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Acute Medicine 2014; 13(4): 178-180178
Viewpoint
© 2014 Rila Publications Ltd.
D J Nicholl
Background
The neurological examination is a fundamental
part of undergraduate and postgraduate medical
examinations, yet a number of threads of evidence
suggest a level of assessment in acute neurological
emergencies that would be insufficient to pass an
undergraduate medical examination.
Acute neurological emergencies
Epilepsy
Seizures account for 2–3% of emergency department
attendances in the UK, yet the NASH (National
Audit of Seizures in Hospital) showed that only a
minority had a reasonable neurological examination
(only 36% of patients had plantar reflexes examined).
Only 70% of ‘first seizure’ patients had an ECG,
despite clear guidance from the National Institute
for Health and Clinical Excellence. Following the
emergency attendance or admission, care was poorly
coordinated, with only half of patients referred on to
‘first seizure’ or epilepsy services.1
Subarachnoid haemorrhage
The UK national confidential enquiry into patient
outcome and death (NCEPOD) in subarachnoid
haemorrhage, in 18% of cases, when initially
assessed, no neurological examination was either
performed or documented.2
• 32% of secondary care hospitals had no
protocol or policy to investigate and treat
acute onset headache.
• 43% (32 of 75) of patients in primary care had
their diagnosis of aneurysmal subarachnoid
haemorrhage overlooked, a delay that may
have affected the outcome in 72% (23/32).
• 13% (49 of 383) of patients in secondary care
did not have a timely diagnosis of aneurysmal
subarachnoid haemorrhage; in 10 (20%) of
these, the outcome was adversely affected.
• 13% (51 of 383) patients in secondary care
experienced a delay related to their CT scan; 7
deteriorated as a result.3
Other admissions on the acute medical take
A recent study identified that 33% of patients
admitted on the medical take as neurological
emergencies could not recollect being examined
with a tendon hammer, while 48% said they had not
been examined with an ophthalmoscope.4 In the US,
the figure was even worse- only 14% of those with
symptoms which would necessitate examination
with an ophthalmoscope (mainly headache) were
actually examined with one.6
These findings are disturbing as neurological
disorders carry such a high risk of mortality and
morbidity if poorly managed (table 15- lists those
disorders I have personally seen in ‘table top reviews’
(our local process for case review where a concern
of patient harm has been raised)over 12 years- in all
instances there have been issues in relation to the
quality of the neurological assessment.
Why do failings in neurological
assessment occur?
The reasons are complex and are reviewed elsewhere,
but neurophobia- a fear of neurology may have a role,
combined with difficulties in access to equipment,5
such as an ophthalmoscope.6 Some groups have, in
effect, dropped direct ophthalmoscopy altogether
and opted for other modalities. The use of non-
mydriatic ocular fundus photography (comparable to
a diabetic eye camera) is one (expensive) solution7,8
- a camera costs in the region of $25,000. Others
are developing Smartphone applications for retinal
photography ($500/adaptor) which are being trialled
in developing nations. The latter could be very
promising more generally.9
It is possible there is an over-reliance on imaging-
a false reassurance could occur with many of the
disorders listed in table 1 if a CT scan was ‘normal’.
Conversely, there is the risk of VOMIT- victim of
modern imaging technology- causing harm from
inappropriate imaging.5 This is why the neurological
assessment is crucial prior to requesting any imaging
or investigation. Decades before the existence of
MRI, the late Bryan Matthews’ made the somewhat
David J Nicholl
Dept of Neurology,
City Hospital, Birmingham,
Correspondence:
David J Nicholl
Dept of Neurology,
City Hospital, Birmingham,
B18 7QH
Email:
David.nicholl@nhs.net
Abstract
The aim of this paper is to outline the background to several recent papers which highlight deficiencies in acute
neurological care- all of which highlight (to differing degrees) issues in relation to neurological assessment with some
proposed solutions. Given that 10% of acute emergency admissions are for neurological conditions (up to 20% if stroke
included), this should be of concern to all acute medical physicians.
