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Grand Rounds-Physical Examination for Nerve Injuries and Tumors

David Kline

August 15, 2014

Transcript

- Hello, and welcome to another session of the Grand Rounds. Our discussion today and the presentation is from a Department of Neurosurgery at LSU Health Sciences Center. I would like to specifically thank the chairman of the department, Dr. Frank Culicchia for allowing us to videotape the important presentation by the pioneer of peripheral nerve surgery. Dr. David Kline. Dr. Kline will talk about examination of peripheral nerves as it relates to injuries and tumors. Again, thank you for joining us.

- I can always tell when a resident, intern or medical student, had not examined one of my patients and how could I tell? Because the patient obviously had not been undressed. So we have a wonderful guy, who you all know, Gabe Tender, who is a volunteer and so, here's the first thing I'm gonna ask of him Gabe, take off your shirt.

- Yes sir. I know he's been working out a little bit and he's an associate professor here at LSU, so I hope he'll forgive me someday for this. So what, I'm gonna have you stand first because, and just turn a little bit like this, the most neglected part of an examination for a peripheral nerve lesion is the upper back. And why do I say that? I say that because there's some very important nerves there. The accessory that innervates the trapezius, okay? The long thoracic that innervates the serratus anterior, the rhomboids that are innervated by the dorsal scapular. So I'm going to look very carefully at his back, and see whether there's any loss of infraspinatus, supraspinatus, deltoid, rhomboids, okay? Accessory and trapezius covers over the supraspinatus, and I'm gonna ask him to do some things. And first thing I'm gonna ask him to do is to push out on my hand, with his hand. Now, just keep your arm bent. Yes, the textbooks show winging of the scapula this way, by having somebody lean up against the examiner or lean against the wall, I'm here to tell you that that only tells you that one of those three things that I mentioned accessory nerve, dorsal scapular to rhomboids or long thoracic to serratus anterior is out. So how do I check those? Well, I look for rhomboid atrophy, and I ask him to bring his shoulders back together can you do that? And he bunches up appropriately because the rhomboids run from lateral scap... or medial scapula over to spinous processes. And when they're out, you can see loss on one side, rarely on both sides. I'm gonna check a little bit for the trapezius and accesory by having him shrug his shoulders up and feeling here, but keep in mind the levator scapulae which is not innervated by the accessory can also elevate the shoulder. So what do I do? How do I get rid of that or maybe impune that accessory? I ask him to straighten his arm all the way out and push forward on me. Now, if his scapular wings, that's long thoracic nerve, okay? and that's goes to serratus anterior so if it wings, then I say, okay, this is long thoracic not accessory. If doesn't wing, then maybe the accessory is the culprit. Now while I'm here, of course I'm going to palpate on the other side of his supraspinatus and trapezius for any masses, any irregularities I'll feel along the clavicle at the same time, and I'll go like this and I'll go like that to see whether there's any radiating pain or tunnels like phenomena. And although we're looking for nerve things, I'm gonna have him turn his head off to the side and over to this side, and then I'm gonna have him rotate, rotate as I palpate and then I'll hit him up here and I'm getting so old now that I have trouble reaching the top of Gabe's head so I hope you'll forgive me for that. And seeing whether he has radiating pain out here. All right and while I'm back here, this is not approximately innervated nerve, 'cause all the others are, I mean, dorsal scapular, you know, goes to rhomboids and that comes off C5. Accessory cranial nerve 11 goes to trapezius. Long thoracic, which comes off the back usually of C6, but has input from C6 seven, sometimes eight and even five. They come off fairly proximally, but one muscle that's very important back here that doesn't, is innervated by thoracal dorsal and that is a latissimus dorsi, so that's an adductor, okay? So arm across, but in addition, it contracts when I have the patient cough or it should. Cough, really deep. and I'm palpating that now. And I bring this up because occasionally you'll see a patient who says, I can't move my arm, it's paralyzed, you know? And you look at them and you try to test them he doesn't move anything, you even take the pen to him and he says, I can't feel that. So what do you do? You come back here and you him cough and latissimus dorsi contracts beautifully, guess what? He has a problem, but it's not organic. It's inorganic, it's psychotic, it's neurotic, it's a problem up here but a different level problem. And when I was visiting professor at Walter Reed, they