INTRODUCTION

A seizure disorder is a condition in which the neurons in the brain function

abnormally, resulting in sudden, brief changes in how the brain works. These
changes result in seizures, which involve convulsions, muscle spasms, and loss of
consciousness. A person needs to have two or more seizures to be classified as
having a disorder. Also known as convulsions, epileptic seizures, and if recurrent,
epilepsy. It is a sudden alterations in normal brain activity that cause distinct
changes in behavior and body function. They are thought to result from abnormal,
recurrent, uncontrolled electric discharges of neurons in the brain.
Pathophysiology is poorly understood but seems to be related to metabolic
and electrochemical factors at the cellular level. Predisposing factors include head
or brain trauma, tumors, cranial surgery, metabolic disorders (hypocalcemia,
hypoglycemia or hyperglycemia, hyponatremia, anoxia); central nervous system
infection; circulating disorders; drug toxicity; drug withdrawal states (alcohol,
barbiturates); and congenital neurodegenerative disorders.
Seizures happen when your brain cells, which communicate through electrical
signals, send out abnormal signals. However, even mild seizures that happen more
than once should be treated, because they could cause harm if they happen while
you are driving, walking, or swimming, for example. It sometimes do cause brain
damage, particularly if they are severe. However, most seizures do not seem to
have a detrimental effect on the brain. Any changes that do occur are usually
subtle, and it is often unclear whether these changes are caused by the seizures
themselves or by the underlying problem that caused the seizures.
While epilepsy cannot currently be cured, for some people it does eventually
go away. The odds of becoming seizure-free are not as good for adults or for
children with severe epilepsy syndromes, but it is nonetheless possible that seizures
may decrease or even stop over time.
HISTORY
Seizure was one of the first brain disorders to be described. It was mentioned
in ancient Babylon more than 3,000 years ago. The strange behavior caused by
some seizures has contributed through the ages to many superstitions and
prejudices. People once thought that those with seizures were being visited by
demons or gods. However, in 400 B.C., the early physician Hippocrates suggested
that seizure was a disorder of the brain -- and we now know that he was right.
Seizure is a brain disorder in which clusters of nerve cells, or neurons, in the
brain sometimes signal abnormally. Neurons normally generate electrochemical
impulses that act on other neurons, glands, and muscles to produce human
thoughts, feelings, and actions. In seizure, the normal pattern of neuronal activity
becomes disturbed, causing strange sensations, emotions, and behavior, or
sometimes convulsions, muscle spasms, and loss of consciousness. During a
seizure, neurons may fire as many as 500 times a second, much faster than normal.
In some people, this happens only occasionally; for others, it may happen up to
hundreds of times a day.
Famous people who are known or rumored to have had epilepsy include the
Russian writer Dostoyevsky, the philosopher Socrates, the military general
Napoleon, and the inventor of dynamite, Alfred Nobel, who established the Nobel
Prize.
STATISTICS
More than 2 million people -- about 1 in 100 -- have experienced an unprovoked
seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed
with epilepsy, seizures can be controlled with modern medicines and surgical
techniques. However, about 25 to 30 percent of people with epilepsy will continue
to experience seizures even with the best available treatment. Doctors call this
situation intractable epilepsy. Only when a person has had two or more seizures is
he or she considered to have epilepsy.
What Causes It?

A seizure disorder can be caused by a variety of factors. Anything that

disturbs the normal pattern of neuron activity -- from illness to brain damage to
abnormal brain development -- can cause a seizure. The condition may develop as
the result of abnormality in brain wiring, an imbalance of nerve signaling chemicals
called neurotransmitters, or some combination of these factors. Seizure disorders
are not contagious and are not caused by mental illness or mental retardation.
Diagnosing a Seizure Disorder
Experiencing a single seizure does not necessarily mean that a person has a seizure
disorder. Only when a person has had two or more seizures is he or she considered
to have a disorder. Brain scans and electroencephalograms (EEGs) are common
tests used to make a diagnosis.
PROGNOSIS
While a seizure disorder cannot currently be cured, for some people, it does
eventually go away. One study found that children with idiopathic epilepsy, or a
seizure disorder with an unknown cause, had a 68 to 92 percent chance of
becoming seizure-free by 20 years after their diagnosis. The odds of becoming
seizure-free are not as good for adults or for children with severe seizure disorders,
but it is nonetheless possible for seizures to decrease or even stop over time. This is
more likely if the disorder has been well-controlled by medication or if the person
has had surgery.
Most seizures do not cause brain damage; however, it is not uncommon for
people with a disorder, especially children, to develop behavioral and emotional
problems, sometimes the consequence of embarrassment and frustration or
bullying, teasing, or avoidance in school and other social settings.
For many people with a seizure disorder, the risk of seizures restricts their
independence (some states refuse driver's licenses to people with a disorder) and
recreational activities. People with a seizure disorder are at special risk for two lifethreatening conditions: status epilepticus and sudden unexplained death.
Most women with a seizure disorder can become pregnant, but they should
discuss their condition and the medications they are taking with their doctors.
Women with the condition have a 90 percent or better chance of having a normal,
healthy baby.