Are the skills of neurological
assessment in need of resuscitation?
178
Viewpoint
Acute Medicine 2014; 13(4): 178-180
Are the skills of neurological assessment in need of resuscitation?
© 2014 Rila Publications Ltd.
179
prescient comment ‘if [investigations] can be carried
out by the signing of a form requesting someone else
to do them there is a temptation to obtain as much
information as possible by this simple method’.10
In my own Trust there has been an 18% increase
in MRI requests just in the last year, the USA now
spends over $1billion dollars per annum just on MRI
imaging for headache.5 Given the risk of finding
incidental findings on MRI,11 there should be a wider
debate on appropriate use of investigations. In the
US, there has been a big emphasis on the “Choosing
Wisely” campaign to try and prevent inappropriate
investigations in a wide range of conditions.12 Finally,
MRI is not an infinite resource- a source of helium is
essential as a coolant for MRI scanners, yet there is a
global shortage of Helium.13
A neurological assessment
for the 21st century
For all of the above reasons, I argue that we need to
ensure that a proper neurological assessment does
need to occur in any acute medical patient. This does
not need to be lengthy and time-consuming (a rapid
neurological assessment can be performed in less
than 3 minutes)5 but it does need to occur. Moore
et al identified 22 core items in the neurological
examination that are key (in a patient where the
history suggests that there are unlikely to be abnormal
findings on neurological examination):14
• fundoscopy,
• light reflex,
• visual fields,
• pursuit extraocular movements,
• facial muscles,
• tongue,
• gait,
• tandem gait,
• pronator drift,
• rapid alternating movements of arms,
• finger-nose,
• tone in arms and legs,
• power in arms and legs,
• reflexes (biceps, brachioradialis, triceps, patellar,
Achilles, plantar)
• light touch.
If we can ensure that these core items are
performed and all acute physicians are knowledgeable
in the initial assessment and management of the
conditions listed in table 1, we will likely see a
major step forward in the care of patients with acute
neurological conditions.
Clearly clinical skills are relevant to all acute
medical specialties, not just neurology, and it is quite
correct to challenge physical signs of uncertain value
(eg Tinel’s sign in suspected carpal tunnel syndrome,
the clinical assessment of suspected community
acquired pneumonia- see Simel & Rennie15 for
many excellent examples). Studies such as the TOS
audit provide one method, via patient recall, to audit
completeness of examination for clinically relevant
physical signs.4 TOS assumed that all doctors have
access to a stethoscope as a surrogate control for
the questions regarding recollection of examination
with a tendon hammer and ophthalmoscope. This
may not always be the case in the future- as some
have suggested dropping the stethoscope for a
handheld ultrasound scanner.16 If this is to happen, it
is essential that such new technology, as with PEEK,9
are properly evaluated. Other forms of patient recall
audit in other medical domains could include- rectal
examination in suspected melaena, or HallPike
manoeuvres in episodic vertigo.
If there is one lesson I have learned from
performing the TOS audit it is this: if I read
“Neurology NAD” in the patient’s notes, this should
never mean ‘not actually done’. That truly is the
path to self-fulfilling neurophobia for the clinician
concerned.
Table 1. Acute neurological emergencies which are
common causes of missed diagnosis or error (adapted from
Nicholl and Appleton (2014))
Diagnosis Risks of missing the diagnosis
IschaemicStroke
(especiallyposterior
circulationstroke)
PlainlmCTscancanbenormalin
initialstages,posteriorcirculation
strokesaredifculttovisualiseonCT.
Poorlymanaged
epilepsy
Riskofdeathorharmfromdelayedor
inappropriatetreatment
Neuromuscular
disorders
Initialpresentationofbothmyasthenia
gravisandGuillain-Barrésyndrome
may(inearlyphases)bemisdiagnosed
asabrainstemstrokeorpossiblecord
compression(mortalityrateof8.7%
and7.7%respectivelyinthosepatients
requiringintensivecare.)