had such a patient who had been in two roadside blasts, and the first one left him with a partial plexus palsy, which over a nine month period recovered, and he somehow re-enlisted, got back over to Iraq, was in a second blast and after this one said, I can't move my arm at all but the EMGeer said, we don't find any evidence of deinnervation on EMG, what's the problem? So I got to see him and the problem was on the side that he couldn't move anything, the left arm, shoulder, forearm, wrists and, he had a beautiful litissimus dorsi, so he needed psychiatric help. Okay while I'm here, I'm going to look at supraspinatus. Can you bring your arm part of the way out to the side? Yes, that first 30 degrees is supraspinatus. I'm going to palpate it here and you'll notice as I examine his limbs I'm gonna be palpating at the same time I'm providing resistance. And while I'm here, I may as well do the deltoid, because that's this big muscle C5, C5 to posterior division upper trunk, posterior division of upper trunk to posterior cord, posterior cord to axillary nerve. Whereas supraspinatus is C5 to upper trunk to suprascapular nerve and infraspinatus, which is the external rotator out like that is down here and then you see how he bunches up. And sometimes when there's doubt, I'll come over and I'll lend some of my avor ploy, my own belly to him to hold the elbow in and see whether he can move it out and with what force he can do that. And of course, I'm looking for adduction here too, across the chest as well as down to the side, 'cause those are functions of latissimus dorsi and pectoralis major. All right, now I'm gonna have Gabe turn around a little bit, are we still okay? And I'm gonna look at upper arm innovation. And first thing I'm gonna test is what you all hear about all the time, the biceps pull up now, Gabe, and I'm gonna do that from both the flat, up can you come down here? I'm gonna test it both ways, and then with a partially bent and up, and sometimes you'll see the difference there so it's important to test most of those. That's of course C6, C6 to upper trunk, upper trunk to anterior division of upper trunk, anterior division of upper trunk to lateral cord, lateral cord to musculocutaneous. Now often forgotten, is the other major flexor of the elbow. And that is the brachioradialis. And the brachioradialis, it's got a different pathway. That's C6, down into posterior division of upper trunk, posterior division of upper trunk to posterior cord, posterior cord to radial nerve of all things. And it's the second muscle after the triceps innervated by the radial nerve. So how do we test that? We turn part of the way between pronation and supination and have him pull it up and you can see the tendon come up here and it's a very strong flexor of the fore arm and how many patients have we seen where the referring doctor says, well, you know, I don't understand he's got good flexion, I think his biceps has got to be okay Well, it wasn't, you know, because it was all brachioradialis doing that. While we're here, we're gonna look at triceps and I'm gonna feel that and I'm gonna also do that in two positions all the way up like that and feel the triceps and then halfway down between full flection and extension and feel it again. All right? And I meant to mention, with the deltoid of course, you can look at the posterior third, the intermediate third or lateral third and the anterior third. And certainly that's valuable in somebody who you suspect has axillary nerve palsy because they least involved, you know, will often times be the anterior third or so it'll appear because the biceps tendon goes across that joint and it substitutes at least for the anterior third but then when you bring deltoid back and look at it, its close to your third, wow, you collapse it very easily. Okay. So what about triceps? Well largely C7, but also C8 in some patients C6 as input. And of course again, that's mainly middle trunk and middle trunk down to posterior division, posterior division to posterior cord, posterior cord to radial nerve. first muscle innervated by the radial nerve, the second being the brachioradialis. All right. I may recheck his pectoral muscles here, pull in to the side, pull in to the side and there, of course in him good in full. Now Gabe, could you sit down at this point in time? Yeah, okay. Now I like to take his hand in mine because I'm gonna test two things that are terribly important. The Supinator, which is the next major muscle innervated by the radial nerve, or perhaps after extensor carpi radialis. Turn palm up, and I'm gonna palpate that here, although admittedly it's hard to isolate that by palpation, palm up. With the arm extended and then pronator, I'm gonna do that in two ways. I'm gonna do that with the arm extended, can you palm down? That's good, and then I'm gonna flex, now palm down again, because there are two pronators that work to provide pronation. We can talk a bit about that input which of course comes the median, which is the first