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Neurological Examination of Malingering
Published in Alan R. Hirsch, Neurological Malingering, 2018
Jose L. Henao, Khurram A. Janjua, Alan R. Hirsch
Patients trying to mimic different types of spinal cord injuries should be tested to elicit specific signs of malingering. Organic disease would lead to diminished reflexes below the level of spinal cord damage. If below T9, the patient would exhibit abdominal muscle weakness. Charles Edward Beevor has described this (Desai, 2012). Beevor’s sign is tested with the patient in the recumbent position. Patient are asked to raise their heads or sit up while the physician focuses on the umbilicus. A positive sign would be the umbilicus moving in the cephalic direction more than one centimeter, or moving rostrally more than one centimeter for the inverted Beevor’s sign; both are positive tests for true disease (Leon-Sarmiento, Baona, and Bayona-Prieto, 2007). Positive signs will provide reassurance to the physician that this is not malingering since the sensitivity of this sign is 95% and specificity is 93% (Leon-Sarmiento et al. 2007). If patients do not exhibit this positive finding it suggests possible secondary gain. In a patient without true disease, the umbilicus will stay stationary because both parts of the abdomen muscles are working against each other to stabilize the umbilicus in the same position. Organic diseases such as amyotrophic lateral sclerosis and facioscapulohumeral muscular dystrophy, demonstrate Beevor’s sign. This physical finding is often missed since physicians routinely test their patients in the seated position.
Discussions (D)
Published in Terence R. Anthoney, Neuroanatomy and the Neurologic Exam, 2017
The sign of Babinski (= Babinski reflex) is particularly interesting in this regard, as several authors explicitly state that it is wrong to speak of a negative or a positive Babinski. As examples: “it is semantically inaccurate to say that the Babinski was negative or positive’” (waLt, p. 178); “The Babinski sign is referred to as being present or absent, not positive or negative” (VanA&R, p. 63); and ‘“Babinski flexor’ is a contradiction of terms” (Bick, p. 197). Nevertheless, several authors, both of basic and of clinical texts, do use the words “positive” and “negative” to describe the Babinski sign or reflex (e.g., clinical—T&D, p. 177; Bann, p. 110: basic—DSR&W, p. 188; M&F, p. 149). Authors who do use the words “positive” and/or “negative” in relation to a given sign are often inconsistent in this regard. For example, Adams and Victor (1985) refer to a certain finding as the Kernig sign on p. 267, 270, but as the “positive Kernig sign” on p. 268. Similarly, Gilroy and Meyer (1979) refer to a certain finding as “Beevor’s sign” on p. 53, but as a “positive Beevor’s sign” on p. 655. As a final example, DeJong (1979) is inconsistent with regard to at least three different findings. He refers to a certain finding as “Kernig’s sign,” but also uses phrasing such as “the Kernig sign is positive” (p. 483–484 [including Fig. 39–1]); he refers to another finding as both “the Laxfegue sign” and “the positive Lasègue sign” (p. 593–594 [including Figs. 47–1, 47–2]); and he refers to a third finding as the “Romberg sign” (p. 395), but also states that “The Romberg sign may be negative” (p. 728).
Synovial sarcoma mimicking a thoracic dumbell schwannoma- a case report*
Published in British Journal of Neurosurgery, 2020
Susanth Subramanian, Gandham Edmond Jonathan, Bimal Patel, Krishna Prabhu
A forty-six-year-old lady presented with mid back pain without any radiation and progressive tightness and weakness of both lower limbs for six months duration. There was no history of any bowel or bladder involvement. There was graded sensory loss below T10 level with no sacral sparing. Deep tendon reflexes were exaggerated in lower limbs. Beevor’s sign was positive and plantar reflex was extensor bilaterally. She was bedridden at the time of presentation. Routine haematological and biochemical parameters were normal. X-ray of thoracic spine was normal. MRI spine with gadolinium showed a well-defined dumbbell shaped intradural extramedullary tumour with a large extradural component at T7-T8 level with extension through the neural foramina on left side. The tumour was isointense in both T1, and T2 weighted imaging with homogeneous enhancement in the post-gadolinium imaging. The tumour was compressing and displacing the thoracic spinal cord to the right side. The tumor eroded the lamina and the left T8 pedicle (Figures 1 and 2). Based on the MRI findings a possibility of an intra and extradural nerve sheath tumour was considered.
Challenging questions regarding the international standards
Published in The Journal of Spinal Cord Medicine, 2018
Ryan Solinsky, Steven C. Kirshblum
Clinically, testing for trunk control in patients with spinal cord injuries is performed for select Paralympic sports.26,27 Yet even in these controlled environments, sufficient isolation and grading of these muscles remains a barrier. Additionally, Beevor’s sign is a clinical measure of rectus abdominis innervation. In this clinical exam, if partial innervation of the rectus abdominis is present with interruption of the spinal cord signaling from T10 to L2, provocative maneuvers will cause the umbilicus to displace rostrally with abdominal activation. This finding is due to imbalance in the innervation of the portion of the rectus above the umbilicus with the portion below. A negative Beevor’s sign (no umbilical displacement), however, represents a balance of muscle innervation above and below the umbilicus. Without further testing this finding may represent either full innervation or no innervation of abdominal musculature. Currently, assessment of Beevor’s sign is listed as an optional test for the International Standards (with instruction available as part of the International Standards Training e-Learning Program- InSTeP).12