Epilepsy Seizure Types and Symptoms

Based on the type of behavior and brain activity, seizures are divided into two broad
categories: generalized and partial (also called local or focal). Classifying the type of
seizure helps doctors diagnose whether or not a patient has epilepsy.
Generalized seizures are produced by electrical impulses from throughout the
entire brain; partial seizures are produced (at least initially) by electrical impulses in
a relatively small part of the brain. The part of the brain generating the seizures is
sometimes called the focus. The most common types of seizures are listed below:
Generalized Seizures
(Produced by the entire brain)

Symptoms

1. "Grand Mal" or Generalized

tonic-clonic

Unconsciousness, convulsions, muscle

rigidity

2. Absence

Brief loss of consciousness

3. Myoclonic

Sporadic (isolated), jerking movements

4. Clonic

Repetitive, jerking movements

5. Tonic

Muscle stiffness, rigidity

6. Atonic

Loss of muscle tone

Generalized Seizures
There are six types of generalized seizures. The most common and dramatic, and
therefore the most well known, is the generalized convulsion, also called the grandmal seizure. In this type of seizure, the patient loses consciousness and usually
collapses. The loss of consciousness is followed by generalized body stiffening
(called the "tonic" phase of the seizure) for 30 to 60 seconds, then by violent jerking
(the "clonic" phase) for 30 to 60 seconds, after which the patient goes into a
deep sleep (the "postictal" or after-seizure phase). During grand-mal seizures,
injuries and accidents may occur, such astongue biting and urinary incontinence.
Absence seizures cause a short loss of consciousness (just a few seconds) with
few or no symptoms. The patient, most often a child, typically interrupts an activity
and stares blankly. These seizures begin and end abruptly and may occur several
times a day. Patients are usually not aware that they are having a seizure, except
that they may be aware of "losing time."
Myoclonic seizures consist of sporadic jerks, usually on both sides of the body.
Patients sometimes describe the jerks as brief electrical shocks. When violent, these
seizures may result in dropping or involuntarily throwing objects.
Clonic seizures are repetitive, rhythmic jerks that involve both sides of the body at
the same time.
Tonic seizures are characterized by stiffening of the muscles.
Atonic seizures consist of a sudden and general loss of muscle tone, particularly in
the arms and legs, which often results in a fall.
Partial Seizures
(Produced by a small
area of the brain)
1. Simple(awareness is
retained)
a. Simple Motor

Symptoms

a. Jerking, muscle rigidity, spasms, head-turning

b. Unusual sensations affecting either the vision,
hearing, smell taste, or touch

b. Simple Sensory
c. Simple
Psychological

c. Memory or emotional disturbances

2. Complex
(Impairment of
awareness)

Automatisms such as lip smacking, chewing, fidgeting,

walking and other repetitive, involuntary but
coordinated movements

3. Partial seizure with

secondary
generalization

Symptoms that are initially associated with a

preservation of consciousness that then evolves into a
loss of consciousness and convulsions.

Partial Seizures
Partial seizures are divided into simple, complex and those that evolve into
secondary generalized seizures. The difference between simple and complex
seizures is that during simple partial seizures, patients retain awareness; during
complex partial seizures, they lose awareness.
Simple partial seizures are further subdivided into four categories according to
the nature of their symptoms: motor, autonomic, sensory, or psychological. Motor
symptoms include movements such as jerking and stiffening. Sensory symptoms
caused by seizures involve unusual sensations affecting any of the five senses
(vision, hearing, smell, taste, or touch). When simple partial seizures cause sensory
symptoms only (and not motor symptoms), they are called "auras."
Autonomic symptoms affect the autonomic nervous system, which is the group of
nerves that control the functions of our organs, like
theheart, stomach, bladder, intestines. Therefore autonomic symptoms are things
like racing heart beat, stomach upset, diarrhea, loss ofbladder control. The only
common autonomic symptom is a peculiar sensation in the stomach that is
experienced by some patients with a type of epilepsy called temporal lobe epilepsy.
Simple partial seizures with psychological symptoms are characterized by various
experiences involving memory (the sensation of deja-vu), emotions (such as fear or
pleasure), or other complex psychological phenomena.

