I expect all of you to fail. Well, maybe Laura will pass, right? But if you make between a 30 and a 40 on this first PowerPoint, or I'm sorry, on this first CNIM mock exam, I'll be happy. Doesn't mean if you make in the 20s that it's terrible, but most people score under 50 the first time they take this.
Um, the exception to that are people that have been in the field for a while, or maybe people that have, uh, you know, been studying for the exam already. Um, I may expect you a couple of you to do better than that, but it's not a pass or fail, right? This is a tool. That's all it is.
I want to see where you're at right now. And, uh, what I would like for you to do when you're sitting for this exam, this mock exam, if you can allot four hours, on Thursday afternoon to do this, that'd be great. Some of you, it may have been a long time, or you may never have sat for a 250 question exam.
That in itself can be a bit demanding. For you to take this exam, what I would like for you to do is read every word of every question. Then I would like for you to mentally highlight the words, the keywords in the question. What are keywords?
Well, an example would be all of the following, except. Except would be the keyword because it changes the meaning of the question, basically. You have to understand what the question is actually asking you about. So mark those keywords, most likely, least likely, except, including, all that apply. Special attention to those phrases.
The next thing, once you've read every word of the question and you've highlighted mentally the keywords, then I want you to categorize that question. Is this an anatomy question? Is it a guidelines question dressed up like something else?
Because ABRT loves to do that. They will ask you a question about. hook wire electrodes, which is a guidelines question. And they'll go into this long explanation about during a vestibular schwannoma removal or a two centimeter vestibular schwannoma removal, the surgeon is wanting to stimulate the facial nerve, which types of electrodes are best for recording CMAPs in stimulation to a facial nerve. The question is a guidelines questions.
The guideline states that hook wire electrodes should be used for that. But you see, it's dressed up in a lot of other things. So you want to focus on categorizing that question.
Once the question is categorized, then you can go back and fall on what you've learned so far. Now, there's going to be a lot that you're not going to know. So if you have no idea, and this is what I want you to do only in this mock exam.
If you have no idea of what it's asking or the answer, I don't want you to answer it. Because otherwise, if you answer it and guess it, it can skew the results that we're trying to get from the exam. If you think you know it and you want to take a shot, you feel better than 50%, then go ahead and answer it. So there's a very... Very good reason why we do this.
And we have to make sure that you are where you should be right now based on what we've taught you thus far. This is as much a benefit for us as it is for you. It benefits us so we can benefit all of you.
So if you have no idea and there will be some on there that we have not covered and you don't know, don't answer it. But the rest, I still want you to read every word of every question. I want you to categorize or highlight the words, the specific words. I want you to categorize that if you can.
And then I want you to read every word of every answer and then choose the best answer. When you start studying for your CNIM in second semester, part of our studying technique is when you're practicing on practice exams, it's to read the... each word and know not only why the correct answer is correct, but why the incorrect answer is incorrect. That's not what we're doing right now. So any questions about that?
You'll have four hours to complete it. It's 250 questions. If you can't be uninterrupted for those four hours, find a time that you can between now and class next Tuesday. and complete that exam so that we can get a good assessment of where you're at, what we still need to work on.
what we may need to remediate, and what we may need to just reiterate. So that'll help us to be able to help you. That's going to be Thursday.
I do want you to watch as an assignment, I want you to watch the central nervous system pathology lecture, which was scheduled for today. But I wanted to jump ahead and go ahead and do this neurologic exam, PowerPoint, and then at three, Adam and I will show you how to do a motor and sensory exam. Three o'clock class will not take that long. We're going to take this in sections and it's coming right where it needs to, I think, before you guys start into your clinicals. So any questions about the CNIM, the mock CNIM before we get started?
Nope, none. Okay. Also.
You'll take this again at week 10 of the second semester, right before we start the CNIM board prep, and we will expect you to be exponentially better. Then if you're making a 35 in the second semester, we've got some really big problems that we have to work through, but you won't be. All right, let's get into this. All right.
So hopefully you guys have already watched the introduction to pathology. It's a pretty standard introduction. And I want to get more into the neurologic exam, which is specific to what we do.
In all of education and intraoperative neuromonitoring, I would say that apart from just a handful of things, there's a lot of things that we can do to help you get better at this. Pathology is one of the things that's most overlooked, and it also is one of the issues in neuromonitoring that can most lead to a false negative. I've seen at least half a dozen legal cases where patients were permanently paralyzed, and I believe in reviewing these cases, that had the intraoperative neuromonitorist been properly educated in neuropathology and understood the importance of preoperative assessment, reading the chart, knowing what you're reading, answering this question, how the patient's pathology will affect monitoring, that at least five, if not all six, but for sure five of these situations would never have happened, that there would have been an intervention prior to there being a permanent injury. And it's devastating to think that, you know, this patient would not have had to suffer. And then all of the fallout beyond the patient suffering, but first and foremost, the patient would not have to suffer the way they still do.