muscle off the median and is that pronator teres. There are after that, a bunch of muscles that provide wrist flection, pull up like that, and the AIN, which is flexor profundus to the forefinger, pull that down towards me, okay and sometimes this finger although this finger shares a tendon with that to the ring finger, so you pretty much have to isolate that by extending it to just test this one can you bring it down now? Okay. And then flexor pollicis longus, that's the AIN palsy. And that's a frequent board question too almost as frequent is PIN palsy ritual , get to in a moment . And we'll finish off the median in a moment too. But while we're at it, let's just look at the rest radio and look at PIN. And there are two extensors to the wrist, there is the extensor carpi radialis, which is the more proximally innervated muscle, can you pull it over in that direction? Yeah And then there's the extensor carpi ulnaris, which is next down in line, and then the extensor communis, can you bring your fingers up and back? And this one you have to be a little careful of, because your interossei can produce some spread and make it look like extensor radio communis. So how do we get rid of that? We just ask him to come over here, and put that hand flat on the table and lift his fingers one at a time. And you know, PIN palsy entrapment beneath the supinator it's hallmark is weakness and extensor carpi ulnaris, extensor pollicis longus and extensor communis So the fingers and sometimes some are totally out, so that produces finger drop and other times they're all out or all weak and then we'll talk about sensation for the radial nerve a bit later. Well, what are we sort of leaving out here? We're leaving up ulnar nerve 'cause that's another nerve and that's coming off of lower trunk, C8-T1, okay? And it's coming off its divisions down to medial cord and medial cord going down to most of the ulnar innervated muscles. Now one that's an interesting muscle, is flexor carpi ulnaris, can you come over that way? And I like to do that with a hand horizontal over that way. And it's interesting because you can have a divided nerve here at the olecranon notch level or even higher up and still have that muscle working because branches takeoff from arm level, as well as below the elbow level, right below it, after the nerve goes through the olecranon notch level so it's amazingly often spared with all nerve lesions. The ulnar nerve then doesn't do too much until it gets to the flexor profunda, and so pull that down now, and again, I'm splitting the first interphalangeal joint. I'm asking him to pull it down. And I usually use my little finger to test that like this one for the ring finger, I'm gonna use my ring finger to test it and I should be able to break it. While I'm here of course, I'm gonna test the median innervated profunda. And again, I'll use my long finger here then my forefinger here for that. Then the only nerve after the profunda, it doesn't do superficialis cause that's median nerve, it comes all the way down here, sort of beneath the flexor carpi ulnaris and then it gives off a dorsal sensory branch that comes around the back of the hand, dorsal ulnar sensory branch and provides sensation there and then it comes down and goes into IANs canal under the hypothenar eminence to do first, the abductor of the little finger, can you pull that over? And again, I like to do that from the horizontal, I don't give him a chance to get it back that that would be radial. I give him a horizontal target, horizontal to what I want, okay? And then the opponents down neural nerve for the little finger, down here Gabe, I'll give you a little different target, you may have to adjust that and I should be able to spread my fingers apart. And in his case I can, if I can, there may be weakness in the opponents, okay? We've already talked about the lumbar scouliosis and this has straightened that out. Straighten that out, okay, I shouldn't, my little fingers shouldn't slide off his little finger and my ring finger shouldn't slide off his ring finger. Okay, we did the abductor. What about the interossei? Well, again, good way to do that, is to get the hand on a flat surface and ask him to spread the fingers apart. And then I'm gonna give some resistance here to all of them to see if there's any weakness and another way that I think the residents or somebody like Gabe remembers me doing a lot, is in the clinic. I'll just put my hand up against his, okay. Spread the fingers, okay. Now those are interossei, you're not having much, if any extensor communis mixed in with that. Then we come over here, abductor pollicis. That's the last owner muscle innervated, because we already mentioned, last hour, that flexor pollicis brevis gets input from all our nerves, but also for median nerves, so it seldom makes sense to test that and seldom is it with an ulnar palsy because the median will take over, but abductor pollicis right, at into this part of the palm in there, and of course, people love to do, you