The Neurologic Examination

The purpose of neurologic examination of a child is to assess development and integrity of the nervous system and to determine location and cause of suspected dysfunction. Achieving these goals is often complicated by three impediments: (1) the patient’s age and willingness to cooperate, (2) the complexity of the complete neurologic examination, and (3) the fluctuating nature of neurologic function. Many patients would prefer to play than be examined and often fear the examiner. To win cooperation, it is important to establish a comfortable rapport with young patients by engaging them in play as they sit on the exam room floor or in a parent’s lap. An examiner who feels competent in assessing neurologic function in a child searches first for the most relevant findings while the child is cooperative and begins with the least-threatening maneuvers. Compared with examination of an adult, neurologic examination of a child requires more observation, considerable flexibility, greater patience, and less reliance on instructions that children might easily misunderstand. Not only is repeated examination helpful, because cooperation can change as a function of mood, energy, or familiarity with surroundings, but a complete neurologic examination also may require more than one session. In addition, neurologic function often fluctuates. Children with tic disorders, seizures, complicated migraines, sleep disorders, dystonias, or stereotypies can appear completely normal during examination at one time while manifesting neurologic dysfunction if examined at another. Thoughtful examination, therefore, requires looking for signs associated with presenting symptoms or for subtle abnormalities that suggest an associated or predisposing condition. Neurologic impairment is not merely the sum of abnormal neurologic findings. A child typically manifests patterns of impairment, and the goal of examination is to discern coherent patterns amid abnormal findings. For example, a decrease in the width of one thumbnail, together with slightly greater floppiness of the ipsilateral foot and slight external rotation of that leg, can provide the only evidence of a subtle hemiparesis. Although it is important to be familiar with classic presentations of neurologic dysfunction, a good examiner must also be able to discern subtle presentations of hemiparesis, paraparesis, brainstem abnormality, or autonomic dysfunction. Although the neurologic examination is formally divided into several sections to help us remember the complete exam and to facilitate analysis of our findings, it should be tailored in response to the specific symptoms and needs of the child being evaluated. Highlighted below are approaches that are commonly useful; more detailed examinations are described elsewhere.