Some of these cases were 18. 20 years ago, and these patients are still in wheelchairs. This could have been avoided had proper education been afforded the neuromonitorist, or if the neuromonitorist would have educated themselves. So it's extremely important, and it is also the most overlooked, I think.
at least in my opinion and from my experience, the most overlooked opportunity to properly be educated in this field. So let's take a look at this. What is the neurologic exam and what are our objectives in this class? We'll talk about components of the neurologic exam, methods for performing a motor exam, The differences in clinical presentations of upper motor neuron lesions and lower motor neuron lesions.
The role of reflex testing as part of the neurologic exam. We seldom do this, but it's important to understand how it can play a part. We'll talk about methods for performing the sensory exam, and then we'll show you how to do this in the three o'clock class. Then application of neurologic exam in our particular practice, and then procedures for localizing a neurologic lesion, preoperative assessment, and roles of the neurologic exam.
Now, there will be more than you need for intraoperative neuromonitoring here. We will kind of... pull out from this lecture the things that we deem most important right now. You will see some of this again in second semester when we talk more about neuromonitoring of cranial nerves and how to do the exam there.
But we really want to discuss how the test and the metrics that are used can properly allow you to understand neurological function that this patient has or doesn't have. We could say neurologic dysfunction. It's given us an overall view from a neurologic standpoint how this patient is functioning.
Now, neurologists and all clinicians or MDs really understand the importance of this. It's rare that you would go even for a physical or especially if you had an emergency room visit from like a head injury or something like that, where this MD does not give you at least a cut down version of a neurologic exam. Just about every history and physical that you see on a chart will have a neurologic exam noted on there. It's important for us because we want to make sure that everything that is working neurologically when the patient is coming into the OR is working when the patient leaves the OR, or at least we should have an explanation for it.
Now, one of the foundational concepts of a neurologic exam is how to look at the patient from a global view. For example, if a patient comes in and they have leg weakness and numbness in a certain distribution of their leg, you... probably will be able to understand which nerve root is compressed, which myotome and dermatome associates with that nerve root.
And the more of these you do, you'll be able to pick out when someone has an L5 herniated disc, L5 S1 herniated disc in which nerve roots being compressed and, and you know, how much is motor and how much is sensory just by walking in and having them explained to you. before you even touch the patient, the symptoms that they're experiencing. And the more you do this and the more experience you gain, I think the better clinician you become.
Now, an overall view of a neurologic exam, the different components generally consist of mental status. This is where when I worked in psych, when I was in my undergrad, program when I worked in the psych unit, I would always chart the patients awake and oriented times three or sometimes times four. And that means to be oriented means that they know who they are, they know where they are, and they know what the situation is and then what time and date it is. Most of the patients that we had on the adult psychiatric unit would fail this exam from one reason or another.
Cranial nerves, of course, we've spent a little time in peripheral nerve anatomy and peripheral nervous system anatomy to start learning, you know, name, number and function of the cranial nerves. And if we know what the function of the cranial nerves are and the effect of that function, in other words, the seventh cranial nerve closes the eye, you know, cranial nerve three open, holds the eye open. If we're assessing a patient and they can't close their eye on their own, they have to reach up and manually move the eyelid down and their face is drooping.
And we know that that's probably. a deficit in cranial nerve 7. The motor exam, what can this patient move? How much strength do they have moving it? And does it compare equally with the other side or an unaffected side or not? Reflexes.
If a patient is myelopathic and they have a spinal cord condition, they have hyperreflexia. If they have a spinal cord injury initially, they may have hyporeflexia depending on where it's at in the body. level of the spinal cord.
Coordination and gait, we don't do this most of the time. We're not going to have a patient get up off the stretcher and walk heel to toe so that we can assess their gait when they're getting ready to go back and have a lumbar fusion. That's just not something we do. It's still important that you understand how it's done and what it means so that when you're reading the history and physical that the physician or the physician's assistant has put in the chart.
that you'll know what that means as it relates to you. And then, of course, the sensory exam. Why can this patient feel?
How much can they feel? Can they distinguish from their left to their right? Is it completely numb, partially numb? This helps us know where we will be stimulating and where we will be recording from if there's an alteration in this. Now, we do not do a full neurological exam on every patient that we see.
We target the specific neurological structures that are going to be at risk during the procedure. So as we are walking back to see the patient, we get our schedule the day before. We go ahead and understand what procedure is going to be performed. And unless there's an exception to the rule. We know the anatomical structures that'll be at risk.
