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Pathological reflex

Nerve reflex under pathological conditions

Pathological reflex does not appear under normal circumstances (except for infants), only in central nervous system Abnormal reflection only occurs when damage occurs. Spinal and cerebral pathological reflexes are mainly caused by Pyramidal fasciculus After the damage, the brain lost its inhibition And appeared. This reflex can also occur in infants under one and a half years of age due to the incomplete development of the nervous system, which does not belong to Pathological 。^[1]

Chinese name: Pathological reflex
Foreign name: pathologic reflex^[2]
Also called: Pyramidal tract sign
Genus: Neurological examination

Form: Pathological condition, showing nerve reflex
Babinski: Outer edge of sole
Gordon sign: Press the gastrocnemius with a certain strength
Positive performance: Thumb back extended, the remaining four toes fanned out
Clinical significance: It indicates that the cone bundle is damaged

catalog

one Classification of pathological reflex
two Introduction to Pathological Reflex
three palmomental reflex

Classification of pathological reflex

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1． Babinski sign : Also known as Babinski Zheng. The examinee lies on his back with his lower limbs straight. The doctor holds the ankle to be examined, draws the outer edge of the sole with a blunt headed bamboo stick, moves from back to front to the heel of the little toe and turns to the inside. The normal reaction is plantar flexion, and the positive reaction is dorsiflexion of the big toe, Residual toe Fan out. Babinski sign is the most important sign when pyramidal tract is damaged.

2． Oppenheim sign : Also known as Oppenheim Zheng. The doctor used his thumb and index finger to slide and press along the front edge of the examinee's tibia from top to bottom. The positive expression is the same as Babinski sign 。

3． Gordon sign : Also known as Gordon Zheng. During the examination, press the gastrocnemius muscle with a certain strength, and the positive expression is the same as Babinski sign 。

four Chaddock sign : Also known as Chadok's sign and Cha's sign. It belongs to pathological reflex. The positive expression was dorsiflexion of the big toe, and fan-shaped spread of the other four toes.

Introduction to Pathological Reflex

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It is mainly the manifestation when the pyramidal tract is damaged, so it is called pathological reflex. The occurrence of pathological reflex must be central nervous system Damaged. But infants under 1 year old are normal primitives Protective reflection 。 Later with nervous system Is mature, Pyramidal fasciculus and Extrapyramidal system It is gradually perfected and formed. Later, with the development and maturity of the nervous system, the pyramidal tract and extrapyramidal tract are gradually perfected and formed myelin sheath , so that these reflections are suppressed by the cone bundle. When the cone bundle is damaged, inhibition If it is relieved, the pathological reflex will appear. Pathological reflex is mainly Babinsky sign And a group of related signs. The appearance of Babinski sign in most cases indicates that the pyramidal tract has Organic lesion 。 However, in some cases, such as Hypoglycemic coma or general anesthesia When, there may be Transitory Pathological reflex was positive. At this time, if intravenous injection Hypertonic Sugar or anaesthesia If it is relieved, the pathological sign will disappear rapidly, which seems to fail to show Pyramidal fasciculus Occurred tissue damage 。 The reaction with positive pathological reflex is generated by stimulating different parts of the lower limb. There are many methods and names, but Babinski syndrome is common. Sometimes Babinski is negative, but stimulating other parts to elicit positive reaction still has clinical value. The main pathological reflexes in clinic are as follows : Babinsky Gordon's sign 、 Chadok sign 、 Oppenheim sign 、 Hoffmann sign (disputed)

Etiology and mechanism

1. Babinsky sign: afferent nerve is Tibial nerve , the posterior horn cells of the center in sacral cord 1 - lumbar cord 4-5 and anterior horn cells of sacral cord 1-2, the efferent nerve is Deep peroneal nerve 。 Babinski sign is a fairly reliable indication of pyramidal tract injury, which is often seen in pyramidal tract injury, but also in deep sleep, deep anesthesia, drugs or alcoholism , myelopathy cerebral apoplexy 、 Epilepsy When Todd's paralysis occurs later and Hypoglycemic shock Etc. People who are allergic to pain and have excessive pain due to foot pricking, Chorea Or hand athetosis No random movement 。 Babinski sign may appear, which is due to hyperactivity of the patient.

