Chapter 2 Neurologic Examination of the Older Child

As it is usually feasible to perform a more rigorous examination of older children, detailed discussion of the conventional neurologic examination of children is provided in this chapter, including evaluation of the cranial nerves.

Examination of a child older than 2 years should be as informal as possible while maintaining a basic flow pattern to permit complete evaluation. The older child has acquired a large repertory of skills since infancy (Box 2-1). For children between 2 and 5 years old, the Denver Developmental Screening Test II may be useful in evaluating various motor skills [Frankenburg et al., 1992] (see Chapter 1). Many neurologic functions of children between the ages of 2 and 4 years are examined in the same manner as those of children younger than 2 years. As is the case with younger children, some patients between 2 and 4 years old may be most comfortable sitting on a caregiver’s lap. The examining room should be equipped with small toys, dolls, and pictures with which to interest the child and provide for ease of interaction. Observation and play techniques are essential means of monitoring intellectual and motor function. Children may choose to move about the examining room and may be attracted to these various playthings. After 4 years of age, the components of the neurologic examination are more conventional and routine, and by adolescence, the examination is much the same as the adult examination.

Physical Examination

Deep Tendon Reflexes

Deep tendon reflexes (i.e., muscle stretch reflexes) are readily elicited by conventional means with a reflex hammer while the child is sitting quietly. In the case of the biceps reflex, it may be helpful for the examiner to place his or her thumb on the tendon and strike the positioned thumb to elicit the reflex. If the child is crying or overtly resists, the examiner should postpone this portion of the examination. The child may be reassured if the examiner taps the brachioradialis reflex of the caregiver before performing the same act on the child. Deep tendon reflexes customarily examined include the biceps, triceps, brachioradialis, patellar, and Achilles reflexes. Each tendon reflex is mediated at a specific spinal segmental level or levels (Table 2-1) [Haymaker and Woodhall, 1962; Hollinshead, 1969].

Table 2-1 Muscle Stretch (Tendon) Reflexes

Reflex	Nerve	Segmental Level
Biceps	Musculocutaneous	C5, C6
Brachioradialis	Radial	C5, C6
Gastrocnemius and soleus (ankle jerk)	Tibial	L5, S1, S2
Hamstring	Sciatic	L4, L5, S1, S2
Jaw	Trigeminal	Pons
Quadriceps (knee jerk)	Femoral	L2–L4
Triceps	Radial	C6, C8

The response to elicitation of deep tendon reflexes can be characterized as follows:

1. no response

2. hyporeflexic response

3. normal response

4. hyperreflexic response or unsustained clonus

5. sustained clonus.

The findings for each elicited reflex can be noted (e.g., 3/5 or 4/5) as appropriate. A stick man figure can be used to indicate the position of each quantitated reflex. Obviously, the examiner will to some extent have individual quantitation standards, but consistency will develop over time. Hyperactive reflexes or clonic responses to tapping of the reflex usually result from corticospinal dysfunction. Hyperreflexia may also be indicated by an abnormal “spread” of responses, which includes contraction of muscle groups that usually do not contract when a specific reflex is being elicited (i.e., crossed thigh adductor or finger flexor reflexes). Although a bilateral brisk reflex response may be normal, particularly when only one reflex is involved, unilateral hyperreflexia virtually always signals a pathologic process.

Hyporeflexia may be associated with lower motor unit involvement (e.g., anterior horn cell disease, peripheral neuropathy, myopathy). However, hyporeflexia may occasionally be found with central depression, impaired central control of the gamma loop (central hypotonia), or involvement of the posterior root (intramedullary or extramedullary). With anterior horn cell involvement (e.g., infantile spinal muscular atrophy), the patellar reflexes are greatly diminished or absent early because the cells subserving the proximal muscles of the legs are profoundly involved first. Sensory involvement, particularly peripheral, is often detectable in patients with neuropathies. Similarly, the distal deep tendon reflexes tend to be involved earlier and to a greater degree. Tendon reflexes may be normal early in the course of certain myopathies, including the muscular dystrophies, and may become absent later.