So three patients. Yeah. Wow.
Okay. We're able to. Yeah. Sorry about that. Sometimes people forget.
All right. So we will know what's at risk and make sure that we do a motor and sensory exam on the aspect of the body that. and the neurological structures that are at risk.
So I'm going to skip through some of this. One of the reasons that we write out the PowerPoints like this is so that you can go back and you can read them and understand each and every aspect of a mental status exam, for example. Now, it's not uncommon for us to get a patient that may have mental status dysfunction from...
one way or another from one aspect or another. And so when we do get a patient like this, if they have dementia and they can't properly answer the questions for you, it's good to note that on your chart. If you're asking the patient to dorsiflex or to press down on the gas, so to speak, when we're holding the bottom of their feet and we say, push down and they're just talking about Christmas and it's the middle of July, you have to know that the patient was unable to follow simple commands.
Or if you're asking them questions about how they were injured or how they came to be in the OR for this certain procedure, and they're rambling on about something that happened 40 years ago, you may want to put that the patient is a poor historian. So you can't get a proper assessment that... prior to surgery.
And at that point, you kind of fall back on the H and P that's written in the chart. So from a mental status exam, these are the things that we're primarily concerned with as intraoperative neuromonitorist. We'll leave this here. You certainly can go back and read this.
And it's not something that we'll go into in detail during this presentation. We will go back over the cranial nerves, especially 3 through 12, right? Specifically 3 through 12, because these are the ones that we are most likely to monitor. You will never be monitoring cranial nerve 1, at least not until someone figures out a way to possibly do this. It'll be rare if you monitor cranial nerve 2 just because visual evoked potentials in surgeries, which...
is how you would monitor this. They're very underwhelming in what they're able to deliver and what use they're able to bring to the procedure. So let's begin in maybe about four down where it says pupillary responses. Of course, if the patient is completely blind, they may or may not have pupillary constriction and accommodation if there's optic nerve damage.
But we also know that a special function of cranial nerve three is to constrict the pupil. So if you go in to pre-op a patient, perhaps they've had a head injury. and you see that their pupil is dilated on one side and not the other, and you kind of close the blinds and put a shade over that or shine a light there, and it doesn't constrict when you shine the light, then you could certainly ascertain that there's some cranial nerve 3 dysfunction there.
Cranial nerves 3, 4, and 6 are the eye movement muscles. If you remember the functions of these and the muscles that they innervate, that will let you know specifically which one may be impacted. For example, if it's cranial nerve six, they may not be able to accommodate appropriately or abduct the eye appropriately. So you just, again, look at the function.
of the nerve and look at the presentation of the patient. Cranial nerve five, of course, if they have numbness or they have a severe pain in their face or their gums or their eyes or their nasal mucosa, and they can't chew appropriately, you know, then you can ascertain that they have a facial nerve, or I'm sorry, a trigeminal nerve dysfunction. How would you test this? You could place your...
and we'll show you more about this at three, but you could place their hands along the border of the lower jaw and ask them to clench their teeth together. If you feel equally that the masseter muscles contract, then you could say that you have five out of five strength or normal strength in the masseter muscles. Facial expression, cranial nerve seven. or the facial nerve innervates all the muscles of facial expression.
And it's pretty easy to test this. You have the patient arch their brow and close their eyes tightly and squint and grimace and smile broadly and frown. By doing these things, you're testing all of the muscles that are innervated by cranial nerve seven. Again, if you're in there for a lumbar effusion, don't be having them do all these things.
It would be weird. But if you're having a parotidectomy, or if they're doing a vestibular schwannoma removal, or anything to do with the brainstem, you would want to test the function of the cranial nerves specific to where in the brainstem a procedure was taking place. For example, if the surgeon has diagnosed the patient with a tumor in the medulla, then you're going to focus.
predominantly on the lower cranial nerves, cranial nerves 8, 9, 10, 11, and 12. And so you'd have to understand the function of those nerves to know which modalities to use and obviously do a pre-op exam of motor and sensory exam of those nerves. So if it's a situation with hearing, then we're very concerned with cranial nerve eight, right? So there's no motor component of cranial nerve eight.
So you could snap your fingers on each side of the patient's ear and ask them if it sounds the same on either side. If it's cranial nerve nine or 10, if it's cranial nerve 10, you would want to ask the patient to speak. to say their vowels because the recurrent laryngeal nerve, which is a branch of cranial nerve 10, innervates the vocal cords. Cranial nerve nine, you could ask the patient if they're having any problems swallowing food because it, again, innervates the stylopharyngeus muscle, which elevates the soft palate and allows the patient to be able to swallow.