2. Chardock sign: the same as Babinsky sign.

three Gordon's sign : Same as Chardoch sign.

4. Oppenheim: the same as Gordon's sign.

5. Hoffmann sign: upper limb pyramidal tract disease (injury or lesion), common in Cerebrovascular disease It can also be seen in cervical spondylosis. Such as bilateral Hoffman's sign Positive, but not Nervous system signs There is no positioning significance.

Inspection method

one Babinsky sign : Patient Supine position , with a blunt point a stimulus Pricking Lateral margin of foot , from heel forward to Little toe The root turns inward again, causing Hallux Back extension, other four toes flexion and fanning, called "open fan sign", is a typical positive performance of Babinsky sign. The second method is to stimulate the lateral edge of the sole when only the big toe dorsiflexion occurs, and the other four toes do not bite, bend or fan open. The third method is to stimulate the outside of the sole, the big toe and other four toes are dorsiflexion, accompanied by fan-shaped separation of the four toes. In clinical practice, there is an "open fan sign" of the toe but no dorsal extension of the toe. It can only be considered that there is a possibility of pyramidal tract injury, but it cannot be confirmed that Babinski sign is positive.

two Gordon's sign : The patient lies flat, and the examiner squeezes Gastrocnemius muscle , the dorsiflexion of big toe is positive. Its clinical significance is the same as Babinsky sign.

3. Chadok's sign: the patient is in a supine position, both lower limbs are straight, and a blunt pointed object is used to gently stroke from back to front Instep Foot appears on the lateral skin Hallux Back flexion is positive. his susceptibility It has the same clinical significance as Babinsky sign.

four Oppenheim sign : The examiner used his thumb and index finger to press and move along the front of the patient's tibia from top to bottom. The reflex is the same as Babinski sign, and its clinical significance is also the same.

five Hoffmann sign : The examiner gently clamps the distal side of the patient's middle finger with the right index finger and middle finger Interphalangeal joint The patient's wrist is slightly extended back, the fingers are slightly flexed, and the thumb is flicked downward to press the nail of the middle finger. The thumb is flexed inward, and the other fingers flexed are positive reactions.

Amyotrophic lateral sclerosis

Early unilateral distal extremity Muscular atrophy , other limbs gradually appear Amyotrophy , lower limbs and trunk can be affected occasionally, and finally facial muscle and Lingual muscle Atrophy occurs only after being affected, and it develops to systemic muscular atrophy only after 1-2 years. The early pyramidal tract damage is not obvious, so early diagnosis is more difficult, and the diagnosis can only be made with clear pyramidal tract signs. About half have Babinski sign, none Sensory disturbance and incontinence , occurs bedsore Rare, early Ant sense , pain, etc.

cerebral hemorrhage

(cerebra haemorrhage) hypertension Medical history, often occurring between 50 and 60 years old, physical activity Or sudden onset of illness when emotional excitement, rapid development, early headache , vomiting, etc Intracranial hypertension sign ， Consciousness obstacle , with Meningeal irritation sign and hemiplegia 、 aphasia Such as local brain symptoms, coma and limbs may occur when the condition gets worse Muscular tension Low, nasal sound breathing, repeated vomiting, often with unequal size of bilateral pupils, usually with dilated pupils on the bleeding side. In some cases, both eyes stare at the bleeding side. The opposite side of the bleeding focus is hemiplegic, with low muscle tension, and Babinski sign is positive. acupuncture There was no reaction on the paralyzed side. Waist wear Bloody cerebrospinal fluid ， CT display high-density Stove. MRI T1W, T2W intracerebral High signal Zone.

