPTOMS
• The prototypical positive symptom is tingling (pins and needles);
other positive sensory phenomena include itch and altered sensations
that are described as pricking, bandlike, lightning like shooting feelings
(lancinations), aching, knifelike, twisting, drawing,pulling, tightening,
burning, searing, electrical, or raw feelings.
• Such symptoms are often painful.
• Because positive phenomena represent excessive activity in sensory
pathways, they are not necessarily associated with a sensory deficit (loss)
on examination.

SYMPTOMS
• Negative phenomena represent loss of sensory function and are
characterized by diminished or absent feeling that often is experienced
as numbness and by abnormal findings on sensory examination.
• Whereas sensory symptoms may be either positive or negative, sensory on
examination are always a measure of negative phenomena.

TERMINOLOGY
• Paresthesias and dysesthesias are general terms used to denote positive
sensory symptoms.
• The term paresthesias typically refers to tingling or pins-and-needles
sensations but may include a wide variety of other abnormal sensations,
except pain; it sometimes implies that the abnormal sensations are perceived
spontaneously.
• The more general term dysesthesias denotes all types of abnormal
sensations, including painful ones, regardless of whether a stimulus is
evident.

Another set of terms refers to sensory abnormalities found on examination.
• Hypesthesia or hypoesthesia refers to a reduction of cutaneous
sensation to a specific type of testing such as pressure, light touch,
and warm or cold stimuli;
• Anesthesia refers to a complete absence of skin sensation to the same
stimuli plus pinprick.
• Hypalgesia or analgesia to reduced or absent pain perception (nociception).
• Hyperesthesia means pain or increased sensitivity in response to touch.
• Allodynia describes the situation in which a non painful stimulus, once
perceived, is experienced as painful, even excruciating.
• Hyperalgesia denotes severe pain in response to a mildly noxious stimulus.
• Hyperpathia, a broad term, encompasses all the phenomena described by
hyperesthesia, allodynia, and hyperalgesia.

• Disorders of deep sensation arising from muscle spindles, tendons,
and joints affect proprioception (position sense).
• Manifestations include imbalance (particularly with eyes closed or in the
dark), clumsiness of precision movements, and unsteadiness of gait, which
are referred to collectively as sensory ataxia.
• Other findings on examination, include reduced or absent joint position and
vibratory sensibility and absent deep tendon reflexes in the affected limbs.

• Origin of aberrant sensations
SYMPTOM STRUCTURES AFFECTED
Paresthesia , tingling ,buzzing Large fibres(in nerve or posterior
columns)
Burning, heat , cold Small fibres
Prickling pain Combined small and large fibre
Band tightness Lemniscal system of the cord
Lancinating pain Small fibre neuropathy and
radiculopathy
Hyperalgesia Partial peripheral nerve damage

EXAMINATION
• OBJECTIVES
 To demonstrate clearly and consistently the limits of any areas of abnormal
sensation.
 To determine which modalities are involved within those limits.
 To compare the findings with known patterns of abnormal sensation.

EXAMINATION
Questions to be posed while examining:
 Is there a sensory loss at all?
 Is there a sensory level and if yes , at what spinal segment?
 Is there a graded sensory loss?

EXAMINATION
EFFECT OF AGE ON SENSORY FUNCTION
• A matter of importance in the testing o f sensation is the progressive
impairment of sensory perception that occurs with advancing age.
• This requires that sensory thresholds , particularly in the feet and legs, be
assessed in relation to age standards.
• The effect of aging is most evident in relation to vibratory sense, but
proprioception, the perception of touch, and fast pain are also diminished
with age.
• It is probably caused by neuronal loss in dorsal root ganglia and are
reflected in a progressive depletion of fibers in the posterior columns.

EXAMINATION
RULES OF EXAMINATION
 Before beginning a sensory examination , the patient should be explained the
exact nature of test and carefully instructed as to what he is supposed to do.
 Care should be taken not to tire the patient out or prejudice his mind by
suggestions.
 In order to ensure accuracy , the patient’s eyes must be kept close or covered.
 Patient is instructed to make his response prompt ,as soon as the artificial
stimulus is percieved,by uttering the word “yes”to indicate his ability to feel
the stimulus.
 Otherwise ,the phenomenon of delayed response,which indicates a delay of
conduction,may be completely overlooked.