Complex partial seizures, by definition, include impairment of awareness.

Patients seem to be "out of touch," "out of it," or "staring into space" during these
seizures. There may also be some "complex" symptoms called automatisms.
Automatisms consist of involuntary but coordinated movements that tend to be

purposeless and repetitive. Common automatisms include lip smacking, chewing,

fidgeting, and walking.

The third kind of partial seizure is one that begins as a focal seizure and evolves into
a generalized convulsive ("grand-mal") seizure. Most patients with partial seizures
have simple partial, complex partial, and secondarily generalized seizures. In about
two-thirds of patients with partial epilepsy, seizures can be controlled
with medications. Partial seizures that cannot be treated with drugs can often be
treated surgically.

Complications of Epilepsy
Complications of complex partial seizures are easily triggered by emotional stress.
The limbic structures (i.e., hypothalamus, hippocampus, amygdala) of the brain may
be damaged by seizure activity. The limbic system is concerned with emotion and
motivation.
These patients may develop cognitive and behavioral difficulties, such as the
following:

Interictal personality: humorlessness, dependence, obsessions, anger, hypoor hypersexuality, emotionality

Memory loss: short-term memory loss attributable to dysfunction in the

hippocampus, anomia (inability to recall words or names of objects)

Poriomania: prolonged aimless wandering followed by amnesia

Violent behavior: aggression and defensiveness when subjected to restraint

during a seizure
Complications associated with tonic-clonic seizures may involve injury, such as the
following:

Aspiration (inhalation into the lungs) of secretions or vomited stomach

contents

Skull or vertebral fractures, shoulder dislocation

Tongue, lip, or cheek injuries caused by biting

Status epilepticus
Status epilepticus is a medical emergency in which seizures recur without the
patient regaining consciousness between events. This condition can develop in any
type of seizure but is most common in tonic-clonic seizures. Status epilepticus may
cause brain damage or cognitive dysfunction and may be fatal.
Subsequent seizures become briefer, more localized, and may be reduced to
myoclonic activity. Complications may include:

Aspiration

Cardiac arrhythmias

Dehydration

Fractures

Myocardial infarction (heart attack)

Oral and head trauma

Pulmonary edema (fluid build-up in the lungs)

COMMON COMPLICATIONS:

Hypoxia or anoxia from airway occlusion

Traumatic injury
Brain damage
Depression and anxiety

Risk factors for epilepsy include:

Any injury to the brain, either from external (environmental) or internal
(medical/metabolic) sources can increase your risk of epilepsy.
Brain injury can be caused by:

Head injury

Stroke

Alzheimers disease

Tumors (primary or metastatic)

Heart failure

Kidney failure

Liver failure

Any condition that deprives the brain of oxygen, such as near-drowning

Sleep deprivation

Infectious diseases, such as:

Meningitis

AIDS

Viral encephalitis

Hydrocephalus (excess fluid in the brain)

Celiac disease (intolerance to wheat gluten)

Metabolic conditions, such as low blood sugar , high or low salt, low
magnesium or calcium

In some cases, epilepsy can result from genetic abnormalities inherited at birth.
Different causes and types of seizures are more or less likely depending on your
age.
In children, risk factors include:

High fever

Poor nutrition

Other factors that can increase your risk of epilepsy include:

Exposure to:

Lead

Carbon monoxide

Other environmental toxins

Certain illegal drugs

Overdose or withdrawal of antidepressants and other medications

Medication interactions

Alcoholism

Cysticercosisan infection caused by a pork tapeworm

NORMAL ANATOMY AND PHYSIOLOGY OF THE NERVOUS

SYSTEM
Introduction
The human nervous system is made up of two main components: the central
nervous system (CNS) and the peripheral nervous system (PNS). The CNS is
composed of the brain, the cranial nerves, and the spinal cord. The PNS is made up
of the nerves that exit from the spinal cord at various levels of the spinal column as
well as their tributaries. The autonomic nervous system (divided into the
sympathetic and parasympathetic nervous system) is also considered to be a part
of the PNS and it controlls the body's many vegetative (non-voluntary) functions.