Cerebral thrombosis

(cerebrate Thrombosis) mostly occurs in the elderly over 60 years old, with hypertension history and Cerebral arteriosclerosis And coronary heart disease or diabetes History, more men than women. It often occurs during sleep or quiet rest. It reaches the peak within 1-4 days, and the coma is mild. Headache and vomiting are rare. Pupils unchanged ， Fundus arteriosclerosis , contralateral to the focus Limb paralysis , often with hemiplegia aphasia , hemiplegia, hemianopsia, etc. There is resistance in the neck, low muscle tension, and Babinsky sign, Cardock sign and Galden sign are positive on the diseased side. Cerebrospinal fluid examination How normal, Brain CT Displays low density areas. MRI、T1M Low signal T2M slightly high signal area.

Multiple sclerosis

Multiple sclerosis mostly occurs between 20 and 40 years old, rarely under 10 years old (3%) and over 50 years old (5%), and women are more than men. Most patients have a history of remission and recurrence, most have diplopia, unilateral or bilateral Limb weakness , Limb Paresthesia , pyramidal tract damage can lead to spastic limb paralysis, which can be manifested as paraplegia and quadriplegia Triplegia , hemiplegia or Monoplegia ， Tendinous reflex Hyperactivity, positive Babinski sign.

Epidemic nerve Myasthenia

（benign epidmic neural myasthenia ）At the initial stage Low fever Or none fever ， incubation period About 1 week, with upper respiratory tract infection ， Pharyngalgia , gastrointestinal symptoms, etc. whole body Lymph node enlargement , with Enlargement of cervical lymph nodes Obviously, headache Stiff neck And neck pain and muscle pain. Nystagmus , diplopia, Myoclonus , throat muscle weakness, limb weakness, tendon reflex normal, hyperfunction or decline, positive pathological signs. Fascicular fibrillation , accompanied by muscle pain and tenderness, skin allergy. Insomnia and abnormal sweating 、 Emotional instability , inattention, depression Hysteria Like attack, etc.

Hypertensive encephalopathy

(hyper progressive or severe) Slow progressive hypertension Patient, presenting with severe headache dizzy , vomiting Head distension or Insanity 。 Hypochondriac Comprehensive development It may take 12-48 hours, and then general convulsions, myoclonus, coma and Focal Neurological disorders, and hemiparesis, aphasia, focal seizures, and retina Sexual or cortical blindness may also occur Papilledema ， Retinal hemorrhage And exudation, blood pressure suddenly rises. Pathological reflex was positive. Waist wear cerebrospinal fluid More normal, the pressure increases.

Multiple cerebral infarction dementia

(dematerialized multiple cardiovascular infection) The main symptoms are Memory loss , mental retardation, Disorientation , poor judgment and lack of Insight 。 The near memory declines obviously and is easy to forget, but the far memory is generally kept well. I don't know people who are very familiar with me, so I mistook the time and place. Professional knowledge is also forgotten, poor computing power, poor expression, even incoherent, and indifferent spirit, Unresponsive , selfishness, egotism, accompanied by emotional instability, irritability, paranoia, delusion, etc. Late dementia, radial artery 、 Dorsalis pedis artery 、 Femoral artery Normal pulsation on both sides, audible Vascular murmur 。 Tendon reflex increased and Babinski sign was positive on both sides. Palmchin reflex Sucking reflex Positive interbrow reflex.

Uveoencephalitis

(uveoencephalitis) The onset age is 25-50 years old, often in spring. First Symptoms of meningeal irritation 、 Lethargy Consciousness disorder, sometimes with hemiplegia and aphasia. Hemiplegic side Increased muscle tone The tendon reflex was enhanced and Babinski sign was positive. Acute within 1-2 weeks after onset Diffuse Uveitis , sudden loss of vision, Ciliary body Hyperemia, iris Posterior adhesion, pupillary narrowing, Vitreous opacity , or retina Edema 。 regard papilla Congestion, unclear edges, and even retinal detachment. Appearing tinnitus 、 deaf and Balance disorder 。 Can appear Skin leukoplakia , white hair and hair loss, etc.