EXAMINATION
• RULES OF EXAMINATION
 The time elapsing between the stimulus and response , under normal
circumstances ,is one-tenth of a second.
 In disease states , it may be as long as 10 seconds.
 Patient under no circumstance must be asked “did you feel that ” , when a
stimulus is applied.
 In stuporous or semi conscious patients , response to painful stimuli in the
form of wincing , facial grimacing or limb withdrawl , may be the only means
available of assessing sensory function.

EXTROCEPTIVE SENSATIONS
TOUCH OR TACTILE SENSATIONS
 Tested with a wisp of cotton or a fine , soft paint brush touched lightly to
the skin , or a mere touch of a finger tip , the patient being instructed to
say “ yes “ on immediately feeling the touch.
 Touch sensation is recorded as anaesthesia when absent , hypoasthesia
when reduced and hyperesthesia when excessive.
 Defining an area of hypoesthesia is better achieved by starting within the
the area of hypoaesthesia and moving the stimulus out into areas where
sensation is normally perceived.
 In hysterical anaesthesia , in addition to a non anatomical distribution of the
sensory loss , it is common to find a change in the location of anaesthesia with
successive tests.

PAIN
 A sharp pin with a rounded head is generally sufficient to produce uniform
and graduated stimuli.
 The following are note worthy:
1 .The shaft of the pin should be long enough to allow the examiner’s index finger
and thumb to slide downwards on impact.
2 .A short pin held with index finger on the head of the pin usually produces an
indelicate and variable stimulus.
3 .A gentle , but firm and uniform touch is required.
4. Hollow needles should never be used . Puncturing the skin is heavy handed and
does not produce an accurate response in an alarmed patient . Also poses the risk
of transmitting disease.

PAIN
• The patient should be asked to judge whether the stimulus feels as
sharp on one side as on the other.
• Always suggest the stimuli should be the same, as by language such
as, “Does this feel about the same as that?”
• Avoid such language as “Does this feel any different?” or “Which
feels sharper?” Suggesting there should be a difference encourages
some patients to over analyze and predisposes them to spurious
findings and a tedious, often unreliable examination.

PAIN.
• A commonly used technique is asking the patient to compare
one side to the other in monetary or percentage terms.
• For example, “If this (stimulating the apparently normal side) side is
a rupee’s worth (or 100%), how much is this (stimulating the
apparently abnormal side) worth?”.
• The latent time in the response to stimulation is eliminated and the
delineation more accurate if the examination proceeds from areas of lesser
sensitivity to those of greater sensitivity rather than the reverse.

• PAIN
• If there is hypalgesia, move from areas of decreased sensation to those of
normal sensation.
• If there is hyperalgesia, proceed from the normal to the hyperalgesic area.
• There may be a definite line of demarcation between the areas of normal
and abnormal sensation, a gradual change, or at times a zone of
hyperesthesia between them.
• If testing is done too rapidly, the area of sensory change may be misjudged.
• Applying the stimuli too close together may produce spatial summation;
stimulating too rapidly may produce temporal summation. Either of these
may lead to spurious findings.

TEMPERATURE
• Temperature sensation may be tested with test tubes containing warm and
cool water, or by using various objects with different thermal conductivity.
• Ideally, for testing cold, the stimuli should be 5°C to 10°C (41°F to 50°F),
and for warmth, 40°C to 45°C (104°F to 113°F).
• The extremes of free flowing tap water are usually about 10°C and 40°C.
• Temperatures much lower or higher than these elicit pain rather than
temperature sensations.
• The tubes must be dry, as dampness may be interpreted as cold .

TEMPERATURE
• Testing temperature may be useful when the patient does not tolerate
pinprick stimuli, has confusing or inconsistent responses to pain testing,
or to help map an area of sensory loss.
• Temperature testing may not be very reliable in patients with circulatory
insufficiency or vasoconstriction causing acral coolness.

PROPIOCEPTIVE SENSATIONS
SENSES OF MOTION AND POSITION
• Sense of motion, also known as the kinetic or kinesthetic sense, or the
sensation of active or passive movement. Consists of an awareness of
motion of various parts of the body.
• The sense of position, or posture, is awareness of the position of the body or
its parts in space.
• These sensations depend on impulses arising as a result of motion of the
joint and of lengthening and shortening of the muscles.

