• THOSE MULTIPLE EPONYMOUSLY NAMED BABINSKI-LIKE SIGNS!

    28 September at 20:53 from atlas

    31 October 2017.

    The Babinski ( Joseph Babinski 1857-1932, a French Neurologist of Polish origin) sign is well known and practised by medical students and doctors as a routine.  This eponym refers to the dorsiflexion of the great toe with or without fanning of the other toes and withdrawal of the leg , on plantar stimulation in patients with pyramidal tract dysfunction.The neural mechanism starts with the S1 derma tom receptor nerve stannous endings--> afferent arc via the tibial nerve --> spinal cord segments involved being L4,L5 ,S1 and S2.Efferent ; motor response back through the L5,S1 roots to the sciatic nerve to its bifurcation.Toe flexors are innervated by the tibial nerve.Toe extensors(EHL,EDL) are innervated by the deep peroneal nerve.Loss of normal pyramidal tract descending control  of the reflex arc to SUPPRESS extensor withdrawal results in the upgoing toes.In patients over 1 year of age, the Babinski sign is always pathological.It may be normal in the 1st year of life.With lesions of the pyramidal tract there is segmental disappearance of toe downward response , the flexor synergy is disinhibited and the EHL muscle is again recruited into the flexion reflex of the leg producing the sign of 'Babinski'.

    Brissaud's reflex refers to contraction of the thigh and leg muscles including the TFL , as well as the toe extension.

    The physiologist looks on the Babinski reflex as simply part of the 'primitive flexion reflex'

    Alternative methods:

    (i) Chaddock's sign: great toe extension by stimulating the dorso-lateral foot from the posterior portion of the skin between the lateral malleolus  anteriorly along the edge of the foot,

    (ii)Gordon's sign: squeezing the calf.

    (iii)Oppenheim sign:applyng pressure along the tibia

    (iv)Gonda's sign: pressing the 4 th toe downwards and then releasing it witha snap;

    (v)Stransky sign: vigorous adduction of the little toe follower by  its sudden release

    (vi) Schaefer's sign:squeezing the tendachilles

    (vii) Rossolino's sign: flexion of the toes , on quick percussion of the patient's toes with the fingertip

    (viii)Mendal Bechtrew sign: flexion of the 4 outer toes induced by talling on the dorsum of the foot in the region of the cuboid bone

    (ix)Bing's sign : giving pinpricks on the dorsolateral surface of the foot

    (x)Moniz sign: forceful passive plantar flexion of the ankle

    (xi) Throckmorton sign: pressing over the dorsal aspect of MTP joint of the great toe

    (xii)Strumpell sign: application of forceful pressure over the anterior tibial region

    (xiii)Cornell sign: scratching the dorsum of the foot along the inner side of the extensor tendon of the great toe

    (xiii) Bekhterev-Mendel reflex: flexion of 2-5 toes on percussion of dorsum of foot

    it seems to matter little that Remak first described the extensor plantar response in a patient with transverse myelitis in 1893!(Pearce JMS.Babinski or Remak? J R Coll Physicians  Lond n1996;30:190.) 

    HOFFMANN reflex

    The Hoffmann reflex is sometimes described as the upper limb equivalent of the Babinski sign, because both indicate UMN dysfunction.Mechanistically they differ significantly; the finger flexion reflex is a simple monosynaptic reflex involving the FDP that is normally FULLY inhibited by the upper motor neurones.the pathway producing babinski's sign is more complex , and is NOT monosynaptic.

    Paul Hoffmann (1884-1962) was  a German physiologist in Freiburg described tapping or flicking the terminal phalanx of the middle or ring finger-a +ve response is seen with flexion of the terminal phalanx of the thumb.

    A Babinski sign is considered pathological (> 1 year) whereas a +ve Hoffmann reflex may be found in normals with hyper-reflexia. Hoffmann's reflex that is unilateral , or has an acute onset, however is worrisome.

    Hoffmann's reflex (not Tinel like response!) is a DTR (spindle fibre) with a mono-synaptic reflex pathway in Rexed layer IX of the cord whereas the Babinski sign is not a DTR but polysynaptic as discussed above.

    GONDA'S SIGN

    Flexing then suddenly releasing the 4th toe elicits an extensor reflex-it is one of the Babinski like responses.

    REVERSED CHADDOCK SIGN( or TASHIRO SIGN)

    The optimal receptive fields for Babinski and chaddock reflexes are the lateral plantar surface and the external inframalleolar area of the dorsum respectively.The major problem of stroking the lateral part of the sole are false +ve responses with foot withdrawal, tonic foot response or equivocal movements.on the other hand the receptive field of Chaddock's reflex (external infra-malleolar area)-is definitely suitable for eliciting an extensor response.In fact, the "reversed Chaddock method" , is equally sensitive and involves stimulating the dorsum (not sole) of the foot from medial to lateral (sural nerve),with LESS false +ve responses, according to K.Tashiro of Khokkado University, Japan)-suggesting it be named Tashiro sign(reversed Chaddock sign).

    CHADDOCK REFLEX

    Elicitation of an extensor (Babinski-like) response via stimulation of the skin over the lateral malleolus.It was identified by charles Gilbert Chaddock( 14/11/1861-20/7/1936 an American Psychiatrist and Neurologist) in 1911.Kisaku Yoshimura  in 1906, a Japanese internist, introduced the so-called Chaddock reflex 5 years earlier than Chaddock's original report.

    The ownership of the 15 or so extensor plantar responses is controversial , with indeed definite evidence that Babinski did not FIRST report the sign etc....

    Patients and IMEs are advised to follow the advice of their treating medical practitioner / indemnity insurer  at all times.The opinions stated herein are those of the author.

    Dr Michael Coroneos is a senior Brisbane neurosurgeon with six surgical Fellowships and was honoured to be elevated to Master CIME status by the American Board of Independent Medical Examiners (by  3 examinations and training 2012 to 2017) in May 2017.

    Qualifications and Memberships : MCIME  FRACS  FACS(USA)  FRCS(Glasg) FRCS(IRE)  FRCS(ENG) FRCS(EDIN)SN MB BS(1st Cl Honours, 1980, UQ) MNSA MNSQ MAPS MASE 

    Senior Clinical RACS  OSCE Examiner/ Mortality Assessor RACS (QASM)/ Honorary  Clinical Adjunct Assistant Professor and Examiner / Senior Neurosurgeon/ Master CIME/ Member RACS Academy Surgical Educators.