Subarachnoid
haemorrhage(SAH)
Althoughonly~2%ofSAHpatients
haveanormalCTheadscaninitially,
thereareriskswithamisseddiagnosis:
casefatalityrate~50%&mean
medicolegalcostofaclaimfordamages
inSAHintheUKstands~£211,000.
Missedcord
compression
Riskisfromdelayeddiagnosiswith
signicantmorbidityanddisabilityasa
consequence
Idiopathic
intracranial
hypertension
Imagingnormalbutpotentialfor
irreversiblesightlossifnotmanaged
appropriately
Functional
disorders
Riskisfromdelayeddiagnosis,over-
investigationandiatrogenicharm.
Acute Medicine 2014; 13(4): 178-180
Are the skills of neurological assessment in need of resuscitation?
© 2014 Rila Publications Ltd.
180
1. Marson T. UK epilepsy audit shows major deficiencies in care: who
should respond and how? Pract Neurol 2013;13:2-3 doi:10.1136/
practneurol-2012-000488
2. Subarachnoid Haemorrhage: Managing the Flow (2013) Accessed
18th May, 2014 http://www.ncepod.org.uk/2013sah.htm
3. Nicholl D, Weatherby S. Subarachnoid haemorrhage: the canary
in the mine, or the elephant in the room? Pract Neurol. 2014
Aug;14(4):204-5. doi: 10.1136/practneurol-2014-000816. Epub
2014 Mar 5.
4. Nicholl DJ, Yap CP, Cahill V, et al. The TOS study: can we use
our patients to help improve clinical assessment? J R Coll Physicians
Edinb 2012;42:306–10.
5. Nicholl DJ, Appleton JP. Clinical neurology: why this still matters
in the 21st century. J Neurol Neurosurg Psychiatry. 2014 May 29. pii:
jnnp-2013-306881. doi: 10.1136/jnnp-2013-306881. [Epub ahead
of print] Review.
6. Wong SH. A bright idea- solving the chronic lack of neurological
examination equipment on the wards with the Walton Neurostand.
Pract Neurol 2008;8:318-321 doi:10.1136/jnnp.2008.156851
7. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic Ocular
Fundus Photography in the Emergency Department. NEJM
2011;364:387–89.
8. Pérez MA, Bruce BB, Newman NJ, Biousse V. The use of
retinal photography in non-ophthalmic settings and its potential
for neurology Neurologist. 2012 November ; 18(6): 350–355.
doi:10.1097/NRL.0b013e318272f7d7
9. Portable Eye Examination Kit http://www.peekvision.org/
Accessed 18th October, 2014
10. Matthews B. Practical neurology. Oxford: Blackwell Scientific
Publications, 1963;1–256 (page 2).
11. Morris Z, Whiteley WN, Longstreth WT Jr, Weber F, Lee YC,
Tsushima Y, Alphs H, Ladd SC, Warlow C, Wardlaw JM, Al-
Shahi Salman R. Incidental findings on brain magnetic resonance
imaging: systematic review and meta-analysis. BMJ. 2009 Aug
17; 339:b3016.
12. Choosing Wisely http://www.choosingwisely.org/ Accessed
October 18th, 2014
13. BBC News Is it right to waste helium on party balloons? http://
www.bbc.co.uk/news/magazine-24903034 Dated18 November
2013. Accessed October 18th, 2014
14. Moore FG, Chalk C. The essential neurologic examination: what
should medical students be taught? Neurology 2009; 72: 2020-2023.
15. JAMA Evidence: The rational clinical examination- evidence-
based clinical diagnosis. Edited by Simel DL & Rennie D.
McGraw-Hill, New York 2008.
16. BBC News website An electronic revolution in the doctor’s bag
28th Sept 2014. Accessed 18th October 2014 http://www.bbc.
co.uk/news/magazine-29376437
References