• Motion and position sense are usually tested together
 by passively moving a part and noting the patient’s appreciation of the
movement.
 recognition of the direction, force, and range of movement.
 the minimum angle of movement the patient can detect.
 the ability to judge the position of the part in space.

SENSES OF MOTION AND POSITION
Testing joint position sense
Pseudoathetosis
Romberg’s test
TESTING JOINT POSITION SENSE
• Patient is asked to say “yes” ,each time he feels movement at a particular
joint , when slow and passive movements are being carried out by the
examiner.
• He is then asked in which direction the movement had taken place.
• Each joint of the hands and feet is examined individually

TESTING JOINT POSITION SENSE
• The big toe or index finger is usually selected for testing.
• The examiner should hold the sides of distal phalanx with the right hand ,while
the left hand is used to steady the interphalangeal joint.
• The phalanx is moved up or down taking care to avoid a push-pull stimulus.
• Patient must understand what is exactly meant by “up” or “down” movement of
the toe
• He is asked to shut his eyes during the test and state the direction of toe in
relation to neutral position.
• To begin with, the test movements have to be somewhat large,once the idea of
the test becomes clear to the patient , the smallest possible movements that are
detectable should be employed,avoiding sudden or quick jerks at all times

PSEUDOATHETOSIS
• Patients with impaired joint position sense in their fingers may exhibit
so called pseudoathetosis
• Outstretched fingers drift up or down or to the side
when the patient has his eyes closed.
• This is because , proprioception having failed, vision is
the only means by which the patient knows where
his fingers are and can keep them in one place

ROMBERG’S TEST
• Ask the patient to stand with his feet side by side.
• Having established that his balance is satisfactory
with his eyes open, ask him to close his eyes, having
reassured him that nothing untoward will happen.
• If he loses balance with his eyes closed, the test is
positive.
• You need to be prepared to catch the patient if he shows signs of toppling.

VIBRATION SENSE
• A low frequency tuning fork of 128 Hz is used to test the vibration sense.
• It must be first demonstrated to the patient by pressing the base of the tuning
fork on the sternum, both during and after the cessation of vibration.
• Patient is asked to say “ buzzing” or “yes” when he feels the vibration and
“no” when he feels only pressure.
• When this is made clear to the patient he is asked to close his eyes and
vibration sense tested.

VIBRATION SENSE
• Sensation may be tested on the great toes, the malleoli, the tibial tuberosities,
anterior superior iliac spines, sacrum , spinous processes of the vertebrae,
sternum, clavicle, styloid processes of the radius and ulna and the finger
joints.
• Testing should compare side to side and distal to proximal sensation.
• If vibration is absent distally, the stimulus is moved proximally to the
metatarsophalangeal joints, then the ankle, then the knee, then the iliac
spines, and so forth.

PRESSURE SENSATION
• Pressure or touch-pressure sensation is closely related to tactile sense, but
involves the perception of pressure from the subcutaneous structures rather
than light touch from the skin.
• It is also closely related to position sense and is mediated via the posterior
columns.
• Pressure sense is tested by a firm touch on the skin or by pressure on deep
structures (muscle masses, tendons, nerves), using finger pressure or a blunt
object.
• The patient should both detect and localize the pressure.
• Strong pressure over muscles, tendons, and nerves tests deep pain
sensibility.

CORTICAL OR COMBINED SENSATIONS
• Cortical sensations are those that involve the primary sensory areas of the
cortex to perceive the stimulus and the sensory association areas to interpret
the meaning of the stimulus and place it in context.
• The term combined sensation describes perception that involves integration
of information from more than one of the primary modalities for the
recognition of the stimulus.

STEREOGNOSIS
• Stereognosis is the perception, understanding, recognition, and identification
of the form and nature of objects by touch.
• Inability to do this is astereognosis.
• Astereognosis can be diagnosed only if cutaneous and proprioceptive
sensations are intact; if these are significantly impaired, the primary
impulses cannot reach consciousness for interpretation.
• Patient is asked to close his eyes,familiar objects such as coins,keys are
placed in each hand,and he is asked to name each.
• If he is unable to name them, he may be asked to describe each in terms of
size,shape and texture.