If it's cranial nerve 12, which is the hypoglossal, you would have the patient stick their tongue out. You know, these are found again in the medulla. And if the patient sticks their tongue out and it deviates to the right side, then the lesion would be on that side. The tongue will point toward the weakened side.
If it's cranial nerve 11, then it's the sternocleidomastoid or trapezius muscle. You just ask the patient to shrug their shoulders while you have your hands on top of their shoulders to see if there's weakness on one side or the other. And this basically is the same way, the same way we do a cranial nerve exam is the same way we do a lumbar exam of lower extremities or upper extremities.
We know which structure is at risk. And if it was any of these cranial nerves, you know the function of those cranial nerves, then you test the muscles or the sensation that those cranial nerves are responsible for mediating. And so if we're having an L5-S1 fusion, you think about nerve roots above and below. So we would look at nerve roots L4 through S1 or S2.
S2, it's fused. So anything in the sacral, you know, S1 generally is going to give you a good understanding of it. So then we have to think about myotomes or muscles that innervate each of these, that are innervated from these nerve root levels, and we test them that way.
Now, when we're doing a motor exam, it's more than just testing strength. This is what we focus on most of the time, but you should kind of take a look too. Sometimes you'll be doing a preoperative exam on a patient and you lift up the lower part of the blanket that's covering them in pre-op. And sometimes you can immediately see that there's wasting of muscle or atrophy of muscles.
And sometimes it's very specific to the nerve root that is compressed. I would not say that that's commonplace, but I also would say that sometimes people need to take a step back and look, you know, observe what you're, you know, how this patient is presenting. You know, look at the muscles, palpate the muscle, feel.
This talks about inspection and palpation, muscle tone testing, and then functional testing and strength testing. We'll go through these. Again, sometimes it's good just to look and compare, right?
Is this patient coming in and they have a C5 compressed nerve root on the right side and you're looking at the deltoid and you see that there's atrophy on the impacted side. Compare. We don't just rush in and do a motor and sensory exam.
So it's important. And here's an example. Look at the upper right corner.
Look at that muscle on the right side compared to the left. You see distinct atrophy in not only the tibialis anterior muscle, but also the gastrocnemius. Look at it here versus here. And this is what we talk about when we talk about observation and inspection.
If you miss this, then you have your eyes closed. This patient was coming in to have a parotidectomy. She's got an enlarged parotid gland right here. You don't see it here. You see it here.
And so in a patient like this, you definitely would check the cranial nerve innervated muscles. So again, this would be atrophy of the muscle. Now, if this was a normal leg and this was extremely swollen, then this would be hypertrophy. You also look for other things like twitches in the muscle or fasciculations.
These fasciculations would indicate certainly that there's motor units that are dropping out and not feeding into the muscle like it should. It's also indication. If a patient has fasciculations that they may have a lower motor neuron disease.
I do this rarely, but sometimes it's important to do. This is more of a motor exam that would be done by a clinician other than intraoperative neuromonitorist. But every now and again, you'll see something you want to look at this to see, especially if you see a patient with hypertrophy.
One of the things they'd be concerned about would be myositis. But it's pretty rare that I would actually do the palpation part. I just want you to know what that is.
Muscle tone testing. This is where... The patient's asked to relax and then the clinician will move the muscles, move the limb at the joints to see if there's any abnormal resistance or if they're very stiff or rigid in the joints.
Again, not something that we would do routinely, but it's good to know what it is if you see it in the H&P. Functional testing. There's several tests that you have to understand what they are because it's on your CNIM exam. And it's also good to know what they mean so that if you see it written in the chart that you'll know how the nervous system is impacted.
Like if someone has parietal drift, it means that there's a somatosensory disruption between their feet and up to their brain. If someone has a Tenel sign, it means that you can tap like the wrist, for example, over the nerve and they feel tingling running down. If someone has a positive Babinski response, it means that they have an upper motor neuron lesion. And don't worry, we'll get into this more when we go back and go over central nervous system and peripheral nervous system pathology.
Now, I hate this. I hate one component of this chart. I'm going to grab a pen and I say this every time I give this lecture.
And then I forget to do it. Take that out. There's no four minus. Imagine that you're looking at a linear scale.
What is less than four? would be three plus, right? So there can be a four plus, but there's no four minus.
I hate that, and I'm not sure exactly. I think Daniel Willett pulled this from somewhere and put it on here, and I threaten every time to take it off, and I really need to do that. So we use something called the MRC or the Medical Research Council strength scale when we assess a patient's strength.
Now. Our protocol is that our clinicians go in, they do a motor exam of a patient, and then we document what our findings are. And we do it using this MRC strength scale. And when our students start doing this and trainees start doing this when they first start, they're way wrong on how they assess. So I want to spend some time to go over this.
