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DeJong’s The Neurologic Examination EIGHTH EDITION William W. Campbell, MD, MSHA, COL, MC, USA (Ret) Professor Emeritus Department of Neurology Uniformed Services University of Health Sciences Bethesda, Maryland Richard J. Barohn, MD, Lt Col, USAFR, MC (Ret) Gertrude and Dewey Ziegler Professor of Neurology University Distinguished Professor Vice Chancellor for Research University of Kansas Medical Center Kansas City, Kansas Acquisitions Editor: Chris Teja Development Editor: Ariel S. Winter Editorial Coordinator: Kerry McShane Marketing Manager: Rachel Mante Leung Production Project Manager: Linda Van Pelt Design Coordinator: Joan Wendt Manufacturing Coordinator: Beth Welsh Prepress Vendor: Spi Global Eighth edition Copyright © 2020 Wolters Kluwer Copyright © 2013 by Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2005 by Lippincott Williams & Wilkins. Copyright © 1992 by JB Lippincott Co. All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Names: Campbell, William W., Jr. (William Wesley), author. | Barohn, Richard J., author. Title: DeJong’s the neurologic examination / William W. Campbell, Richard J. Barohn. Other titles: Neurologic examination Description: Eighth edition. | Philadelphia : Wolters Kluwer, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2018059855 | ISBN 9781496386168 (hardback) Subjects: | MESH: Neurologic Examination—methods | Nervous System Diseases—diagnosis Classification: LCC RC348 | NLM WL 141 | DDC 616.8/0475—dc23 LC record available at https://lccn.loc.gov/2018059855 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. shop.lww.com RUSSEL N. DeJONG, MD 1907–1990 Dedication To Rhonda, Robbie, Wes, Matt, Shannon, Ella, and Will. And to all our former residents and fellows, for all they taught us. FOREWORD Standard textbooks of neurology commonly include an introductory chapter on the clinical examination but otherwise provide little guidance as to how this is best performed. The exception is De Jong’s The Neurologic Examination, first published in 1950, which was intended to present in detail the information necessary to perform a complete and clinically useful examination, accompanied by limited descriptions of the findings in common neurologic entities or disorders. If anything, the need for such an account has increased with the passing years. The art of the neurologic examination is being lost as clinical medicine becomes depersonalized and as new diagnostic and monitoring techniques are used in its place. Moreover, little time is left to learn the intricacies of the physical examination in today’s crowded medical school curriculum. The publication of this new (eighth) edition of De Jong’s classic text, authored by William Campbell and Richard Barohn, is therefore timely and to be welcomed. It is a pleasure to introduce the book and its authors to another generation of readers. Dr. Campbell is professor emeritus and former chair of the neurology department at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. I have known him since he was a resident in San Francisco more than 40 years ago. He has had an illustrious career and is well known for his clinical skills and diagnostic acumen. He has authored a number of clinical studies on different aspects of neuromuscular disorders and received the Distinguished Physician Award of the American Association of Neuromuscular and Electrodiagnostic Medicine in 2011. Almost 20 years ago, he took over DeJong’s book—the fortunes of which had declined as technologic advances came to influence the practice of neurology—and single-handedly rewrote and revived it. The sixth edition, the first that he authored, was published in 2005 and soon restored the reputation of the book, earning for it a well-deserved place on the bookshelf of many neurologists. He remained the sole author for the seventh edition, published in 2012, but now has been joined by Richard Barohn in preparing this eighth edition. Dr. Barohn, professor and former chair of the department of neurology at University of Kansas Medical Center, is another accomplished neuromuscular clinician and investigator. In 2013, he received the Distinguished Researcher Award of the American Association of Neuromuscular and Electrodiagnostic Medicine and was named a University Distinguished Professor at the University of Kansas for his achievements. The book that Campbell and Barohn have authored serves an important need as a guide to both trainees and established physicians. The neurologic examination can be lengthy, often requires much attention to detail, is sometimes performed in difficult or unpleasant circumstances, and may be overwhelming to trainees. Its importance, however, cannot be overemphasized. The findings obtained thereby help to confirm a suspected diagnosis, determine whether any further investigations are needed, indicate the clinical relevance of any laboratory or imaging abnormalities, and suggest the extent and prognosis of many disorders. The competently performed examination also helps to establish a bond between patient and physician that is essential to the welfare of the former and professionally satisfying to the latter. The neurologic findings become especially meaningful as their relationship to changes in the structure and function of the nervous system comes to be understood. One of the goals of the present volume is to emphasize such a relationship, and the authors have achieved this aim admirably. The text in this new edition has been shortened slightly by reducing discussions of various disease entities to focus on the clinical findings and their significance. Numerous illustrations—most in color—increase the breadth of the book. Several of the older figures from earlier editions have been replaced, and new figures have been added. A number of videos are embedded in the text, with links to many more, as well as to Dr. Campbell’s instructive neurosigns.org Web site. In consequence, readers of this book will be able to learn more easily the intricacies of the examination and what to seek when examining patients with different neurologic disorders. They will come to understand the nature and importance of different neurologic signs and will be able to learn from expert clinicians how best to elicit them. Earlier editions have previously received wide recognition and are deservedly familiar to many clinicians. This new edition, which is both scholarly and practical, is even better. It is a mine of information and will be an important resource for many years to come. Perhaps remarkably in this 21st century but following in the tradition of its predecessors, this new edition is written in its entirety by these two eminent physicians and thus has a uniformity of style that is pleasing. The various chapters fit seamlessly together to produce an integrated and well-rounded