know, this test where they take an envelope of some sort, this one doesn't have money in it Gabe so no sense looking. Yes, so hold that envelope by coming down like that. And then if they bend the tip of the forefinger, which is median innervated, to try and hold that envelope, then you know, they have all their weakness and their abductor is weak and that's called a froment sign. Can you sort of, yeah, reproduce that? Froment, F R O M E N T, okay. And again, we'll do the median and ulnar and radial sensation. We do need to talk a little bit though about several things connected with median. Remember we got past the flexor profundus, and then after that, you know, or before that the flexor superficialis. Now I like to put my fingers here, hold down towards the palm of the hand. That's should be flexor superficialis, mainly flexing these proximal digits rather than the distal digits. Then after that, we come down to the profunda, which I already talked about AIN, 'cause that's flexor pollicis longus like that and then opponents pollicis, and again, if you'll forgive me videographer, I'll have to shift here, put that down on my, no, just without bending your thumb, just put it down straight, if I can separate my fingers, then he has weakness in the bones and I give him a target over here, close to the base of the little finger, push down like that. Now as probably, some of you recognize a lot of people with severe medium palsy can still do an opposition maneuver, how did they do that? Well, they do that by using ulnar innervated flexor pollicis brevis to come across the thumb, a little bit and then abductor, to complete that, and then if their median lesion is low, they have flexor pollicis longus innervated up here they can bend the tip of the thumb down like that and there you have an opposition movement and you need to know about that. Other thing you need to know, if there's a combined radial and median palsy, and again videographer forgive me, you've got to substitute for extensor pollicis longus by pushing, putting your forefinger like that. And now opposition, okay substitute for it by putting your forefinger like that. Now hold that up against me, that'll be true opposition 'cause otherwise, excuse me, without the extensor pollicis longus, when they try to do opposition, the thumb comes back like that. And true opposition, is at right angles to the palm. Now somewhat controversial is the sensory area. And I'm gonna share with you my prejudices. I like to have both hands down on the knees and I ask the patient to close their eyes, okay? And then there are autonomous zones for the median nerve, as well as the ulnar nerve, less certain for the radial nerve, but for the median nerve, it's this part of the forefinger down, a little past the intermediate phalange, and on the back of the distal phalange somewhat less so on this finger and of course this part of palm and of course this part of the thumb, the volar part of the thumb. So I'm gonna do this and I like to use my own fingers so I can modulate the amount of touch I'm giving, making sure it's equal. And I'll ask him now, is there any difference in my touch here? And of course, if he has a median palsy, he's gonna say yes, I don't feel this well. If it's a right median palsy on the right and the same is gonna be true here on that part of the forefinger, maybe less true over here on the long finger. If I think he's simulating, maybe a couple tone of patients that said mobile operations, complaining of numbness all the time. What do I do? I ask the patient to turn his hand now palm down and I go over here and I test this back of the forefinger. If he tells me that's fine, guess what? I'm very suspicious of him because, if it's out on that lower surface of the forefinger, it's always held back there, unless there's a digital, you know, palmer entry or something, but for a median palsy, that'd be so. How about the ulnar nerve? Well, it's autonomous zone is somewhat similar, but for the little finger, and so I'm gonna check and do that with my touch. And sometimes a harder touch will give a response, but that's valuable because I sort of modulated how bad his sensation is. I'll do the same thing here on the ring finger, and very importantly, I'll do it on the back because if it's a true ulnar nerve sensory loss, it should extend to the back of the little finger less so the ulnar of the ring finger, and certainly over the hypothenar eminence unless, okay, the dorsal sensory branch is fair 'cause if the lesion is at a risk level, it may have spared that dorsal sensory branch, which comes off about an inch above the flexor crease and winds around so that he would have good sensation back here even though it may be absent there or over here. Now I also like to do PIN and this is the part of the torture that I promised your coordinator for. She said, torture doctor Tender plenty. No she didn't, but I'm just making that up, okay. So palm down and I'm gonna say, you know, is there, do you feel that? Is that sharp or dull?

