Letter: The Neurological Examination

Abstract

To the Editor: We read with interest the article “The Neurological Examination” published recently in Operative Neurosurgery.1 The authors have very lucidly summarized the vital crux of the neurological examination in an easy-to-understand and engaging way. Though primarily targeted at the medical students, we think it to be a ready reckoner for the surgical neurology residents as well as the busy neurosurgical practitioners to brush up their clinical knowledge. It was surprising but heartening to see this article published in Operative Neurosurgery. We believe that articles pertaining to basic history-taking and neurological examination still should find place in the neurosurgical literature. There has been this recent talk of clinical examination, as we know it, to be rendered obsolete.2 Investigations (radiological and others) will take over and decide everything. However, we think and firmly believe that the obituary of the clinical examination is not going to be written so soon. We need to understand the relevance of the clinical examination and its connection with the modern radiological investigations. The clinical examination was devised when there were no other tools to diagnose neurological diseases. The clinical examination flourished, advanced in the absence of a viable alternative, though it had its limitations. Neurological illnesses were diagnosed and localized, and neurosurgical procedures were carried out just based on the clinical examination.3 The arrival of modern investigational tools made the diagnosis and localization even more accurate. The tests were ordered based on the level localized by clinical examination. The investigations, at times, highlighted the limitations of the clinical examination. Radiological investigation as a stand-alone method bypassing clinical findings to diagnose and plan treatment is fraught with danger. This has been proven more than once, for example, by the lumbar discectomy surgery done based on the magnetic resonance imaging (MRI) finding of a disc bulge for a patient with low backache! What needs to be understood is that the clinical examination has to be tailored and understood according to the available information. Suppose a patient has back pain, and on MRI it is discovered that the patient has a spinal cord intramedullary lesion. The patient undergoes an uneventful surgery to excise the lesion and makes an excellent recovery. One day the patient gets up in the night and has a fall due to posterior column dysfunction, which has been completely ignored. The clinical examination provides both the physician and the patient vital information about the problems that are there and likely to be faced during the course of treatment. This lack of awareness many a time is the source of conflict between the doctor and the patient. The clinical examination should be used to order relevant radiological investigations; otherwise, it will lead to overtreatment and also many a time incorrect treatment. The neurological examination, as it has been taught, is still very relevant in this day and age. The clinical examination findings and radiological findings are complementary to each other. The clinical examination is the first point of contact of the patient with the physician and forms a very solid bond that goes a long way in the treatment process.4 We are still human beings with feelings, and we wonder how many of us will be comfortable with a machine deciding about treatment and executing it. It is like entering symptoms in a program, and then the software deciding the investigations and diagnosis, and another machine finalizing the treatment. That might be the future, but not yet! Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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