Five out of five would be normal strength. Now, it's not your strength. It's a little bit subjective, and it's what it would be for that patient.
You ask that patient, do you have any weakness? No. And then if it's an 83-year-old Meemaw, you ask her to contract her biceps or to do hand strength.
You have to assess that based on what you would expect from an 83-year-old Meemaw, not from Adam who... played college football and could break your hands if he squeezed them, right? And so this is one of the things that I have to tell our students.
You're not going by, is this normal strength for you, but is it normal power or normal strength for the patient and their condition, their age, their fitness level? So that's just why we compare one side to the other. And we have a conversation with the patient.
And we'll go into this at three in a bit more detail, but yeah. Five out of five would be normal strength. And this would be generally if we're doing an ACDF, a cervical spine case, we're going to have the patient adduct their deltoid. So they'll raise their arms up and you test their deltoid strength. We'll show you how to do that.
You test their bicep strength. So you hold their wrist or their hands and say, make a muscle and they pull it toward themselves. Then you tell them to push away, which is testing the triceps. And then you test the wrist flexors and then hand grip.
This would be a common motor exam. for a patient that was about to undergo a cervical spine case. And if it was normal in all of those muscle groups, you would put five out of five and then you would list the muscles. And if it was only, it was five out of five on each side, you would list each muscle and say bilaterally. Four plus out of five is some muscle groups are stronger than their counterparts on the other side.
then you would say it's four plus if it's a little bit less when compared to the other side. Four would be moderate movement against resistance, right? They can move you if you hold their, put your hands at the bottom of their feet and say, press down like you're pressing on the gas. And they could do it full strength on one side, but they're a little weaker on the other side.
Then you could say that's four out of five. This is where we make an enormous drop. From four to three is the difference between someone that can get up and walk and move around and someone that is nearly paralyzed.
Three out of five means that the patient can't move against any resistance whatsoever. And that is significantly weak. On any routine cases that you have, patients that are not already hospitalized and they've not been in an accident, if they come in for an elective surgery, it's extraordinarily rare to see anyone that has a strength of three out of five.
That is extremely weak. And, you know, I said at the outset of this particular slide that we have to spend a lot of time addressing this with our... students and new hires and trainees.
And it's because they kind of think, well, zero is kind of weak. Five is really strong. Three is moderately weak, but they can still move against resistance.
No, that would be four. There's a huge drop off in strength from four out of five to three out of five. Look at it. It is movement against gravity, but not against resistance. So if I'm asking them to make a muscle with their bicep and I'm holding down on their wrist, even if I'm slightly holding down and they can't move at all, that's three out of five.
And that is markedly weak. Look at two. Movement, if you eliminate gravity, like maybe side to side, or you're holding their arm up and you ask them to move, that's significantly weak as well.
And then one out of five is just a slight flicker of a movement. And then, of course, zero out of five is completely paralyzed. But I can't impress upon you enough that three out of five is significantly, significantly weak, almost paralyzed. So just keep that in mind when we're doing these assessments that you'll see a lot of four out of fives. four plus out of five and five out of five, you'll see fewer three and beyond out of five, unless there's been an accident where the spinal cord is injured.
Now, many parts of the motor exam can help distinguish between an upper motor neuron lesion and a lower motor neuron lesion. Here are some of the things right here, what you would see, and these are signs, not symptoms. If you watch the...
pathology lecture, I believe we discussed the difference between signs and symptoms. If not, we'll review that. A sign is something that you can physically see. You can see. A symptom is something that the patient experiences and has to explain to you.
For example, a patient says, I am very nauseated. That's a symptom that they're explaining to you. If they're throwing up, That's a sign that you could say they are definitely nauseated.
Right. Sign is blood pressure. A symptom is a patient having a feeling that their head's about to explode. Right. So a sign literally is something that you can see or test like an asymmetric muscle.
a symptom is something that the patient explains to you. So weakness, you can see this in both upper motor neuron lesions and lower motor neuron lesions. Atrophy. initially in an upper motor neuron lesion, you will not see this. In other words, if after some time and there's no use of that muscle, then an upper motor neuron lesion, you know, because of disuse, you could see atrophy.
But with a lower motor neuron lesion, you will generally see atrophy because of denervation or a lack of innervation there. Fasiculations, you will see this in lower motor neuron lesions, not in upper. Reflexes, upper motor neuron lesions show hyperreflexia, so exaggerated reflexes. Lower motor neurons show a decrease in or high.
I'm sorry, I got distracted. Lower motor neurons are hyporeflexic. Muscle tone, hypertonia, you see that in upper motor neuron lesions, and not in lower, hypotonia in lower motor neurons lesions.