Brain
The human brain serves many important functions ranging from imagination,
memory, speech, and limb movements to secretion hormones and control of various
organs within the body. These functions are controlled by many distinct parts that
serve specific and important tasks. These components and their functins are listed
below.
Brain Cells: The brain is made up of two types of cells: neurons (yellow cells in the
image below) and glial cells (pink and purple cells in the image below). Neurons are
responsible for all of the functions that are attributed to the brain while the glial
cells are non-neuronal cells that provide support for neurons. In an adult brain, the
predominant cell type is glial cells, which outnumber neurons by about 50 to 1.
Neurons communicate with one another through connections called synapses.

Meninges: The bony covering around the brain is called the cranium, which
combines with the facial bones to create the skull. The brain and spinal cord are
covered by a tissue known as the meninges, which is made up of three layers: dura
mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic
membrane which, on its outer surface, is attached to the inside of the cranium. This
layer completely covers the brain and the spinal cord and has two major folds in the
brain, that are called the falx and the tentorium. The falx separates the right and
left halves of the brain while the tentorium separates the upper and lower parts of
the brain. The arachnoid layer is a thin membrane that covers the entire brain and
is positioned between the dura mater and the pia mater, and for the most part does
not follow the folds of the brain. The pia mater, which is attached to the surface of

the entire brain, follows the folds of the brain and has many blood vessels that
reach deep into the brain. The space between the arachnoid layer and the pia mater
is called the subarachnoid space and it contains the cerebrospinal fluid.

Cerebrospinal Fluid (CSF): CSF is a clear fluid that surrounds the brain and spinal
cord, and helps to cushion these structures from injury. This fluid is constantly made
by structures deep within the brain called the choroid plexus which is housed inside
spaces within the brain called ventricles, after which it circulates through channels
around the spinal cord and brain where is it finally reabsorbed. If the delicate
balance between production and absorption of CSF is disrupted, then backup of this
fluid within the system of ventricles can cause hydrocephalus.
Ventricles: Brain ventricles are a system of four cavities, which are connected by a
series of tubes and holes and direct the flow of CSF within the brain. These cavities
are the lateral ventricles (right and left), which communicate with the third ventricle
in the center of the brain through an opening called the interventricular foramen.
This ventricle is connected to the fourth ventricle through a long tube called the
Cerebral Aqueduct. CSF then exits the ventricular system through several holes in

the wall of the fourth ventricle (median and lateral apertures) after which it flow
around the brain and spinal cord.

Brainstem: The brainstem is the lower extension of the brain which connects the
brain to the spinal cord, and acts mainly as a relay station between the body and
the brain. It also controls various other functions, such as wakefulness, sleep
patterns, and attention; and is the source for ten of the twelve cranial nerves. It is
made up of three structures: the midbrain, pons and medulla oblongata. The
midbrain is inovolved in eye motion while the pons coordinates eye and facial
movements, facial sensation, hearing, and balance. The medulla oblongata controls
vegetative functions such as breathing, blood pressure, and heart rate as well as
swallowing.

Thalamus: The thalamus is a structure that is located above the brainstem and it
serves as a relay station for nearly all messages that travel from the cerebral cortex
to the rest of the body/brain and vice versa. As such, problems within the thalamus
can cause significant symptoms with regard to a variety of functions, including
movement, sensation, and coordination. The thalamus also functions as an
important component of the pathways within the brain that control pain sensation,
attention, and wakefulness.
Cerebellum: The cerebellum is located at the lower back of the brain beneath
the occipital lobesand is separated from them by the tentorium. This part of the
brain is responsible for maintaining balance and coordinating movements.
Abnormalities in either side of the cerebellum produce symptoms on the same side
of the body.

Cerebrum: The cerebrum forms the major portion of the brain, and is divided into
the right and left cerebral hemispheres. These hemispheres are separated by a
groove called the great longitudinal fissure and are joined at the bottom of this
fissure by a struture called the corpus callosum which allows communication
between the two sides of the brain. The surface of the cerebrum contains billions
of neurons and glia that together form the cerebral cortex (brain surface), also
known as "gray matter." The surface of the cerebral cortex appears wrinkled with
small grooves that are called sulci and bulges between the grooves that are called
gyri. Beneath the cerebral cortex are connecting fibers that interconnect the
neurons and form a white-colored area called the "white matter."