• STEREOGNOSIS
• Bunch of keys should not be used since the sound of rattling may betray its
nature to the patient.
• The test should be carried out simultaneously with both hands , using
identical objects.
• Astereognosis is usually accompanied by agraphesthesia and other cortical
deficits; it may occur in isolation as the earliest sign of parietal lobe
dysfunction

TWO POINT DISCRIMINATION
• This is tested by simultaneously touching areas of skin with two points of an
ordinary compass or hairpin or the heads of two ordinary pins.
• The patient’s eyes being closed , the points are placed on the skin ,
sufficiently wide apart to be recognised instantaneously as two points
(double contact) and then gradually brought together , until the patient
reports being touched with a single point only.
• The minimum distance between two points that is appreciated as a double
contact by the patient is noted. This distance varies considerably in different
parts of the body.

TWO POINT DISCRIMINATION
• Normal two-point discrimination is about 1 mm on the tip of the tongue, 2 to 3
mm on the lips, 2 to 4 mm on the fingertips, 4 to 6 mm on the dorsum of the
fingers, 8 to 12 mm on the palm, 20 to 30 mm on the back of the hand, and 30
to 40 mm on the dorsum of the foot.
• Greater separation is necessary for differentiation on the forearm, upper arm,
torso, thigh, and leg.
• The findings on the two sides of the body must always be compared..

GRAPHAESTHESIA
• It is the ability to recognize letters or numbers written on the skin with a
pencil, dull pin, or similar object.
• Testing is often done over the finger pads, palms, or dorsum of the feet.
• Letters or numbers about 1 cm in height are written on the finger pads, larger
elsewhere.
• Easily identifiable, dissimilar numbers should be used (e.g., 3 and 4 rather
than 3 and 8).
• Loss of this sensory ability is known as agraphesthesia or graphanesthesia.

BAROGNOSIS
• It is tested by using two coins of different weights but of equal or
nearly equal size.
• They are placed alternatively and synchronously on the extremity or
the part to be tested , the patient being asked to indicate which is
heavier.
• The capacity to detect weight differences is less on the affected side.
• When objects of equal weight are placed in both hands , the one in the
affected hand always feel lighter in weight.

TOPOGNOSIS
• Localisation of touch
• Consists of ability to localise stimuli applied to parts of the body with the
eyes shut.
SENSORY INATTENTION
• Sensory extinction, inattention, or neglect is loss of the ability to perceive
two simultaneous sensory stimuli.
• Testing for tactile extinction uses double simultaneous stimuli at homologous
sites on the two sides of the body.
• Light touch is most often used. Extinction occurs when one of the stimuli is
not felt.
• If using pinprick (with equally sharp pins), the stimulus on the abnormal side
may feel blunt compared to the normal side.

SENSORY LOCALISATION
• Diminution or loss of sensation may occur because of lesions involving the
 Peripheral nerves
 Nerve roots
 Spinal cord
 Brainstem
 Higher centers of the brain.
• Localization depends on the pattern and distribution of the sensory
abnormality.

• The primary modalities may be impaired because of disease involving
peripheral nerve, spinal root, or sensory pathways within the central
nervous system.
• When the primary modalities are normal in a particular body region, but the
cortical modalities are impaired, a parietal lobe lesion may be responsible.
• When some primary modalities are involved more than others, the sensory
loss is said to be “dissociated.”.

• The pathways conveying pain and temperature (the spinothalamic
tracts) run in a different location than the pathways conveying touch,
pressure, position, and vibration (the posterior columns, dorsolateral
funiculus, and medial lemniscus).
• After running divergently through much of their central course, the
pathways converge again as they approach the thalamus and remain
together in the thalamocortical projections.

• When the pathways are close together, such as in the peripheral
nerve, spinal root, or thalamus, disease processes tend to affect all
primary modalities to an approximately equal degree.
• When the pathways are remote from each other, such as in the
spinal cord and brainstem, a disease process may affect one type of
sensation and not another, producing dissociated sensory loss.

• A common example of dissociated sensory loss is lateral medullary stroke,
or Wallenberg’s syndrome.
• There is a very characteristic pattern of sensory loss , which only involves
pain and temperature and completely spares light touch.
• The pain and temperature loss involves the ipsilateral face, because of
involvement of the spinal tract of cranial nerve V, and the contralateral body,
because of damage to the lateral spinothalamic tract, sparing the light touch
pathways that are running in the midline in the medial lemniscus.

