The Neurologist’s Tools

A doctor’s visit may instill some trepidation even in the bravest among us. There is  always the concern about what the outcome of the visit will bring: either good news or something a little worrisome.  With the advent of so much easily accessible information literally at our fingertips, the visit may actually begin with some on line “research” that turns up some concern over a long neglected symptom which suddenly is thrust front and center. Is that persistent twitch merely an overworked muscle or the start of some dreaded progressive neuromuscular disorder?  It’s been said that getting information from the internet is a little like drinking from an open water hydrant.  You’re likely to drown before your thirst is satisfied.

Before that trip to the neurologist, it’s worth reviewing the tools we have available to figure out the nature of that twitch.  I am not jumping into discussing MRIs, and PET scans just yet.  A little more basic information first.  You may not be a trained neurologist but you possess the same tools we use.  Our senses.

Listening.  The history from the patient and progression of symptoms are the first clue.  Clearly rapidity of progression is obvious and portends a worse outcome, whereas slow progression may point to a hereditary or genetic illness with onset in later life and therefore allows more opportunity for accommodating new limitations.  Sight.  Is there atrophy of muscle? Assymetry in different postures? Any visible fasciculations, a strange quivering of muscles just below the skin?  Touch.  Palpation of muscles, assessment of muscle tone and strength in the hands of an experienced neurologist  are the next clue as to the nature of the evolving disorder.  Smell and Taste.  Strange as it may seem so much of medical practice in the days before modern tools were available depended on the physician using all his senses, including smell as for the odor of uremia in kidney disease, and taste as for the excess of salt on the skin of  a patient with cystic fibrosis.  It may be a lost art, but knowledge of these earlier ways of diagnosing are the basis for understanding the nature of many disorders.

Imaging. Often over utilized modern era of imaging began in the mid-1970s with the arrival of the first CT scans.  X-rays had already been around for several decades but the computed X-ray images was a novel way to use this old technology and opened many new horizons in the exploration of disease progression.  MRIs, originally called nuclear magnetic resonance do not use X ray, and in fact there is no radiation involved at all.  Magnetic resonance imaging relies on the excitability of hydrogen atoms in water dispersed throughout the body to produce the images in multiple planes of view, not merely axial as with CT scans. Thus a more three dimensional image is produced.  PET scans provide a means of “biopsy” without actual incision.  The chemical composition of a mass can be discerned and its nature revealed.

EEG. The electroencephalogram is produced by the electrical activity of cerebral structures.  Where  a seizure is arising, and what is the nature of the seizure are all answered by this test.  sometimes a prolonged EEG study with video monitoring is the best way to find the answer.  The test is minimally invasive and in the course of running the test which may be from 20 minutes to well over an hour, several procedures such as hyperventilation and photic stimulation are employed to provoke abnormalities which may otherwise be hidden form view.

EMG. A testing tool to assess the integrity of nerve function and muscle status.  Not a comfortable test at times as it requires  applying brief electrical shocks to the nerve under study and see how well it carries that charge.  The muscle testing portion utilizes a thin needle to pierce the muscle fibers. The needle then acts as microphone of sorts and the sound produced characterizes the health of the muscle fibers.

These are some of the tools neurologists use.  No technology now available or likely to ever be developed can replace the history taking and the examination as performed by a thoughtful clinician, distilling his knowledge and experience, to bring comfort and provide assurance to a distressed patient.

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