Lobes: Several large grooves (fissures) separate each side of the brain into four
distinct regions called lobes: frontal, temporal, parietal, and occipital. Each
hemisphere has one of each of these lobes, which generally control function on the
opposite side of the body. The different portions of each lobe and the four different
lobes communicate and function together through very complex relationships, but
each one also has its own unique characteristics. The frontal lobes are responsible
for voluntary movement, speech, intellectual and behavioral functions, memory,
intelligence, concentration, temper and personality. The parietal lobe processes
signals received from other areas of the brain (such as vision, hearing, motor,
sensory and memory) and uses it to give meaning to objects. The occipital lobe is
responsible for processing visual information. The temporal lobe is involved in visual
memory and allows for recognition of objects and peoples' faces, as well as verbal
memory which allows for remembering and understanding language.

Hypothalamus: The hypothalamus is a structure that communicates with the

pituitary gland in order to manage hormone secretions as well as controlling
functions such as eating, drinking, sexual behavior, sleep, body temperature, and
emotions.

Pituitary Gland: The pituitary gland is a small structure that is attached to the
base of the brain in an area called the sella turcica. This gland controls the secretion
of several hormones which regulate growth and development, function of various
organs (kidneys, breasts, and uterus), and the function of other glands (thyroid
gland, gonads, and the adrenal glands).
Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus
which are heavily connected to the cells of the cerebral cortex. The basal ganglia
are associated with a variety of functions, including voluntary movement,
procedural learning, eye movements, and cognitive/emotional functions. The
various components of the basal ganglia include caudate nucleus, putamen, globus
pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts
can cause a number of neurological conditions, including Parkinson's disease and
Huntington's disease.

Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as
compared to spinal nerves that initiate in the spinal cord. These nerves are
responsible for specific activities and are named and numbered as follows:
Cranial

nerve

Cranial

nerve

(Olfactory
II

(Optic

nerve):
nerve):

Smell
Vision

Cranial nerve III (Oculomotor nerve): Eye movements and opening of the eyelid
Cranial
Cranial
Cranial

nerve
nerve

nerve

IV
(Trigeminal
VI

(Trochlear
nerve):

Facial

(Abducens

nerve):
sensation
nerve):

Eye
and
Eye

movements
jaw

movement
movements

Cranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste sensation
Cranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balance
Cranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowing
Cranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensation
Cranial nerve XI (Spinal accessory nerve): Control of neck and shoulder muscles
Cranial nerve XII (Hypoglossal nerve): Tongue movement

Pineal Gland: The pineal gland is an outgrowth from the back portion of the third
ventricle, and has some role in sexual maturation, although the exact function of
the pineal gland in humans is unclear.

Spinal Cord
The spinal cord is a long, thin, tubular bundle of neurons and support cells that
extends from the bottom of the brain down to the space between the first and
second lumbar vertebrae, and is housed and protected by the bony vertebral
column. The spinal cord functions primarily in the transmission of signals between
the brain and the rest of the body, allowing movement and sensation, but it also
contains neural circuits that can control numerous reflexes independent of the
brain.
General Structure: The length of the spinal cord is much shorter than the length
of the bony spinal column, extending about 45 cm (18 inches). It is ovoid in shape
and is enlarged in the cervical (neck) and lumbar (lower back) regions. Similar to
the brain, the spinal cord is protected by three layers of tissue, called spinal
meninges. The dura mater is the outermost layer, and it forms a tough protective
coating. Between the dura mater and the surrounding bone of the vertebrae is a