Hepatic myelopathy

This disease is not rare in fact, because most patients hepatic encephalopathy Coexistence, clinical symptoms are affected by the consciousness and Dyskinesia Misdiagnosis due to concealment. Pathological examination The posterior and lateral tracts of spinal cord Demyelination changes 。 The disease is slow in onset, progressive, weak in both lower limbs, unstable in walking, and may be accompanied by physiological sphincter Obstacles. Lower limbs Muscle strength , decline, muscle tension increase, tendon hyperreflexia often clonus , pathological reflex was positive. tuning fork Vibration and joints Positional sense Decrease, pain and touch are normal. Muscle strength of paralyzed limbs is 3-4 levels. Completeness Paraplegia is rare, no obvious Lesion Sense level. Blood ammonia rise.

Subacute combined degeneration

（ subacute The disease is not obvious family history Or gender differences. Most of them have chronic onset in middle age, Gradualness Aggravated, early toe and finger end Symmetry Abnormal sensation, gradually extending to the proximal end. Both lower limbs are weak, Hypotonia , mild muscular atrophy, slow tendon reflex. Both deep and shallow senses may have obstacles, which are distributed around, and may be accompanied by muscle tenderness, Posterior funiculus And Lateral funiculus There are weakness of limbs, increased muscle tension Abdominal wall reflex Disappear. Babinsky sign and Kardak sign are positive. With incontinence, which may be accompanied by Pernicious anemia The pallor of, indigestion and Glossitis 。 around Hemogram And bone marrow smear showing high giant cell hemoglobin nature anemia 。

Hyperparathyroidism

The main symptoms of hyperparathyroidism are glossal muscle tremor, glossal muscle atrophy, similar to amyotrophic lateral funiculus Sclerosis 。 Yes, you can hoarseness ， Vocal cord paralysis ， Dysphagia 。 A few patients have Neurogenic deafness Or tendon hyperreflexia. When tapping one tendon reflex, the opposite limb also has active reflexes, and Babinski sign is positive. The muscles at the proximal end of the lower limbs are often prone to fatigue and weakness. Pelvic girdle and Scapular girdle The muscles of 40% often have pain and abnormal sensation after exercise, and muscle atrophy may occur. The muscle tension of the invaded muscle is low and the tendon reflex is active. Back pain with tenderness, Unfixed position.

Hysterical paraplegia

(hysteric paraplegia) Most women have mental factors before illness Spastic paraplegia It can be seen all the time, and it is changeable. It shows relaxation and spasticity in an instant. There is no sphincter barrier, bedsore and skin Nutritional disorders And muscular atrophy, tendon reflex And Shallow reflection Normal. There is no Babinski sign. Be rich in Suggestive 。

palmomental reflex

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Etiology and mechanism

Afferent nerve by Median nerve , posterior horn cell column of the center in the cervical spinal cord 5-8 and thoracic spinal cord 1, spinal cord thalamus Fasciculus pons facial nerve Nuclear. Efferent nerve Facial nerve. This reflex appears when the cortical brainstem tract is diseased, especially when the bilateral cortical brainstem tract is diseased, and it can appear when the supranuclear fibers of the facial nerve are involved. Visible in Cerebral arteriosclerosis 、 Amyotrophic lateral sclerosis , Peripheralness Facial nerve paralysis 、 Bulbar paralysis 、 Polyneuritis This reflex occurs when the afferent or efferent nerve is affected, and the cortical bridging bundle (especially bilateral) becomes hyperactive when it is damaged, frontal lobe Opposite side of lesion Metacarpchin reflex Hyperactivity.

clinical manifestation

To scratch lightly or with a blunt needle acupuncture Palm Thenar Partial skin, causing ipsilateral mandible The genius muscle contracted. Normal people can also have this reflex, but bilateral contractions are symmetrical and reflex Muscle contraction The amplitude is very small, and the contraction of the chin muscle is not continuous, but the normal person appears with Pathological The pathological palmar carve reflex is not only limited to the thenar, but also can appear on the back of the hand, upper limbs, trunk, and even stimulate the lower limbs. Pathological palmchin reflex muscle contraction amplitude is large, and the duration is long.