- Sharp

- Sharp, is this sharp or dull?

- Dull

- Okay, is this sharp or dull?

- Sharp

- Is that sharp or dull?

- Dull.

- And I'm gonna do that in the autonomous zone of the median, autonomous zone of the ulnar, both sides compare both sides. And some of my colleagues fought me for that, who are plastic can people, why am I not doing two point discrimination? Well two point discrimination is very good and I love Raymond Curtis when, he's dead now but when he was alive, he made a huge contribution in that area as did others. But, it's not very practical for practical use, but touch and appreciation of pain, sharp and dull is very practical, very practical because that's what you live with, that's what you combine with. What about the radial nerve? Well, the radial nerve it's said to have an autonomous cell. Can you extend your thumb back in this area, in the anatomical snuffbox, can you really bring it back? Gabe doesn't have much of an anatomic stuffbox. You could not be washing toning, Tony, and back in Washington state, you wouldn't be snuffing much snuff, but it's said to be in this area, but we've all seen patients and I think Austin, you have, especially where the radial nerve, motorwise totally out a nerve transected known to be transected. They have pretty good sensation on the back of the hand, but when they do have their loss, of course, it's gonna be up the backward dorsum of the forefinger less so the long finger, up the back of the thumb, because median is over here, over here, over here with variables split with the ulnar ulnar is over here, here, and sometimes here, depending on whether dorsal scapular is distal to the lesion or not, or dorsal of the dorsal ulnar cutaneous nerve. All right, I think now, people say, well, PIN palsy, all right, weakness or loss of extensor carpi ulnaris, okay. Dropped fingers or weakness in extensor communis, and oftentimes the thumb, extensor, extensor pollicis longus, AIN palsy, weakness in flexor Profundus, forefinger down like that, can you pull it down towards me? And weakness in flexion of the flexor pollicis longus so inability to make an O and that's the O sign. Well, what about the all frequent carpal tunnel? That brings me to a very important part of the exam. You're inspecting, you're palpating, but you're also percussing, okay? Is there tunnels in this area, but more importantly, is his phalanx sign positive and time to one minute does that produce paresthesias in the median or hand of any sort. And then some people like to come over and compress over the flexor crease and some people even move it up and compress over where, what I say is the true transverse carpal ligament up here again for a time minute to see whether that produces paresthesias or any sensory disturbance. For the ulnar nerve, very important is to see in my view, whether there's any tunnels along its course, and so disorders that are spontaneous up here are rare, but in the olecranon notch, and then while I'm here, I'm gonna try and find out, by putting the wrist and hand in different positions, not just pure flexion, but flexion protonated, flexion supination in supination whether there's any translocation of the ulnar nerve and you all know, translocation the ulnar nerve doesn't make the diagnosis of ulnar entrapment palsy, but if they have that, it's more likely to be that if there are other symptoms paresthesias in the ulnar distribution or mild weakness and hand intrinsic and, in my experience, a lot of the ulnar palsies where the conduction studies were normal, had very, very mild sensory changes, which you could fault me for, or very mild motor changes, particularly in abduction with the middle finger opposition of middle finger perhaps interossei. We should say, you know, are we checking for thoracic outlet? We might be depending on the symptoms. And I do the old fashion things to see whether the pulse goes out with abduction of the arm, do a reus and bring it back here to see whether the pulse goes out and always matching one side against the other. Are they proof positive of thoracic outlet syndrome? No, they're not. But then, maybe perhaps coupled with some mild hand intrinsic change with or without EMG on concomitant may suggest that as a diagnosis, although as Austin would tell you, I'm pretty conservative about that diagnosis. People say, well, you know, in our series of all our entrapments that we operated on and did direct recording, two spots above and then moved our recording electrode below and at different spots down here, we found 62 people that had normal pre-up induction studies done by excellent electromyographers. Well, they're stimulating here recording from hypothenar or coming down below and stimulating there and recording here, in any case, they're going along a long distance of less involved nerve. And with inching studies that somebody like Austin or John England could do, then your take rate is better on, on showing conductive changes across the elbow. Same can be said for the carpal tunnel. Can you have a carpal tunnel without conducted changes? Yes you can. But then that is a challenge for the electromyographer because instead of just going with sensory electrodes here on forefinger or long and recording here, they come down and stimulate down here so distance across the suspected abnormality is shorter and more likely to show an abnormality. Have I described that poorly, Austin?