space called the epidural space, which is filled with fatty tissue and a network of
blood vessels. The arachnoid mater is the middle protective layer. The space
between the arachnoid and the underlyng pia mater is called the subarachnoid
space which contains cerebrospinal fluid (CSF). The medical procedure known as
a lumbar puncture (or spinal tap) involves use of a needle to withdraw cerebrospinal
fluid from the subarachnoid space, usually from the lumbar (lower back) region of
the spine. The pia mater is the innermost protective layer. It is very delicate and it is
tightly associated with the surface of the spinal cord.
In the upper part of the vertebral column, spinal nerves exit directly from the spinal
cord, whereas in the lower part of the vertebral column nerves pass further down
the column before exiting. The terminal portion of the spinal cord is called the conus
medullaris. A collection of nerves, called the cauda equina, continues to travel in
the spinal column below the level of the conus medullaris. The cauda equina forms
as a result of the fact that the spinal cord stops growing in length at about age four,
even though the vertebral column continues to lengthen until adulthood.
Three arteries provide blood supply to the spinal cord by running along its length.
These are the two Posterior Spinal Arteries and the one Anterior Spinal Artery. These
travel in the subarachnoid space and send branches into the spinal cord that
communicate with branches from arteries on the other side.
Function: The spinal cord is divided into 33 different segments. At every segment,
a pair of spinal nerves (right and left) exit the spinal cord and carry motor
(movement) and sensory information. There are 8 pairs of cervical (neck) nerves
named C1 through C8, 12 pairs of thoracic (upper back) nerves termed T1 through
T12, 5 pairs of lumbar (lower back) nerves named L1 through L5, 5 pairs of sacral
(pelvis) nerves numbered S1 through S5, and 3-4 pairs of coccygeal (tailbone)
nerves. These nerves combine to supply strength to various muscles throughout the
body as follows:
C1-C6: Neck flexion
C1-T1: Neck extension

C3-C5: Diaphragm
C5-C6: Shoulder movement and elbow flexion
C6-C8: Elbow and wrist extension
C7-T1: Wrist flexion
C8-T1: Hand movement
T1-T6: Trunk muscles above the waiste
T7-L1: Abdominal muscles
L1-L4: Thigh flexion
L2-L4: Thigh adduction (movement toward the body)
L4-S1: Thigh abduction (movement away from the body)
L2-L4: Leg extension at the knee
L5-S2: Leg extension at the hip
L4-S2: Leg flexion at the knee
L4-S1: Foot dorsiflexion (move upward) and toe extension
L5-S2: Foot plantarflexion (move downward) and toe flexion
The spinal nerves also provide sensation to the skin in an organized manner as
depicted below.

Vertebral Column
General Structure: The vertebral column is made up of 33 vertebrae that fit
together to form a flexible, yet extraordinarily tough, column that serves to support
the back through a full range of motion. There are seven cervical vertebrae (C1-C7),
12 thoracic vertebrae (T1-T12), five lumbar vertebrae (L1-L5), five fused sacral
vertebrae (S1- S5),and four coccygeal vertebrae in this column, each separated by
intervertebral disks.
The first two cervical vertebrae have very distinct anatomy as compared to the
ramaining vertebrae. The first cervical vertebra, known as the atlas, supports the

head; and pivots on the second cervical vertebra, the axis. The seventh cervical
vertebra joins the first thoracic vertebra. The thoracic vertebrae provide an
attachment site for the ribs, and make up part of the back of the chest (thorax). The
thoracic vertebrae join the lumbar vertebrae, which are particularly study and large,
as they support the entire upper body weight. At the top of the pelvis, the lumbar
vertebrae join the sacral vertebrae. By adulthood these five bones have usually
fused to form a triangular bone called the sacrum. At the tip of the sacrum, the final
part of the vertebral column projects slightly outward. This is the coccyx, better
known as the tailbone. It is made up of three to five coccygeal vertebrae.
A typical vertebra consists of two essential parts: the vertebral body in front and the
vertebral arch in the back. The vertebral arch consists of a pair of pedicles, a pair of
lamina, a spinous process, and four articular processes (joints) that connect the
vertebra to one another, as depicted below.

The vertebral bodies, stacked on top of eachother, form a strong pillar for the
support of the head and trunk. Between each two vertebral bodies exists a hole,
called the intervertebral foramina, which allows for the transmission of the spinal
nerves on either side.

ASSESSMENT
Cranial Nerves
Observation

Ptosis (III)

Facial Droop or Asymmetry (VII)

Hoarse Voice (X)

Articulation of Words (V, VII, X, XII)

Abnormal Eye Position (III, IV, VI)

Abnormal or Asymmetrical Pupils (II, III)

I - Olfactory
Not Normally Tested
II - Optic

Examine the Optic Fundi

Covered elsewhere..

Test Visual Acuity

1. Allow the patient to use his glasses or contact lens if available. You are interested
in the patient's best-corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum
pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until he can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) [2]
6. Repeat with the other eye.