differential diagnosis

（1） Peripheral facial paralysis usually has a history of coldness and infection. All facial muscles on the same side of the focus are paralyzed, and corners of the mouth droop Sail Sign positive. The eyebrow lifting is limited, the forehead wrinkles become shallow or disappear, the eyelids cannot be fully closed, the sclera band is exposed at the lower edge of the cornea, and the eyeball moves up from the healthy side. Contralateral side Latissimus colli Contraction, paralytic side does not contract. because Styloglossal muscle And palatoglossal muscle paralysis. see occasionally Auditory hypersensitivity Paralytic side Orbicularis oculi muscle Reflection Orbicularis oris muscle Reflex, phobia Blink reflex Visual reflex and palmchin reflex are low. 2/3 of the anterior lingual side tendon has taste disorder, tears sometimes overflow, and breast milk occurs Facial nerve paralysis When sucking is limited, paralyzed side Salivary secretion Decrease.

（2） Bulbar paralysis is mostly bilateral Medulla oblongata Loss of neuromotor function and Autonomic nerve Dysfunction, increased salivary secretion, due to dysphagia and lip paralysis Drooling 。 appear soft palate 、 Pharyngeal muscle 、 Laryngeal muscle Glossal Peripheral paralysis 。 early stage Speech disorder ， Lingual muscle Fibrillation with tongue Amyotrophy , the tongue body gradually becomes smaller, and the tongue muscle is severely paralyzed, and the facial and orbicularis oris muscles are involved. Because of the paralysis of this muscle, the pronunciation is unclear, and because of the atrophy of the tongue muscle lips Thinned, unable to close lips, wrinkled lips, unable to whistle. Paralysis of soft palate and pharyngeal muscles, resulting in laryngeal and palatal tone disorders. Then came nasal consonant 。 because vagus Loss of motor function in patients with dysphonia Dysphagia , anti choking of drinking water, Pharyngeal reflex Vanishing and weak chewing. If the facial nerve nucleus is involved, there will be bilateral faces Emotive muscle Peripheral paralysis, stiff and expressionless face, and decreased palmchin reflex. Appears with the aggravation of the disease Respiratory rhythm imbalance. Even Chao's respiration and Apnea And so on. Late appearance Circulatory failure And death.

(III) Polyneuritis (polyneuritis) Pain or feeling in the affected limb Dyskinesia There is tenderness or tenderness in the lesion area, Tendinous reflex Disappear, depth Hypoesthesia Or disappear. Symmetrical lower motor neuron paralysis, Muscular tension Minus, Ankle reflex The decrease of muscle atrophy is usually earlier than the knee reflex, and the distal muscle atrophy is more serious than the proximal muscle atrophy. the legs Muscular atrophy With the tibialis anterior muscle Peroneal muscle , upper limb Interosseous muscle 、 Vermiform muscle , big and small thenar are obvious, and hand Foot drop 。 The skin at the distal end of the limb is symmetrically cool, smooth, thin or dry, without sweat or hyperhidrosis , due to the influence of afferent or efferent nerves, the palmchin reflex is reduced.

(IV) cerebral infarction (cerebrate infection) This disease is mostly seen in patients over 50 to 60 years old hypertension 、 Arteriosclerosis or diabetes The. Men are more than women, and they often get sick in a quiet state or at rest. Frontal lobe and Internal capsule When the disease occurs Mental symptoms and hemiplegia , leaning Sensory disturbance And partial blindness, Dominant hemisphere The lesion is accompanied by aphasia The non dominant side is affected by the sensory neglect disorder and somatosensory disorder of the opposite side. Sometimes, the opposite side of the frontal lobe has positive metacarpchin reflex.

(V) Cerebral arteriosclerosis (cere bra l arteriosclrosis) Most of them are over 45 years old, which can be similar in early stage Neurasthenia Performance, headache , heavy head dizzy 、 tinnitus Blindness, numbness of limbs, tremor, insomnia, forgetfulness, slow thinking, inattention, poor computing power work efficiency Poor Memory loss Brain appears as the disease progresses organic Mental symptoms And dementia, accompanied by personality changes, indifference, carelessness, childishness, lack of hygiene, talkativeness, repetitive language, wordiness or speech reduction. Superficial temporal artery Spindle hard, asymmetric tendon reflex, palm, chin and Positive sucking reflex 。