- [Austin] No comment.

- Okay, nice of you to say so, all right.

- You know, I'm very, It depends on what you take as your goal is to, I'm very reluctant to accept that there are clinically significant...

- Yes, and that's still remains controversial and should people operate on those, you know, or not. And that's another matter altogether sort of outside the topic that we're discussing today. All right, Gabe. Now things get tough because I'm gonna ask you to stand up. And even though Gabe is showing up with a lower extremity injury or tumor, I have him here. So I'm gonna ask him to bend over. I'm gonna see what his range of motion is as I palpate the back and as I progress along that, straighten up, now bend to the right, and bend to the left and then back, okay. But very important here, can you lower, take your green pants off I think you have something underneath that, do you?

- Yes.

- Yeah, this is sort of embarrassing, I guess in some ways, oftentimes neglected with lower extremity lesions is what the buttocks are doing. Do they have equal bulk or is the bulk different? Is there tenderness in the sciatic notch area or down along the course sciatic nerve after comes underneath the muscles back here and heads down towards the popliteal space? Is there any tunnels when I do that? Do I palpate any abnormality? Okay, now Gabe, can you turn around now and just, no take them all, all the way off, take your pants all the way off. Thank you so much. All right, can you kneel on the thing here? I like to bring out the ankle jerk in a kneeling position and oftentimes I add a little Tender Zack maneuver to it. Can I just take your socks off? I guess I'm gonna do that, whether I can or not. I'm gonna compare the ankle jerks here and put pressure on my hand, that's too much, just very gentle, okay, little more, little more, okay. And I'm gonna carefully compare the two and we didn't do much with the upper extremity reflexes. The slightest injury or involvement of the nerve will oftentimes takes us away, but of course it will change for biceps, triceps and wrist, and so forth. I'm just going to move this now off to the side and I'm asking you to climb down, now. And can you lie up on this table? You'll have to be careful because I'll hold it here. Can you just lie down supine? That's good, okay. I think there's a great deal of misunderstanding here also, very important to check a number of things. Can you lie back now? All right, with him prom, we can check for extension of the hip, abduction of the hip and adduction the hip, but very important, it's gonna be flexion of the hip, which is a femoral innervated function, can you lift this up? Okay. And providing resistance to him and palpating in this area, inguinal area. And I may double check abduction. Can you come over this way? and adduction of course, after radial nerve, okay? And I'll do that on both sides and I'll check both sides and I'll check sensation here, whether there's any difference in my touch over the quadriceps, more medially and more laterally in the area of the lateral femoral cutaneous nerve. And I'll do the same with pinprick. But there's a reason I had him laid down. And the reason is this, that occasionally you'll see a patient who says he can't use the leg and how do you double check that? We double check the arm paralysis by contraction of latissimus dorsi that entracted, then his paralysis is less than real if he's claiming total paralysis. And here's a little maneuver you can use for the leg, let's assume that he says he can't move the right leg, he can't lift it off the table, what I'm I gonna do? I'm gonna put my palm under the heel of his opposite leg and I'm gonna ask him to lift it up. Can you lift it up now Gabe? If he has function, of course, I'll see and lift, but if he's not trying, he won't be pressing down with the heel of his good leg on the palm of my hand. Then, sorta nifty is to reverse that and put my palm under the paralyzed, quote on quote sign, and ask him to lift the other side, which he knows is good or at least he claims it is, lift it up. And guess what? I feel him pressing against the palm of my hand with a quote on quote, paralyzed leg. Very important cell of understood maneuver. Do you all get that? You understand that. All