Disease generally decreases muscle tone and may decrease tendon reflexes because of effects on the gamma loop. Enhancement of tendon reflex responses when reflexes are seemingly absent can be promoted by having the child squeeze an object such as a block or ball or perform the more traditional Jendrassik maneuver (i.e., hooking the fingers together while flexed and then attempting to pull them apart).

Other Reflexes

A flexor (plantar) toe sign response is normal in children. Impairment of corticospinal tract function leads to extensor responses. The Babinski reflex is elicited by firm, steady, slow stroking from posterior to anterior of the lateral margin of the sole with an object such as a key or a tongue blade. The stimulus should not be painful. A positive response is a slow, tonic hyperextension of the great toe. This is the constant and necessary feature of a positive response. The other four toes may also hyperextend, or they may slowly spread apart (i.e., fanning).

Flicking the patient’s nail (second or third finger) downward with the examiner’s nail (i.e., the Hoffmann reflex) results in flexion of the distal phalanx of the thumb. No response or a muted response occurs in normal children; a brisk or asymmetric response occurs in the presence of corticospinal tract involvement.

Abdominal reflexes are obtained by stroking the abdomen from lateral to medial with strokes beginning just above the umbilicus, lateral to the umbilicus, and just below the umbilicus directed toward the umbilicus. Unilateral absence of the reflex usually is associated with acquired corticospinal tract dysfunction. However, in 50 percent of normal individuals, no response is elicited in any of the four quadrants.

The cremasteric reflex is elicited in males by stroking the inner aspects of the thigh in a caudal–rostral direction and observing the contraction of the scrotum. The reflex is normally present and symmetric. Absence or asymmetry may indicate corticospinal tract involvement.

Developmental reflexes are discussed in Chapter 3. The persistence of developmental reflexes beyond the expected age of extinction is usually an indication of corticospinal tract impairment [Zafeiriou, 2004].

Cerebellar Function

Head tilt may be associated with tumors of the cerebellum. The tilt is usually ipsilateral to the involved cerebellar hemisphere, but exceptions are common. Herniation of the cerebellar tonsils through the foramen magnum resulting from increased intracranial pressure may cause head tilt; neoplasms that induce increased intracranial pressure, other than those of the cerebellum, may cause head tilt. Cerebellar function is also evaluated during testing of station and gait (see Chapter 5). Cerebellar dysfunction is usually associated with hypotonia.

Tremor in cerebellar disease occurs with action (intention). Cerebellar function is assessed in a number of ways. Hand patting (i.e., alternating pronation and supination of the hand on the thigh while the other hand remains stationary on the other thigh) is a good method for assessing dysdiadochokinesis. The maneuver is repeated with each hand separately to assess the presence of mirror movements (i.e., synkinesis). Other tests that monitor cerebellar integrity include repetitive finger tapping (thumb to forefinger), foot tapping, and finger-to-nose, finger-to-finger (examiner’s)-to-nose, and heel-to-knee-to-shin stroking. These movements are an index of cerebellar function when limb strength and sensation are intact. Breaks in rhythm and nonfluidity of movement, as well as dysmetria, which is suggestive of cerebellar dysfunction, are evident during this phase of the examination.

Cranial Nerve Examination

In older children, the cranial nerve examination may be performed in a systematic fashion, beginning with the first cranial nerve and testing through the twelfth. Examination of infants and younger children usually requires some modification of the sequence and may need some ingenious improvisation of the procedure, according to the degree of cooperation of the child. As is the case with all examinations of infants and young children, the less threatening portions of the examination should be performed first.

Olfactory Nerve: Cranial Nerve I

Olfactory nerve function is rarely impaired in childhood. Cranial nerve I can be evaluated by having the child smell pleasant aromas (e.g., chocolate, vanilla, peppermint) through each nostril while the other is manually occluded. Olfactory sensation is intact if the child appreciates a change in odor; precise identification is often impracticable. Anosmia occurs most commonly in children with upper respiratory infections or after head trauma, often occipital. Neoplasms in the inferior frontal lobe or cribriform plate regions can cause anosmia. Unilateral anosmia is more worrisome than bilateral anosmia because of the possibility of a unilateral neoplasm.

