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Glossary

Anatomy of a Neurosurgery Note

Anatomy of a Neurosurgery Exam

The neurosurgery exam should be listed in a standard fashion as follows: 

1. Airway
2. Mental status
3. Cranial nerves
4. Strength exam
5. Drift assessment
6. Sensory exam
7. Reflexes

Depending on the patient's specific pathology, these elements of the exam may contain more detail and additional elements may be included. These additional elements include:

1. Rectal exam
2. Language function

Airway

The status of the patient's airway. The description should be followed by the O2 concentration, flow, or relevant oxygenation parameters.

Options include:

1. Room air (RA)
2. Nasal cannula (NC), E.g. "6L NC"
3. High flow nasal cannula aka heated high flow nasal cannula. E.g. "HFNC 70% FiO2, 50L/min"
4. Face tent. E.g. "Face tent 100% FiO2"
5. BiPAP. E.g. "BiPAP 40/5" which means 50% FiO2, 5 PEEP
6. Intubated
   1. Pressure support. E.g. "PS 40/5" which means 40% FiO2 and 5 PEEP
   2. Assist control. E.g. "AC 40/5" which means 40% FiO2 and 5 PEEP
7. Tracheostomy
   1. Room air or "trach mask". E.g. "TM"
   2. Ventilated
      1. Pressure support. E.g. "Trached PS 40/5" which means tracheostomy in place, on pressure support ventilation at 40% FiO2 and 5 PEEP
      2. Assist control. "Trached AC 40/5" which means tracheostomy in place, on assist control ventilation at 40% FiO2 and 5 PEEP

Mental status

Two components: 

1. Eyes
   1. Eyes open spontaneously "EOS"
   2. Eyes to voice "ETV"
   3. Eyes to pain "ETP"
   4. Eyes closed "EC"
2. Orientation. E.g. "AOx3"
   1. Own name. A first name is enough. 
   2. Date. The current year is enough. 
   3. Location. The current city or the setting. E.g. "Pittsburgh" or "hospital" or "emergency department"

Language function

This is an optional exam component. Not every patient will have this included but it should be included on patients at risk for aphasia. 

Document the presence of word-finding difficulty or "WFD".

• Naming. Test 3 things. "What is this? A pen. What do you do with it? Write. What comes out of the tip? Ink". "Names 3/3"
• Repetition. Test 2 things. "Repeat after me - 'no ifs ands or buts about it' and 'it's a sunny day in Pittsburgh, Pennsylvania' ". "Repeats 2/2"
• Complex command, i.e. "take your left thumb and touch your right ear". "Complex command 1/1"

Cranial nerves

All patients:

• Extraocular movements intact. "EOMI". If there is a EOM palsy, it should be listed. E.g. "partial L VI palsy"
• Pupils equal, round, and reactive. "PERRL". If there is an asymmetry it should be listed. E.g. "L pupil 3mm reactive, R 5 mm sluggish". "NR" in this context means "non-reactive"
  • Document the presence of an afferent pupillary defect (APD) if present
• Face symmetric. "FS". If there is a facial palsy it should be qualified as central or peripheral
  • Central facial weakness affects the lower half of the face only. "right CFW"
  • Peripheral facial weakness affects the upper and lower face and should be graded using the House-Brackmann grading scale. "right HB6" is read as right House-Brackmann grade 6 peripheral facial weakness
• Facial sensation.
  • Facial sensation intact
  • Right V1-V3 diminished sensation to light touch or pinprick
• Tongue midline. "TML". If there tongue deviation is present it should be noted. E.g. "right CN12 palsy"

Intubated patients:

• Cough reflex - present or absent
• Gag reflex - present or absent
• Corneal reflex - present or absent

May sometimes be abbreviated as "c/g/c".