right, Gabe, can you sit up? And our neurology friends will tell us, can you move forward here? Frequent diagnosis, diabetic neuropathy, well, okay. Now this entangling, maybe in the femoral distribution, but an early loss is gonna be of course the quad reflex. Can you take your hands and pull? Gabe is pretty buffed up so he's, he's not used to this kind of hammer. So checking those and matching them becomes very important. And that's a frequent board question on our boards. You know, they'll give you a patient who complains pain and paresthesias in the thigh and then they lead you down the golden path where you've got an MRI of the back and shows a little change so then you opt for a monogram, but you've neglected to couple things. You haven't gotten an EMG at two or three weeks after the onset of symptoms, and you've not carefully checked the knee reflex and done a careful examination, 'cause if you did, then you'd tumble to the diagnosis particularly after a two hour glucose test at diabetic neuropathy. Now while I'm here, I'm going to ask him again to lift his leg up early femoral nerve, lateral femoral nerve, the quadriceps I'm gonna match that on the two sides. And I mean, iliopsoas and psoas and then I'm going to match quadriceps. Can you extend it out like that? Extend it out like that. And then I'm gonna deal with a sciatic nerve. Remember some branches come off, at almost a pelvic level, but certainly at a sciatic notch level to go to the glutes, but further down the hamstrings get innervated and very important is the lateral hamstring so I'm gonna feel for that tendon over here, pull back and then I'm also gonna check on that at the other hamstring and I'm gonna match up the two sides. Then I've done the quadriceps, I'm gonna come down now and deal with the two divisions of the sciatic nerve, which are the tibial and peroneal. So very important of course, is the peroneal, is there any tenderness or mass in the popliteal area or over the head of the fibula? What about the external or the first branch that's gonna go to the version of the foot, the peroneal, okay? And after that to the tibialis anterior, pull the foot back up, you should see that tendon spring up and then the extensor to the big toe can you pull that back up? And the other extensors, okay? And I'm gonna go over to now the tibial side, and I'm gonna look for inversion of the foot, okay? Plantar flexion, push down, I'm gonna palpate through the gastroc while I'm doing that and toe flexion for big toe and the other toes. And I'm gonna do a careful sensory test. And part of that, is gonna be looking at things like saphenous, which is an early branch off the femoral. Some say that femoral sensory branch, I think oftentimes misunderstood, is the fact that the femoral nerve itself has sensory fibers in it that go to anterior side, so the saphenous is not the total sensory story for the femoral nerve, but it's an early branch and it comes down and gives sensation along the inside of the lower leg, and sometimes over the medial malleolus and closer to the heel. I'm gonna check soleus, which is more lateral sensory character, of the lower leg, major input peroneal but also get some tibial input behind the knee and the popliteal spaces where those branches come off. And then I'm gonna check for peroneal loss of dorsum of the foot and tibial loss on the sole of the foot. And I'm gonna once again, match touch in those areas and see how he responds with the eyes closed. I'm gonna the PIN which I won't torture him there with that at this point in time. For the neurosurgeons in the audience, particularly those getting ready for boards, how do you tell the difference between a disc that's L5 and a peroneal palsy? That's actually pretty straight forward when you think about it because the peroneal palsy, you know, should affect the peroneal distribution but in addition, the disc at L5 is gonna affect inversion of the foot, okay, whereas the peroneal nerve being injured, isn't going to affect the inversion of the foot. So that's a common differential, of course, there's many more that have to do with your EMG tests and so forth, but just a little point. So Gabe Tender, I thank you very much. And be happy to answer questions or hear comments from the audience, thank you. Any?