So hypertonic, hypertonia, increased muscle tone. This is why patients with spinal cord lesions or patients with cerebral palsy, for example, or... can have spasticity. So they have increased muscle tone. They have hyperreflexia.
Whereas patients that have a cauda equina syndrome will have decreased reflexes and decreased muscle tone. Now, we'll only talk about this. bit, these reflexes. It's good to know in case you see this on a patient's HNP, what it means when someone has DTRs, sometimes it's abbreviated like that, deep tendon reflexes, and they're kind of scaled like this.
They're rated zero to five and even five plus. And so If you see a surgeon come in and they check reflexes at the end of a case, or you see them pre-opening a patient and checking reflexes, if they have zero reflex, you know, an absent reflex, if they have one plus, this means that the surgeon kind of reinforces that, the voluntary contraction of the muscle, if they can do that. But If the surgeon moves the joint and tests the reflex, there's not much there. Only one twitch or one reflex or one beat of clonus.
2 plus is normal. So if they check the reflexes and they see a couple of beats of clonus, that is normal. 3 plus would be considered brisk, and it's starting to be indicative of maybe an upper motor neuron issue. A 4-plus or non-sustained clonus, sometimes the patients that have that certainly have a upper motor neuron lesion.
And then, of course, sustained clonus would be 5-plus beats of clonus in response to a deep tendon reflex. If it's 1-plus, 2-plus, or 3-plus, as long as it's symmetric, then that's still within the normal range. If there's no reflexes, hyporeflexia, or anything over four, which would be hyperreflexic, then that would be considered abnormal. Hyperreflexia is spreading of reflexes to other muscles not directly being tested.
For example, if the surgeon has the patient's ankle and they briskly move their foot forward and it starts to have clonus and five plus clonus, for example, and then maybe the tibialis anterior starts to contract as well. That's a spreading of the reflex response. Now, hyporeflexia, generally it can be caused by muscles or sensory neurons or lower motor neurons. And then sometimes neuromuscular junction disorders could show this.
If it's an acute spinal cord injury or acute brain injury, and there's hyporeflexia, that can exist there, but generally not in long-term upper motor neuron lesions. hyperreflexia can be associated with like a brainstem tumor, something in the upper motor neuron area. And this is just an example of how you'll see doctors test for specific reflexes here, not something you'll normally see in surgery or in the pre-op area. I did mention the Babinski response. And here it is in this diagram here.
A normal or negative Babinski sign would be shown in a normal plantar response where the surgeon takes a sharp instrument or a blunted sharp and runs it from the lateral aspect of the heel up and across the toes. Toes should go down. They should flex down when this happens.
If he does the same test and these toes fan and go up, that is a positive Babinski reflex. And that indicates that the patient has an upper motor neuron disease. An exception to that, if the patient is under general anesthesia, and the surgeon comes in and does a Babinski, and you see the toes flex up, don't freak out.
It doesn't mean that the patient suffered a spinal cord injury or a brain injury during surgery. It means that that surgeon is messing with you. I've had the surgeon that Tommy was talking about the other day that told me that Tommy should be wearing a helmet when he comes into the OR because otherwise he'd be banging his head against the wall.
He would do this to our students. He would go in and he would do a Babinski response and the toes would fan up. Well, that's a positive.
Babinski, is that indicative of an upper motor neuron lesion? Yes, unless the patient is under general anesthesia. And because of reflexes being part of.
the impact of general anesthesia. It's not an upper motor neuron lesion. The surgeon's just messing with you if you see a positive Babinski under general anesthesia. Now, there's a few other signs that you need to be aware of.
One is a Hoffman sign, and this kind of shows heightened reflexes or hyperreflexia. And it can be elicited by holding the patient's middle finger, as you see right here, and then loosely flicking the fingernail downward. And then it'll cause the other finger to kind of rebound and slightly extend.
This is indicative of hyperreflexia, and it's called the Hoffman sign. There's also an H reflex that... is done in nerve conduction studies.
And you can even do an H-reflex in surgery in lieu of motor evoke potentials if you're in a situation where anesthesia is not going to give you what you need. It indicates that if your H-reflex goes away during surgery while they're working near the spinal cord, you know that the normal reflex arc is not happening like it should. Some companies will...
They do an H-reflex every time they do motor evoke potentials. So if anesthesia does go too high and they lose their motor evoke potentials, they can still monitor their H-reflex. Don't ever do this. You know, there would be no need for you to do this.
But if you ever see the surgeon do this, do it. a check for an Osinski or bulbocavernous reflex. He is looking to see if the patient has experienced spinal shock. Sometimes if you get a patient that comes in and the patient is, you know, they have a spinal cord injury and they're not responding to anything.