NERVE AND ROOT
• Root (“radicular”) lesions frequently are accompanied by deep, aching pain
along the course of the related nerve trunk.
• With a lesion affecting a single root, sensory deficits may be minimal or
absent because adjacent root territories overlap extensively.
• With polyneuropathies, sensory deficits are generally graded, distal , and
symmetric in distribution .
• Dysesthesias, followed by numbness, begin in the toes and ascend
symmetrically. When dysesthesias reach the knees, they usually also have
appeared in the fingertips.
• The process is nerve length–dependent, and the deficit is often described as
“stocking-glove” in type.

NERVE AND ROOT LESIONS
DISTAL,SYMMETRIC
SENSORY LOSS DUE TO
PERIPHERAL
NEUROPATHY
DERMATOMAL
SENSORY LOSS DUE
TO CERVICAL
RADICULOPATHY
DERMATOMAL
SENSORY LOSS DUE
TO LUMBOSACRAL
RADICULOPATHY

SPINAL CORD
• If the spinal cord is transected, all sensation is lost below the level of
transection.
MID THORACIC LEVEL

SPINAL CORD
• Lateral hemisection of the spinal cord produces the Brown- Sequard
syndrome, with absent pain and temperature sensation contralaterally and
loss of proprioceptive sensation and power ipsilaterally below the lesion
BROWN SEQUARD SYNDROME

SPINAL CORD
• A dissociated sensory loss can reflect spinothalamic tract involvement in the
spinal cord.
• Bilateral spinothalamic tract involvement occurs with lesions affecting the
center of the spinal cord, such as in syringomyelia.
• There is a dissociated sensory loss with impairment of pinprick and
temperature appreciation but relative preservation of light touch, position
sense, and vibration appreciation

SUSPENDED, DISSOCIATED SENSORY
LOSS TO PAIN AND TEMPERATURE DUE
TO SYRINGOMYELIA

SPINAL CORD
• Anterior spinal artery infarction causes dissociated sensory loss.
• The anterior spinal artery infarction involves the anterior two-thirds of the
cord, sparing the posterior columns, which are perfused by the posterior
spinal arteries.
• The patients have dense motor deficits and dense sensory loss to pain and
temperature but normal touch, pressure, position, and vibration.
ANTERIOR SPINAL
ARTERY SYNDROME

SPINAL CORD
• Dysfunction of the posterior columns in the spinal cord or of the
posterior root entry zone may lead to a band like sensation around
the trunk or a feeling of tight pressure in one or more limbs.
• Flexion of the neck sometimes leads to an electric shock–like sensation that
radiates down the back and into the legs (Lhermitte’s sign) in patients with a
cervical lesion affecting the posterior columns, such as from multiple
sclerosis, cervical spondylosis, or recent irradiation to the cervical region.
POSTERIOR COLUMN
SYNDROME

BRAINSTEM
• Crossed patterns of sensory disturbance, in which one side of the face and
the opposite side of the body are affected, localize to the lateral medulla
(lateral medullary or wallenberg’s syndrome)
LATERAL MEDULLARY SYNDROME

THALAMUS
• Hemi sensory disturbance with tingling numbness from head to foot is often
thalamic in origin but also can arise from the anterior parietal region.
• If abrupt in onset, the lesion is likely to be due to a small stroke (lacunar
infarction), particularly if localized to the thalamus.
• Occasionally, with lesions affecting the VPL nucleus or adjacent
white matter, a syndrome of thalamic pain, also called Dejerine –Roussy
syndrome, may ensue

CORTEX
• With lesions of the parietal lobe involving either the cortex or the subjacent
white matter, the most prominent symptoms are contralateral hemi neglect,
hemi-inattention, and a tendency not to use the affected hand and arm.
• On cortical sensory testing, abnormalities are often found but primary
sensation is usually intact.
• Anterior parietal infarction may present as a pseudothalamic syndrome with
contralateral loss of primary sensation from head to toe.

REFERENCES
• Hutchisons clinical methods 23rd edition
• Golwalla textbook of symptoms and physical signs 14th edition
• Bickerstaff’s neurological examination in clinical practice 7th
edition
• Macleod’s clinical examination 13th edition
• Dejong’s neurologic examination 7th edition
• Harrison’s principles of internal medicine 19th edition
• Bradley’s neurology in clinical practice 7th edition
• Adams and victor’s principles of neurology 10th edition

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