Screen Visual Fields by Confrontation

0.Stand two feet in front of the patient and have him look into your eyes.
1. Hold your hands about one foot away from the patient's ears, and wiggle a finger
on one hand.
2. Ask the patient to indicate on which side he sees the finger move.
3. Repeat two or three times to test both temporal fields.
4. If an abnormality is suspected, test the four quadrants of each eye while asking
the patient to cover the opposite eye with a card.

Test Pupillary Reactions to Light

0. Dim the room lights as necessary.
1. Ask the patient to look into the distance.
2. Shine a bright light obliquely into each pupil in turn.
3. Look for both the direct (same eye) and consensual (other eye)

reactions.
4. Record pupil size in mm and any asymmetry or irregularity.
5. If abnormal, proceed with the test for accommodation.

Test Pupillary Reactions to Accommodation

0. Hold your finger about 10cm from the patient's nose.
1. Ask him to alternate looking into the distance and at your finger.
2. Observe the pupillary response in each eye.

III - Oculomotor

Observe for Ptosis

Test Extraocular Movements

1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with his eyes without moving his head.
3. Check gaze in the six cardinal directions using a cross or "H" pattern.

4. Pause during upward and lateral gaze to check for nystagmus.

5. Check convergence by moving your finger toward the bridge of the patient's nose.

Test Pupillary Reactions to Light (See Above)

IV - Trochlear
Test Extraocular Movements (Inward and Down Movement, See Above)
V - Trigeminal

Test Temporal and Masseter Muscle Strength

1. Ask patient to both open his mouth and clench his teeth.
2. Palpate the temporal and masseter muscles as he does this.

Test the Three Divisions for Pain Sensation

1. Explain what you intend to do.
2. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides.
3. Substitute a blunt object occasionally and ask the patient to report "sharp" or
"dull."

If you find an abnormality then:

1. Test the three divisions for temperature sensation with a tuning fork heated or
cooled by water.
2. Test the three divisions for sensation to light touch using a wisp of cotton.

Test the Corneal Reflex

1. Ask the patient to look up and away.
2. From the other side, touch the cornea lightly with a fine wisp of cotton.
3. Look for the normal blink reaction of both eyes.
4. Repeat on the other side.
5. Use of contact lens may decrease this response.

VI - Abducens
Test Extraocular Movements (Lateral Movement, See Above)
VII - Facial

Observe for Any Facial Droop or Asymmetry

Ask Patient to do the following. Note any lag, weakness, or asymmetry:

1. Raise eyebrows
2. Close both eyes to resistance
3. Smile
4. Frown
5. Show teeth
6. Puff out cheeks

Test the Corneal Reflex (See Above)

VIII - Acoustic

Screen Hearing
1. Face the patient and hold out your arms with your fingers near each ear.
2. Rub your fingers together on one side while moving the fingers noiselessly on the
other.
3. Ask the patient to tell you when and on which side he hears the rubbing.

4. Increase intensity as needed and note any asymmetry.

5. If abnormal, proceed with the Weber and Rinne tests.

Test for Lateralization (Weber)

1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork firmly on top of the patient's head.
4. Ask the patient where the sound appears to be coming from (normally in the
midline).

Compare Air and Bone Conduction (Rinne)

1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork against the mastoid bone behind the ear.
4. When the patient no longer hears the sound, hold the end of the fork near the
patient's ear (air conduction is normally greater than bone conduction).

Vestibular Function is Not Normally Tested

IX - Glossopharyngeal
See Vagus Nerve
X - Vagus

Listen to the patient's voice. Is it hoarse or nasal?

Ask Patient to Swallow

Ask Patient to Say "Ah"

o Watch the movements of the soft palate and the pharynx.

Test Gag Reflex (Unconscious/Uncooperative Patient)

1. Stimulate the back of the throat on each side.
2. It is normal to gag after each stimulus.

XI - Accessory

From behind, look for atrophy or asymmetry of the trapezius muscles.

Ask patient to shrug shoulders against resistance.

Ask patient to turn his head against resistance. Watch and palpate the sternomastoid
muscle on the opposite side.

XII - Hypoglossal

Listen to the articulation of the patient's words.

Observe the tongue as it lies in the mouth

Ask patient to:

1. Protrude tongue
2. Move tongue from side to side