If the surgeon meets them there in the OR, many times they'll come in and they'll check this bulbocavernous reflex. And basically you see how it's done here on males. They could put the surgeon may go in or the neurologist may go in and put on gloves and put his finger in the external anal sphincter and squeeze the glands penis to see if it contracts.
And with females, he just presses or squeeze on the clitoris while he has his finger in the anus. First time I saw this, I freaked out. I'm like, should I be taking a picture of this and calling someone?
Because I didn't know what the surgeon was doing. This was 30 years ago, the first time I ever saw this. But if you ever read that there's an absent BCR reflex, then it's indicative of spinal shock in that patient.
You're probably. not going to be able to be effective in monitoring because you're probably not going to get any motor evoke potentials, maybe not any somatosensory evoke potentials either. It's a sign of a injured spinal cord.
Coordination and gait, we're just going to skip right through this. There's some things we'll come back later and look at. The Romberg test, yes, you will see this on your CNIM exam. We'll go over that more. But it basically assesses gait and balance.
In other words, a combination of how the vestibular system and proprioception works together. And the Romberg's performed by asking the patient to put their feet together, just side by side, stand up and close their eyes. Now, if... they have any vestibular disturbance or proprioception disturbances due to spinal cord or nerve root or even upper motor neurons, then they'll start to sway back and forth.
So if it's a positive Romberg's, it means that they have that they swayed back and forth instead of remaining still. And it's indicative of a stibular or proprioceptive issues. A sensory exam, I like to use either the back of a writing pen or a cotton swab if there's a Q-tip in the preoperative exam.
I like to do this, use that. One of the most important things you can do when you're asking the patient to test their sensation in myotomes or in their dermatomes is to have them close their eyes. Because if you go in and you run a Q-tip across the... a medial aspect of the foot on both sides, and they're watching you do that, most of the time, they're going to tell you, well, you know, I feel you touching my left foot and feel you touching my right foot.
But if you have them close their eyes, you say, which foot am I touching? Where am I touching you at? And they should be able to describe each side that you do that. Otherwise, it's indicative of a sensory dysfunction.
This is something that I expect you guys to know at this point, not the reflexes perhaps, but certainly you should start putting the muscles to the nerve roots, myotomes, and sensory aspects to the nerve root, and that would be dermatomes. And what you'll find as a clinician, if you're really paying attention to what's going on and you really apply these fundamental principles, is again... If a patient comes in and you say, can you describe your symptoms to me in a preoperative exam?
And they may say, well, I can't really flex my elbow like I should. It feels weak. You know, my wrist extension, if they describe wrist extension is weak. And then I'm having a kind of numbness or tingling in the outer part of my forearm and my. thumb and my index finger, middle finger, you'll know that that's a C6 nerve root dysfunction.
If they say, you know, it feels weak when I lift my shoulders up or flex my elbow and, you know, the outside of my shoulder and they touch their deltoid feels numb and tingling. You know, that's a C5 nerve root compression. are also known as what? Radiculopathy.
It's a C5 radiculopathy that they're describing to you. And so this is, again, where we start learning this and putting it all together. You know, our knowledge of anatomy, our knowledge of neurologic function, along with the symptoms that the patient's explaining and the signs that you're able to see. This is, if you've got your neurologic secrets book.
you'll notice that it's kind of written in this manner. Neurologists especially are taught to think in terms of disorders. from the muscle to the cortex.
Let's say someone comes in and they say, I've got weakness. Well, weakness can mean many things to many people. Some people describe weakness as, you know, a faint feeling, but is that true weakness?
Or is a weakness a lack of mobility of a muscle? Or is it dizziness? And is dizziness vertigo? Or is it a more along the lines of a syncopal episode. Is the room spinning or do I feel faint?
So you see how people describe things can be different from one person to the next. I walked into a Hamilton Medical Center in Dalton, Georgia, which is in the foothills of the Appalachians. And I walked in there and there's this guy that looked like he'd, you know, walk down out of the hills. If you've ever seen Deliverance, you'll know what I'm talking about. And the guy's sitting there and there's like three family members.
And then there's a kid, about a 12-year-old kid in the room. And I'm doing an EEG on this patient. And I'm going through the HMP. And I said, has he ever had seizures before?
No, had never had no seizures. I'm like, okay. And I'm looking at how he presented to the emergency room.
And I'm like, have you ever seen him like? fall down and shake all over. Oh yeah, yeah, yeah.
Yeah. He has fits, but my terminology of a seizure was different than their terminology of what a seizure was. It was a fit. And so sometimes you have to kind of speak to the audience and at the level that the audience would understand who you're speaking with, of course.
So how do we do this? How do we check? to see where a lesion may be.
