General neurosurgery exam

Introduction

A thorough yet focused neurological examination of a patient has been the cornerstone of any neurosurgery clinician’s training. Although the value of the human touch and in-person evaluation of a patient at the bedside or in a clinic setting cannot be understated, an effective neurosurgical examination can be performed via telemedicine, specifically by use of interactive video calls. In fact, many neurosurgeons were forced to convert many of their patient visits to virtual visits during the COVID-19 pandemic. During this time, instead of the doctor stepping from one clinic room to the next, neurosurgeons were taking live video calls through laptops or cell phones, interviewing and examining patients through screens. Additionally, in contrast to the vast majority of high-risk patients from outside hospitals being immediately transported to larger, more equipped hospitals, emergency room physicians were video calling on-call neurosurgeons while examining patients to determine if transfers to their far-away centers were fully warranted.

A focused neurosurgical interview via telecommunication takes a patient and inquisitive clinician. In Chapter 3 , the reader learned the how to evaluate a stroke patient, the basics of which are similar to the general neurosurgical exam. In 5, 6 , the reader was introduced to the ophthalmological exam, which has many similar components to the eye component of the neurosurgical exam. In this chapter, the reader will be introduced to the basics of a general neurosurgical exam and how best to implement this exam in a remote setting.

Introductory interview questions

All patients should be asked the typical medical interview questions, such as past medical history and surgical history. Other pertinent history questions include chronic medications, such as blood thinners and antiepileptic medications, and family history of disease. All patients should also be asked about handedness (left- or right-handed). Handedness can give an accurate assessment of the laterality of language dominance in patients. One study found that the incidence of right-hemisphere language dominance was found to increase linearly with the degree of left-handedness, from 4% in strong right-handers, to 15% in ambidextrous individuals, and 27% in strong left-handers.

Mental status

Alertness

To begin the general neurosurgical exam, the clinician must quickly assess the patient’s alertness and appropriateness to introductory questions. If a patient is drowsy upon first inspection, this may be a sign of something pathological in the brain, such as hydrocephalus or an intracranial hematoma. If the patient is difficult to arouse, the best course of action should be to send this patient to an emergency department to obtain a noncontrasted head computed tomography (CT).

Orientation

After introducing yourself, there are three orientation questions that can assess if the patient is oriented appropriately:

1.
“What is your full name?”
2.
“Where are we?” or “What place are we in currently?”
3.
“What is today’s date?” or “What year and month is it today?”

These questions ask the orientation on three separate levels: person, place, and time. It is important to understand what the patient’s baseline cognition is before these questions are asked. For instance, if a patient has diagnosed dementia, he or she may not answer these questions correctly at all in the first place. Additionally, if the patient has had a traumatic brain injury (TBI) in the past, his or her appropriateness to these questions may be disrupted on a regular day. The neurosurgical practice of reporting orientation is to say the patient is “oriented times ” some numerical number out of three, which can be qualified immediately afterwards. For example, “Mrs. Jones was only oriented times 1—to person,” or “The patient was oriented times 3.” If the clinician is confident that the patient has a normal baseline, any disruption in orientation should raise suspicion.

Level of consciousness

The Glasgow Coma Scale (GCS) is a quantifiable tool used to assess a patient’s level of consciousness and is widely used among neurosurgery clinicians worldwide. The GCS was originally devised in 1974 as a simple bedside tool to better communicate a patient’s level of consciousness in a wide range of disorders. Additionally, there has been strong evidence that the GCS correlates with clinical outcome in an extensive list of pathologic states, including TBI (see Table 12.1 ).

Table 12.1

Glasgow coma scale.

Behavior	Response	Score
Eye opening	Spontaneous	4
	Response to verbal command	3
	Response to pain	2
	Eyes remain closed	1
Verbal response	Oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible words	2
	No verbal response	1
Motor response	Obeys commands	6
	Localizes to pain	5
	Withdraws to pain	4
	Flexion to pain	3
	Extension to pain	2
	No motor response	1

The GCS ranges from a score of 3 to 15. The GCS is widely used scale to assess outcomes in TBI and is used as a common classification of the severity of the injury:

Severe, GCS 3–8;
Moderate, GCS 9–12;
Mild, GCS 13–15.

A score of ≤ 8 denotes that the patient is in a coma, although a full clinical picture needs to be taken into account. The historical teaching to emergency medicine practitioners was that any patient with a GCS ≤ 8 requires endotracheal intubation; however, many investigators and clinicians argue against this dogma. There may be subtle, reasonable reasons why a person’s GCS may be low that may not be directly related to an injury itself (e.g., recent pain medication given). The authors use GCS mainly as a communication tool among other clinicians and use it to supplement the report of the neurologic exam.

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