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Pain is an infrequent symptom of neurologic disease, but it merits mention. Trigeminal neuralgia, also known as tic douloureux, is the occurrence of severe, jabbing pain lasting only seconds in the distribution of the maxillary or mandibular divisions of the trigeminal nerve (Fig. 21-10). It is frequently provoked by motion, touch, eating, or exposure to cold temperatures. Another cause of facial pain is the cluster headache, already discussed. Herpes zoster infection of a sensory nerve root, also known as shingles, manifests with intense pain

Facial Nerve Distribution

along the distribution of that nerve root. Three to 4 days later, the classic linear, vesicular skin eruption develops along the distribution of the nerve. Figure 8-64 shows the classic dermatologic manifestations of herpes zoster infection of spinal nerve T3.

Sciatica is intense pain shooting down the leg in the distribution of the sciatic nerve. In this condition, there is impingement of portions of the sciatic nerve by the vertebrae. Arthritis of the lumbosacral spine is frequently the cause.

Sometimes the paresthesias associated with demyelinating diseases are so intense that the patient may describe them as pain.

Patients with inflammation of the meninges often complain of pain in the neck and a resistance to flexion of the neck. If meningitis is suspected, have the patient lie on his or her back. Place your hand behind the patient's neck and flex it until the chin touches the sternum. In patients with meningitis, there is neck pain and resistance to motion. This is called Brudzinski's sign. There may also be flexion of the patient's hips and knees. Josef Brudzinski described at least five different physical signs indicative of meningeal irritation. This sign is the best known and most reliable sign. Another sign of meningeal irritation can be elicited while the patient lies on the back and you flex one of the patient's legs at the hip and knee. If pain or resistance is elicited as the knee is extended, a positive Kernig's sign is present.

Impact of Chronic Neurologic Disease on the Patient

The ramifications of chronic neurologic disease on the patient and his or her family are enormous. All family members experience emotional pain while observing the progressive clinical changes. The family bears an immense personal burden in assisting the patient to cope with disability.

One example of a progressive neurologic condition is Alzheimer's disease. A devastating chronic disorder of unknown cause, Alzheimer's disease is the most common diffuse brain degeneration causing brain failure. This condition is characterized by progressive and widespread brain degeneration with a hopeless prognosis.

Memory problems and impairment of intellectual function are the main symptoms of Alzheimer's disease. Depression is common. Patients may have significant cognitive impairment, which ruins their ability to negotiate their environment. They may forget where they live. They may forget to turn off a gas burner on the stove or to put out a cigarette. They may wander aimlessly outdoors.

Manifestations of Alzheimer's disease span a clinical spectrum from awareness of the disability to a vegetative state. Many patients lose touch with reality. During an interview with such a patient, it may become clear that even the ability to describe the patient's own medical history has been lost.

Early in the course of the disease, affected patients may use a number of circumlocutions, such as substituting words when they cannot find more appropriate ones. Another early change is disorientation with regard to time and place. Visual hallucinations are common. Lack of interest in sex is almost universal. Motor behavior diminishes progressively as impairment of consciousness increases. An important characteristic is the development of bizarre thoughts and fantasies that come to dominate consciousness. Delusions, especially delusions of persecution, are common.

In the early stages of the disease—when patients are still aware of their environment but have experienced the symptom of memory loss—mild depression, anxiety, and irritability are common. As the disease progresses, apathy is the dominant feature. Patients may actually appear indifferent and emotionally withdrawn. In others in whom there is increased motor activity, anxiety and fear are common. In these individuals, terror and panic attacks are not uncommon. Hostility and paranoia develop rapidly. Regression and sudden displays of highly charged emotion are the responses to their frequent hallucinations.

In milder cases, depression, hypochondriasis, and phobic features abound. Hysterical conversion reactions, such as hysterical blindness, may occur. Social interaction is lost, and the patient may suddenly explode with anger, anxiety, or tears. As the disease progresses, suicide attempts are common. Emotional lability is often extreme, with periods of laughter followed by crying. With progressive disease, dullness of affect and lack of an emotional response occur as gross neurologic disability develops. In the terminal stages, patients with Alzheimer's disease may show severe body wasting with profound brain failure.

Physical Examination

The equipment necessary for the neurologic examination consists of safety pins, cotton-tipped applicators, a 128-Hz tuning fork, gauze pads, familiar objects (coins, keys), and a reflex hammer.

The neurologic examination consists of assessment of the following:

Mental status Cranial nerves Motor function • Reflexes

Sensory function Cerebellar function

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