Is it in the muscle? Well, if it's muscle, then you can perform an EMG to determine if it's the weaknesses of myopathy. Is it in the neuromuscular junction like Lambert-Eaton myasthenia syndrome or myasthenia gravis?
You also can do a repetitive nerve stimulation as a neurological study. to determine if it's a neuromuscular junction disorder that can cause weakness. Remember, guys, when we think about weakness or strength, if I want to reach out and I worked out before class, so if I'm in there lifting weights, I have to think about it at the cortex first, and it goes all the way down through the muscles, through the spinal cord, plexus, peripheral nerves, neuromuscular junction to the muscle that enables me to lift. the weight. And so when we're trying to locate a lesion or when a neurologist is trying to locate a lesion or an emergency room physician is trying to locate a lesion, they think the other way from the muscle all the way back.
If it's muscle, is it myopathy? And what type of myopathy? And how do I test that?
The same thing if it's neuromuscular junction, what type of neuromuscular junction disorder? And how do you test that? If it's peripheral nerve? You know, is there a compression? Does the patient have carpal tunnel syndrome because the median nerve is trapped in there?
Or is it the plexus? Is it a brachial plexus avulsion or a stretch? If not that, is it the nerve root? And many times we see this in surgery, post-operative.
A few times we've seen it in surgery where the patient had a peripheral nerve injury from positioning on the bed, and the surgeon thought they may have injured the nerve root. during a decompression. I've gotten calls before and actually had to do a nerve conduction study to prove to the surgeon that the problem was a peripheral nerve that was compressed on this specific bed that the patient was on. When in fact, the, you know, the surgeon said, did you see any EMG activity? We said, no, it was clean.
We saw no EMG activity, which would be indicative of a nerve root injury and a lumbar effusion, but the patient woke up with a foot drop. And so I did a nerve conduction study using what's called an inching technique, where I stimulated below the perineal nerve, where I believe the compression was, and I got a normal response. I stimulated above the fib head on the perineal nerve, and I had a diminished response. And I brought the surgeon in and showed him the results and say, no, see, the issue is the peripheral nerve.
It's not the nerve root. Further is the... Lesion in the spinal cord is the patient myelopathic.
or is it on up into the brainstem or subcortical structures or the cerebellum, or is the lesion at the cortex? And when neurologists assess a patient, this is what they quickly think of for a muscle neuromuscular junction, peripheral nerve, plexus, nerve root, spinal cord, brainstem, thalamus, or basal ganglia, or the cerebral cortex. A patient's symptoms of being weak on one side could be in the brainstem, or it could be in the spinal cord, or it could be multiple nerve roots, or it could be at the cortex.
And so it's important for us to kind of understand that. And if you'll read your neurology secrets book, you will see that when it starts talking about pathology, it will, the first chapter, not chapter one, but when it starts getting into pathology, it'll talk about myopathies. then neuromuscular ejection disorders, then peripheral nervous system disorders, then nerve root disorders, and all the way up.
It's important to know what these signs are. You'll see Lhermitte's phenomenon listed on H&Ps sometimes, history and physicals, and you definitely will see this on your CNIM exam. And a Lhermitte's phenomenon basically is a Sometimes you hear it referred to as barber chair phenomenon, but not on your test, I don't think. It's when the head is moved forward, the chin to the chest, and the patient has an electric shock sensation going down the cervical spine and sometimes going on to the hand itself. Now, it's generally indicative of a lesion or compression of the upper cervical spinal cord.
Sometimes it could be something in the medulla. in the lower brainstem as well. Tenel sign, I was telling you about this before. This is when you tap over like your wrist, for example, the median nerve right there, and you feel a tingling sensation.
Now, you know, I've always heard this my whole life, a positive tenels indicates pathology, but I've had a positive tenels when I've tapped the median nerve before, and I've never been diagnosed with carpal tunnel syndrome. I've done nerve conduction studies on myself. There's no indication of carpal tunnel syndrome.
So they say a positive to nails is indicative of pathology, but I don't necessarily agree with that. Now that brings us to a preoperative assessment. Again, one of the things to keep in mind, we will talk about, we'll take a procedure that's going to be performed.
We'll take some what we read about in the patient's chart, and then we'll go in and do a cut down version of a neurologic exam specific to what is going to be at risk in surgery and what we're going to be monitoring in surgery. Generally, you know what, let me, yeah, let's go ahead. I'm going to pick at three o'clock. We're going to pick up right here. and then we're going to kind of have an interactive assessment so we can show you how to do a neurological exam, a motor and sensory exam of the upper extremities.
And I'll refer back to this because there's a lot of detail that I want to go into here. So we'll stop here and I will see you guys right at three o'clock and we'll pick up right here.