The struggle between technology and bedside medicine is nothing new. In his preface to Robert Wartenberg’s 1953 Diagnostic Tests in Neurology, Sir Gordon Holmes lamented, “There has been within recent years an increasing tendency to rely more and more on laboratory, mechanical and other such methods of investigation of patients suffering with symptoms of nervous disorder at the expense of careful clinical observation.” (1) In his introduction to the book, Wartenberg devoted five pages to a section titled Clinic versus Laboratory, in which he observed, “There is a growing and deplorable tendency to overload neurological diagnostics with mechanical, technical and laboratory procedures and to overemphasize their importance … the art of diagnosing with the eyes, ears and fingertips is steadily losing ground.” Some of the technology Wartenberg was exhorting against included: EEG, pneumoencephalography, myelography, EMG, and chronaximetry. Wartenberg quoted Moritz Romberg, who wrote of “the great aim which we must seek to achieve, the emancipation of medical science from the trammels of mere mechanical technicalities.” Romberg wrote this in 1840.
These pioneering clinicians could not begin to imagine the technology of today and the clinicians of today would undoubtedly stand just as amazed at the technology yet to come, assuming humankind survives to see it. The career span of the authors has witnessed the evolution from radioisotope brain scans, pneumoencephalography, and chromosomal analysis to 3T MRI, PET scans, and next-generation sequencing. But the neurologic examination has been an anchor during the evolution of this technology. The clinical encounter has provided the foundation on which all else is built. Without it, all this wondrous technology might never have escaped the lab.
The examination too has evolved to a degree. We have learned that certain things are not very useful, such as provocative testing for thoracic outlet syndrome, while other things are more useful than once thought, such as olfactory testing, since it became clear that olfactory deficits can signal neurodegenerative disorders. Some things have fallen by the wayside, such as the red lens test and the Wartenberg pinwheel. New, useful things have been described, developed, or rediscovered, such as the head impulse test, the PanOptic ophthalmoscope, the finger rolling test, and the Rydel-Seiffer quantitative tuning fork. The exam done by the 21st century neurologist has become more streamlined and focused. There is less need for a detailed coma exam when the CT done in the ER is already known to show a brainstem hemorrhage.
But the examination remains a central pillar of clinical practice. There are certainly areas where it contributes relatively little. This is not a point of argument and never has been. The neurologist seeing mostly headache patients, or seizure patients, or sleep disorder patients, can certainly get by with minimal exam most of the time. But imaging is of little use in these areas as well. The history is paramount. In other areas of clinical practice, such as neuro-ophthalmology, movement disorders, and neuromuscular disease, the exam is indispensable. Perhaps the academic epileptologist will not suffer much from forgetting how to examine patients, until challenged to keep his or her dignity as the ward attending.
The appropriate use of the history and the clinical examination is to focus and utilize the technology to its fullest potential to solve problems in the service of patient care. The effective clinical neurologist knows what the technology is capable of and how to exploit it to answer a question. The history and examination pose the question. Without the examination and clinical correlation, the technology is blind, as a few recent real-life examples show. It does no good to image the lumbosacral spine for a complaint of leg weakness when the exam shows limb girdle weakness. It does no good to image the lumbosacral spine for a complaint of leg numbness when the exam shows pain and temperature loss in one leg and hyperreflexia in the other. It does no good to order a next generation sequencing panel for a limb girdle syndrome when the exam shows a scapuloperoneal syndrome. It does no good to order an EMG when the exam shows a spastic paraparesis. You cannot believe the imaging report that says the bilateral parieto-occipital signal abnormalities are infarcts when the exam and clinical setting shout PML. In one astounding case, the only thing gained by imaging the lumbosacral spine and ordering an EMG in an elderly black man with leg weakness was that the electromyographers found the ice-cold feet, absent distal pulses, and subtle margin of gangrene snaking across the toes that led to the diagnosis of distal aortic occlusion. The patient who undergoes total body MRI and whole genome sequencing will be lost in a sea of incidental findings and variants of unknown significance without a clinician to correlate what the technology has unveiled.
Lack of clinical acumen can have lamentable social as well as medical consequences. In one recent case, a woman admitted to the hospital with a hemiparesis was judged by both a neurologist and a neurosurgeon to have a functional deficit after a normal MRI. In fact, she had suffered an episode of hemiplegic migraine. Her insurance company refused to pay for the hospitalization because of the diagnosis of functional hemiparesis.
This edition of The Neurologic Examination continues the tradition begun by Dr. Russell DeJong in 1950 of discussing the examination in detail and providing supporting elaboration on some of the underlying neuroanatomy and neurophysiology. Several years ago, the author of the sixth and seventh editions (WWC), recognizing that the size of the book makes it intimidating, undertook to make the material more approachable by reorganizing it alphabetically, making the focus strictly clinical, stripping all but the essence and exploiting the new publishing technology. The result was Clinical Signs in Neurology: A Compendium. (2) Clinical Signs has numerous embedded videos, as well as links to outside videos, which can be viewed on its Web site or on portable devices such as iPad, iPhone, and Android. This version of DeJong shares that technology. There are videos, some of which are medleys, consisting of several examples of such things as abnormal gaits or abnormal plantar responses. The book also contains links to outside videos. The University of Utah library is a national treasure for neurologists. It hosts the Neuro-ophthalmology Virtual Education Library (NOVEL) as well as an extensive collection of videos on the general neurologic examination.
After completion of Clinical Signs, the video habit stuck and led to the launch of a Web site, www.neurosigns.org. The Web site now has 72 entries, each with a photo or video and a one or two paragraph description of a sign and its relevance. Because of limits to the number of videos that could be embedded in the text, this edition of DeJong contains frequent links to www.neurosigns.org. Others are welcome to contribute to the site.
And all to what end? The end is to preserve the culture of bedside neurology and to preserve the neurologic examination. In our nearly 20-year journey in the footsteps of Russell DeJong, we discovered the Stanford 25, an initiative developed by the Stanford University School of Medicine, whose motto is “Promoting the Culture of Bedside Medicine.” They identified 25 core aspects of the physical examination every student should master, and much of it is neurology. They believe, as do we, that caring for the patient starts at the bedside with observing, examining, and connecting with our patients.
We owe our gratitude to the many individuals who contributed to this work. Apologies to anyone inadvertently left out. Thanks are especially due to Stephen Reich, Jason Hawley, Robert Laureno, Sanjeev Nandedkar, Richard Dubinsky, Gary Gronseth, Amanda Sebok, Kent Allen, David Roach, Cheryl Lamp, Timothy Horton, and Kimberly Braxton. Expert advice and support was provided by the team at Wolters Kluwer Health, including Chris Teja, Kerry McShane, Ariel Winter, La Porscha Rogers, Anne Malcolm, Joan Wendt, and Shenbagakutti Arunmozhivarman.
William W. Campbell, MD, MSHA, FAAN, FAANEM
Richmond, Virginia
Richard J. Barohn, MD, FAAN, FAANEM
Kansas City, Kansas
1. Wartenberg R. Diagnostic Tests in Neurology: A Selection for Office Use. Chicago: Year Book Medical Publishers, 1953.
2. Campbell WW. Clinical Signs in Neurology: A Compendium. Philadelphia: Wolters Kluwer Health, 2016.