Additional cranial nerves are tested on appropriate patients:

• Palate elevates symmetrically. No abbreviation. If there is uvular deviation, note to which side. E.g. "uvula deviates left"
• Visual acuity graded with bedside Snellen eye chart. "OD 20/40, OS 20/200". OD - right eye, OS - left eye, OU - both eyes.
  • When vision is worse than can be graded on the Snellen chart, it is graded in descending order as follows:
    • Finger counting (FC) - patient reliably counts fingers in that eye or visual field
    • Movement perception (MP) - reliably detects movement but cannot count fingers
    • Light perception (LP) - reliably detects the presence or absence of light but cannot see movement
    • No light perception (NLP) - no light perception, complete blindness. This is often associated with an afferent pupillary defect (APD). 
• Visual fields assessed with bedside finger counting
  • Visual fields full (VFF). No visual field defect. 
  • Left or right homonymous hemianopia (HH). 
  • Quadrantanopia, qualified with superior/inferior and nasal/temporal
  • Bitemporal hemianopia
• Hearing (CN VIII)
• Shoulder shrug (CN XI)

Strength exam

Graded on a scale from 0-5: 

• 0 : no movement across a joint, no muscle activity
• 1 : no movement across a joint, muscle activates
• 2 : movement across joint but not antigravity
• 3 : antigravity but not more
• 4- : slight strength against resistance 
• 4 : antigravity strength against resistance
• 4+ : significant strength against resistance but not full strength
• 5 : full strength  

If a patient is intubated or unable to comply with a detailed strength assessment, strength is graded according to the GCS scale: 

• Flaccid (flac)
• Extensor posturing "ext"
• Flexor posturing in upper limb or triple flexion in lower limb "flex" or "TF"
• Withdraw to pain "wd"
• Localize to pain "loc"
• Follows commands "FC". Usually a reliable thumbs up or toe wiggle. 
• You may occasionally see "spontaneous and antigravity" or "spont AG", which is better than localizing but not as good as following commands. 

Cranial patients

Strength is crudely graded  by extremity and listed as a 2x2 square. The upper half of the square denotes the upper extremities and the lower half the lower extremities. Unless otherwise specified, the right half of the square refers to the patient's left hemibody and the left square to the right hemibody. 

right arm / left arm
right leg / left leg

3 / 5
5 / 4+  means antigravity in right upper extremity, significant strength against resistance but not full strength in left lower extremity. 

In cranial patients, there is not usually a need to define strength in specific muscle groups. 

Spine patients

Unless otherwise specified, notation follows the same convention as for cranial patients but each extremity is assessed on the basis of 5 muscle groups.

right arm / left arm
right leg / left leg

The order of upper extremity muscle groups is:

1. Shoulder abduction
2. Elbow flexion
3. Wrist extension
4. Elbow extension
5. Hand grip

The order of lower extremity muscle groups is:

1. Hip flexion
2. Knee extension
3. Ankle dorsiflexion
4. Great toe dorsiflexion
5. Ankle plantarflexion

Strength in each extremity will often be documented with a series of 5 numbers immediately after one another as follows: 

44+555 / 34+555
55555 / 55555

This should be read as right arm: 4/5 shoulder abduction, 4+/5 elbow flexion, full strength distally; left arm: 3/5 shoulder abduction, 4+/5 elbow flexion, full strength distally. Full strength in bilateral legs. 

Drift assessment

Should be routinely assessed for each arm and described as "RUE drift". It is occasionally qualified on the basis of whether the arm drifts down to the bed. 

Drift can be assessed in the legs but is not routinely. This is most relevant for patients at risk of ischemia in the ACA territory such as in the setting of vasospasm. 

Sensory exam

Most often described as sensation intact to light touch in all four extremities or "SILT x4". May be further refined if there is loss of sensation in an extremity, a dermatome, or below a dermatomal level. Pinprick, temperature, and proprioception are not routinely tested but may be included in the appropriate clinical context. 

Reflexes

Hoffman, clonus, and Babinski should be routinely assessed. Hyperreflexia should be qualified with the side and location of hyperactive reflexes. E.g. "right knee extensor hyperreflexia"

Rectal exam

Document the presence or absence of: 

• Peripheral anal sensation
• Deep anal sensation
• Rectal tone
• Voluntary anal contraction