（6） Multiple encephalomalacia usually occurs over 50 years old, accompanied by hypertension history, and multiple irregular small cysts with a diameter of 0.5-1.5mm appear in the brain. Poor memory, Low intelligence ， capacity of calculation Low, laugh for no reason, lose Directional force , wandering, even dementia. Occurrence of upper and lower limbs on one side cerebellum Sexual ataxia and mild paralysis, tendon hyperreflexia, Babinski sign positive, and ipsilateral palmchin reflex positive. Available Cerebellar ataxia , but not because of cerebellar damage, but because of cortex Pons It is caused by bundle lesion, only slight hemiplegia, but no sensory disturbance and aphasia 。 Available Dysarthria ， Central facial paralysis Tongue paralysis, dysphagia, hand grip Poor, Finger nose test Positive.

Sucking reflex

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Strong grip reflex

sucking reflex palmchin reflex

Etiology and mechanism

one Sucking reflex : Afferent nerve by Trigeminal nerve The first branch is located in the main sensory nucleus of the anterior trigeminal nerve Reticular structure — facial nerve Nuclear, Efferent nerve Facial nerve. This reflection occurs more often in frontal lobe Lesions Pseudobulbar paralysis 。

2. Strong grip reflex: mostly seen in frontal lobe lesions, especially in the anterior area of motion. It is significant when one side exists, indicating that Lateral forehead Leaf lesions. This reflex is physiological in children under two years of age and has no clinical significance. Ankylosing plantar reflex is mostly seen on the opposite side of the lesion, occasionally on the same side. This reflex is Raw reflection 。

clinical manifestation

1. Sucking reflex: gently scratch or gently tap the lips, and immediately appear Orbicularis oris muscle Contraction, upper and lower lips pursed up, causing "sucking" action. Normal people have no such reflex.

2. Strong grip reflex: when touching the patient's palm with a moving object (such as the handle of a percussion hammer) or finger, causing the hand to hold continuously, it means that the strong grip reflex is positive. After two years old Reflection disappears 。 Or this reflection persists, yes Pyramidal fasciculus Damage symptoms.

differential diagnosis

（1） Frontal lobe lesion tumour The clinical symptoms are different due to the different growth speed and development direction. If to both sides Cingulate gyrus Presence of anterior invasion Mutism 、 Autonomic nerve disorder , one or both sides Paralysis of lower limbs And left hand Inactivity , appears in time Consciousness obstacle 。 violation Premotor area The strong grip reflex was positive on the opposite side of the lesion. Positive sucking reflex , or Hoffmam sign and Babinski sign positive, frontal sex Ataxia or Mental symptoms The possibility of frontal pole lesion should be highly suspected.

（2） Pseudobulbar paralysis is characterized by dysarthria and fulminant speech. Labial sound . The throat sounds are ambiguous, monotonous, low and blunt. Dysphagia , cannot push food to the pharynx. soft palate and Pharyngeal paralysis Counter choking occurs. Soft palate reflexes disappear, Pharyngeal reflex Existence is an important sign of pseudobulbar palsy, which is more significant for early diagnosis. Pseudobulbar palsy Yes Upper motor neuron Paralysis, so in addition to physiological Brainstem reflex In addition to being active or hyperactive, there are also some Pathological Reflex, called pathological brainstem reflex, can include sucking reflex Metacarpchin reflex , head up reflection Mandibular reflex , these reflections can be Pyramidal fasciculus Or brain Symptoms Therefore, early diagnosis is valuable.

(III) Alzheimer's disease (Alzheimer's disease) It can occur at any age after the age of 30 sex difference , the onset of illness is insidious, and forgetting is the earliest and most prominent symptom, especially near memory loss. Progressive Intelligent decline 、 Unresponsive , judgment and Understanding Drop, repeat words and meaningless repetitive actions. Inappropriate behavior, excitement, exaggeration, euphoria and decreased ability to work. It can also appear later Vagueness of consciousness , expressionless, rarely blinks, often Extend one's tongue , sucking and licking reflex. Semi flexion posture, slow movement, eventually severe dementia, bedridden, head CT so Brain atrophy and Ventricular enlargement 。

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