The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.



Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5



Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area




Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1


An elderly patient with a history of COPD presents with back pain radiating to the chest. After an extensive workup, a CT scan shows a vertebral compression fracture. You percuss the area and find that this reproduces the pain. Is this the cause of her pain?


Sometimes in emergency medicine we face the dilemma of a new vertebral compression fracture. Is it new or old? MRI can help, but is hard to obtain still. Until recently there was not much literature on this. Closed fist percussion has always been used, and a recent article supports it.(Langdon Ann R Coll Surg Engl 2010) The author also introduces the supine sign, that many of these patients have substantial worsening of their pain when lying supine. In fact this sign was 81% sensitive and 93% specific. Although those statistics may turn out to be less helpful when applied to a broader population, this is an interesting addition to our diagnostic approach at the bedside.


Take home points:

Use closed fist percussion to determine with a compression fracture is acute

Consider pain with supine posture as a sign supporting an acute fracture


Does this patient with a ventriculoperitoneal shunt have a complication? Shunt failure is common, with half of patients experiencing this within the first two years of shunt placement (Livingston 2011). Obstruction is a much more common complication than infection (Piatt 2008). Headache, nausea, vomiting, depressed mental status are common symptoms but have poor specificity. Some have suggested bradycardia as a more specific sign, but it is not sensitive (Livingston 2011). The sensitivity of CT scan is as low as 61% (Mater 2008).


If the history is concerning, but the radiologic tests are negative, further assessment is probably necessary, and the neurosurgeon who manages the patient should probably keep the privilege of directing this. Traditionally, shunt tap was used to assess for obstruction. With a 23 gauge butterfly needle, does fluid easily enter a 3 mL syringe? If significant backflow does not occur, or only with more than a mL of suction, there is a problem (Rocque 2008). An alternative method of testing, familiar to emergency physicians and well-away from surgical hardware, is lumbar puncture. Using cerebrospinal fluid opening pressure to screen for obstruction, some have claimed that this is an equally viable way to assess for shunt complications (Miller 2008). Of course, that only works if it is known to be a communicating hydrocephalus.


Finally, although this test has limited sensitivity, you can palpate the reservoir. If it is hard to compress, that suggests a distal obstruction. If it doesn’t refill within 3 seconds, that suggests a proximal obstruction.



-The history is not sensitive or specific for shunt obstruction

-CT scan of the head, though helpful, has limited sensitivity

-Reservoir hard to compress suggests distal obstruction

-Reservoir slow to refill suggests proximal obstruction