Optic Nerve: Cranial Nerve II

Examination of cranial nerve II, the optic nerve, is one of the critical portions of the neurologic examination because of the long anterior-to-posterior span of the visual pathways within the brain. Formal visual acuity testing is possible with a Snellen chart or a “near card” in older children. Visual acuity and visual field testing should be performed in an appropriately lit room. The visual test objects should be easily visible and without glare. Occasionally, when subtle changes are being investigated, it is efficacious to hold the visual field test object against a background of less contrast, increasing the difficulty of identification.

Function can be difficult to evaluate in the very young child. Gross vision can be assessed in children younger than 3 or 4 years of age by their ability to recognize familiar items of various sizes, shapes, and colors. Beyond 4 years of age, the E test is useful. The child is taught to recognize the E, and to discern the direction in which the three “arms” are pointing and point a finger accordingly. Most older children can be taught the essentials of the test in less than a minute. During the acuity evaluation, Es of different sizes, rotated in different directions, are presented to the child.

For each eye, the visual field (range of vision) is assessed by confrontation with an object that is moved from a temporal to nasal direction along radii of the field. A small (3-mm), white or red test object or toy can be used. A modification of the same procedure can be used for double simultaneous testing by moving two test objects or penlights simultaneously from the temporal to the nasal fields and then from the superior and inferior portions of the temporal and nasal fields while the child looks directly at the examiner’s nose. Finger counting can be used if acuity is grossly distorted. In cases of extreme impairment, perception of a rapidly moving finger can be used.

Visual acuity is rarely affected by papilledema until there is scarring of the optic nerve head. This lack of acuity change is in marked contrast to the early loss of visual activity that accompanies inflammation of the optic nerve.

The optic disc (i.e., optic nerve head) of the older child is sharply defined and often salmon-colored, which differs from the pale gray color of the disc in an infant. In the presence of a deep cup in the optic disc, the color may appear pale, but the pallor is localized to the center of the disc. The pallor of optic atrophy occurs centrally and peripherally, and is accompanied by a decreased number of arterioles in the disc margins. Most commonly, papilledema is associated with elevation of the optic disc, distended veins, and lack of venous pulsations. Hemorrhages may surround the disc. Before papilledema is obvious, there may be blurring of the nasal disc margins and hyperemia of the nerve head.

Pupils should be observed in light that allows them to remain mildly mydriatic. The diameter, regularity of contour, and responsivity of the pupils to light should be examined. When the pupil is dilated and is minimally reactive or unresponsive to light, the patient may suffer from Adie’s pupil. The upper lid is usually at the margin of the pupil. In Horner’s syndrome, impairment of the sympathetic pathway results in a miotic pupil, mild ptosis, and defective sweating over the ipsilateral side of the face (Figure 2-1). Dragging a finger over the child’s forehead may aid in the recognition of anhidrosis. The fixed, dilated pupil usually is associated with other signs of oculomotor nerve dysfunction and may signify cerebral tonsillar herniation.

Fig. 2-1 Bilateral oculomotor nerve paralysis.

(Courtesy of the Division of Pediatric Neurology, University of Minnesota Medical School.)

The presence or absence of the pupillary light reflex differentiates between peripheral and cortical blindness. Lesions of the anterior visual pathway (i.e., retina to lateral geniculate body) result in the interruption of the afferent limb of the pupillary light reflex, producing an absent or decreased reflex. Anterior visual pathway interruption can cause amblyopia in one eye. In this situation, the pupil fails to constrict when stimulated with direct light; however, the consensual pupillary response (i.e., response when the other eye is illuminated) is intact. Various degrees of visual loss may modify this phenomenon so that the full response to direct stimulation is delayed, but the consensual reflex is brisk. The deficient pupillary reflex is revealed by alternately aiming a light source toward one eye and then the other. In the eye with decreased vision, consensual pupillary constriction is greater than the response to direct light stimulation (Marcus Gunn pupil); the pupil of the affected eye may dilate slightly during direct stimulation.

Oculomotor, Trochlear, and Abducens Nerves: Cranial Nerves III, IV, and VI

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