- How about C8 nerve palsy?

- Yeah, C8 and T1. C8 of course is the medial cord, which comes down and gives you all your hand intrinsics except for abductor pollicis, which is more a T1 muscle than C8, okay? But both C8 and T1 do interossei, they do a hypothenar muscles they do some of flexor pollicis brevis the median doing the rest.

- Versus the ulnar

- Yes versus ulnar, yeah very good point. because there isn't a lower trunk or medial cord versus a pure ulnar very important differential and there, of course, you're going to have some thenar loss if it's medial cord, as well as your ulnar distribution loss, you're going to have some abductor pollicis loss opponents pollicis loss and that's an important differential too. So that's good, you brought that out, anything else ? Don't be shy, I'm retired so I can take it all. Yes.

- [Man] Could you introduce Dr.Sumner, 'cause a lot of the residents don't know him and you mentioned him earlier how important he was for your team

- Oh gosh! Well, Austin Sumner, magnificent individual and recruited from Penn after a period of time in San Francisco, I believe And before that Queen Square and a superb electromyographer as is John England and some other people, but truly superb. And I worked with him. I don't know Austin, I guess by the time I retired, it had to be close to 25 years. His predecessor as an electromyographer. Well, let's never forget him too. It was her Earle Hackett and totally different personality, totally different skills and abilities, but also a magnificent individual. And I've been blessed because at Michigan, when I came out of Walter Reed, I had an electromyographer that neither John or Austin or Earle really knew because he was in physical medicine, but he was a suburb individual and I was very lucky with that association myself as a resident and very lucky to come to LSU and have the pleasure of recruiting I think helping to recruit you, you know, I found him to be much more of a horse person and a dog person and all those other things, than a neurologists, I worried about that, but I soon found out he was a superb neurologist and electro biographer so, Austin Sumner wave your hand, so they see who you are.

- You've actually been goosping to a loss to hearing.

- We run a clinic together and Austin would oftentimes see the patients before I, but not always and do his own exam, and I benefited greatly from that because he was very careful about documenting all that and then do his EMG. And then I'd do my exam and history taking, and then we didn't always have a meeting of the mind, but we always had great discussions which led on to lunch and other things and we always respected I think each other greatly, I hope he respected me, I respected you we'll leave it going.

- Absolutely

- Yes Ali

- I'm Ali Edmonds from Tulane Orthopaedics. And when I first came to Tulane in 1976, Dave has taught me a great deal. And..

- Thankyou

- As you can see, he's a master teacher and he's a master surgeon. I'll never forget when I was on top of Tulane Hospital, and the helicopters were airlifting out a bunch of people, Dave showed up with the group of charity patients who were rigged up on, They were lying on doors, they taking the doors off

- Yes

- And they had two patients on one door and they had T tubes ripped up so that when you squeeze one and boot bag, both,

- Chest

- lungs went up. He wanted those patients on helicopter out and he got that But we had been

- Took a long time Took a long time to get that done

- Took a long time, but we have been gifted to have you here for so long. And it's great to see you.

- Great to see you too, and I appreciate everybody coming. And I thank you, Frank, for arranging this and for the AANS who I think is making a video of this, which then will go on to other medical centers and other neurosurgery programs to help encourage involvement in nerve and nerve cases and to help document the findings. And in spite of all the modern equipments like MRI and MRA and all the scanning devices, examination of the patient with a peripheral nerve disorder, whether it be injury entrapment or tumor is still very paramount, very paramount as is skillful electrophysiologic studies, pre and postoperatively and of course my own prejudices for those that we can do intraoperatively as well. But it's an area where I think one of the last areas, at least ,where surgery will go out, will no longer be useful. This is one of the last areas that will persevere because it takes surgery to get to the lesion, to evaluate it, to repair it, to get it out. And there's no good substitutes at all. There may be for many other things, including brain tumors, including aneurysms, but not for nerve disorders. That's my prejudice.

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