Book: Examination of the cranial nerves
Authors: Peter Rothwell
Journal: BMJ (2000)

David Perkin


British Brain and Spine Foundation, £35 




ISBN 1 901893 22 7

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Rating: ★★★★

Neurologists like to think of their specialty as one of the last bastions of clinical medicine. It is often said that a good history and a detailed clinical examination will provide the diagnosis in the vast majority of neurological disorders, with neuroimaging and modern diagnostics serving only to confirm this. In real life, neurological practice falls somewhat short of this ideal, but it probably is true to say that clinical skills are more important in the routine assessment of patients with neurological diseases than in assessment of diseases of most other systems.

Moreover, the nature and complexity of the central and peripheral nervous systems mean that the neurological examination is more taxing than, for example, the observation, percussion, palpation, and auscultation of lumps and bumps. Partly as a consequence of this, the neurology case is the part of finals and professional examinations that students and trainees often fear most, particularly when assessment of the cranial nerves is required. The difficult anatomy and the esoteric, convoluted, and somewhat ritualistic examination of the cranial nerves epitomise what students dislike about neurology.

These misperceptions are unlikely to be undone in the library, either by the 4500 pages of Walsh and Hoyt's Clinical Neuro-ophthalmology or the several thousand pages dedicated to disorders involving the cranial nerves scattered throughout Vinken and Bruyn's 70 volume Handbook [surely some mistake] of Clinical Neurology. Yet, with proper demonstration and explanation, assessment of the cranial nerves should not be difficult, confusing, or time consuming.

David Perkin's video provides an excellent tutorial. For each cranial nerve in turn, the anatomy is described with the aid of a skull, pathological specimens, and schematic diagrams. The technique of examination is demonstrated in clear detail, and auxiliary assessments, such as Hallpike's manoeuvre (a distinctive rendition with some similarities to the tango), are also described. Normal findings are shown with a healthy volunteer, and the commonly encountered abnormal findings are demonstrated with an excellent selection of clinical cases. The only addition that I would make to the suggested examination would be brief testing of cough, speech, and swallowing as a functional screen for the ninth, tenth, or twelfth nerves.

The video is supplemented by a tutor pack, which reiterates the key points, provides lists of questions, and details several interesting and useful case histories. As a whole, the package provides a more versatile teaching resource than other videos or currently available internet sites. A second edition might be improved by replacing the pathological specimens with modern in vivo anatomical imaging such as magnetic resonance techniques.

Given the length of the video (54 minutes) and the slightly disjointed approach that is necessitated by covering each nerve separately, it might have been worthwhile (and less daunting to the medical student or neurosurgeon) to end with a demonstration of the complete and uninterrupted two minute examination that most neurologists use in clinical practice. Overall, however, this is an excellent video for students, trainees, and clinical tutors alike.