Babinski Reflex


Article Author:
Aninda Acharya
Radia Jamil


Article Editor:
Jeffrey Dewey


Editors In Chief:
Jon Parham
Jon Sivoravong


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/1/2019 6:27:23 PM

Introduction

The Babinski reflex (plantar reflex) was described by the neurologist Joseph Babinski in 1899. Since that time, it has been incorporated into the standard neurological examination. The Babinski reflex is easy to elicit without sophisticated equipment. Also, it requires little active patient participation, so it can be performed in patients who are otherwise unable to cooperate with the neurological exam. [1][2][3]

Anatomy

The Babinski reflex tests the integrity of the cortical spinal tract (CST). The CST is a descending fiber tract that originates from the cerebral cortex through the brainstem and spinal cord. Fibers from the CST synapse with the alpha motor neuron in the spinal cord and help direct motor function. The CST is considered the upper motor neuron (UMN) and the alpha motor neuron is considered the lower motor neuron (LMN). Sixty percent of the CST fibers originate from the primary motor cortex, premotor areas, and supplementary motor areas. The remainder originates from primary sensory areas, the parietal cortex, and the operculum. Damage anywhere along the CST can result in the presence of a Babinski sign.

Stimulation of the lateral plantar aspect of the foot (S1 dermatome) normally leads to plantar flexion of the toes (due to stimulation of the S1 myotome). The response results from nociceptive fibers in the S1 dermatome detecting the stimulation. Nociceptive input travels up the tibial and sciatic nerve to the S1 region of the spine and synapse with anterior horn cells. The motor response which leads to the plantar flexion is mediated through the S1 root and tibial nerve. The toes curl down and inward. Sometimes there is no response to stimulation. This is called a neutral response. This response does not rule out pathology.

The descending fibers of the CST normally keep the ascending sensory stimulation from spreading to other nerve roots. When there is damage to the CST, nociceptive input spreads beyond S1 anterior horn cells. This leads to the L5/L4 anterior horn cells firing, which results in the contraction of toe extensors (extensor hallucis longus, extensor digitorum longus) via the deep peroneal nerve. 

Babinski sign occurs when stimulation of lateral plantar aspect of the foot leads to extension (dorsiflexion or upward movement) of the big toe (hallux). Also, there may be fanning of the other toes. This suggests that there is been spread of the sensory input beyond the S1 myotome to L4 and L5. An intact CST prevents such spread. 

In infants with at CST which is not fully myelinated the presence of a Babinski sign in the absence of other neurological deficits is considered normal up to 24 months of age. Babinski’s may be present when a patient is asleep.

Indications

The Babinski reflex is done as part of the routine neurological exam and is utilized to determine the integrity of the CST. The presence of a Babinski sign suggests damage to the CST. Because the CST fiber tracts run from the brain, through the brainstem and into the spinal cord, lesions of the central nervous system (CNS) often affect the integrity of the CST. Thus, the presence or absence of the Babinski reflex can provide very useful information on the presence or absence of pathology affecting the CNS. Babinski reflex is especially important in the setting where there is suspicion of spinal cord injury or stroke, as it may be an early indicator of the presence of these emergency conditions. [4][5][6]

Contraindications

The only contraindication to performing the Babinski reflex is a lesion (such as an infection) in the affected area of the foot that precludes effective performance of the reflex. In such situations, one of the alternative methods of eliciting the response may be done. 

Equipment

The Babinski reflex should be elicited by a dull, blunt instrument that does not cause pain or injury. Sharp objects should be avoided. The dull point of a reflex hammer, a tongue depressor, or the edge of a key are often utilized. 

Preparation

The patient should be relaxed and comfortable. It is best to advise the patient that the sensation may be slightly uncomfortable. Patients may experience both a mildly unpleasant sensation as well as a tickling sensation. The examiner should ensure that the plantar surface of the foot is free of any lesions before proceeding. 

Technique

To test for Babinski’s sign, the instrument is run up the lateral plantar side of the foot from the heel to the toes, and across the metatarsal pads to the base of the big toe.

Many variations of the Babinski’s sign have been described. Each of them designed to elicit dorsiflexion of the big toe. The more common include Chaddock (stimulating under lateral malleolus), Gordon (squeezing calf), Oppenheim (applying pressure to the medial side of the tibia), and Throckmorton (hitting the metatarsophalangeal joint of the big toe). The mechanism by which these alternatives elicit this response is likely similar to the Babinski response. These variations are useful in patients who have a significant withdrawal response to the conventional testing for the Babinski reflex. 

Clinical Significance

The examiner watches for dorsiflexion (upward movement) of the big toe and fanning of the other toes. When this occurs, then the Babinski reflex is present. If the toes deviated downward, then the reflex is absent. If there is no movement, then this is considered a neutral response and has no clinical significance.[7]

The presence of the Babinski reflex is indicative of dysfunction of the CST. Oftentimes, the presence of the reflex is the first indication of spinal cord injury after acute trauma. Care must be exercised in interpreting the results because many patients have significant withdrawal response to plantar stimulation. When this occurs, one of the variations on eliciting a Babinski sign can be utilized.

In comatose patients, one may witness a triple flexion response. In this case, one observes dorsiflexion of the big toe, the fanning of the other toes, dorsiflexion of the foot, as well as knee flexion. The triple flexion response represents profound dysfunction of the CST, with a spread of the reflex to the L3 and L2 myotomes. Care must be made to distinguish this from a withdrawal response. The triple flexion response is very stereotyped whereas the withdrawal response can vary with each stimulation.

Enhancing Healthcare Team Outcomes

Healthcare workers should be aware of other methods of elicitation of the Babinski reflex, especially in patients with an absent toe or infection of the soles. The Hoffman reflex in the upper extremity is considered the nearest equivalent of the Babinski sign. They should also be aware of potentially misleading outcomes if the procedure is performed incorrectly. [Level V]


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Babinski Reflex - Questions

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In which patient is the presence of a Babinski reflex not pathologic?

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When there is damage to the corticospinal tract, which of the following will be positive?

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An 87-year-old male comes in for a routine office visit after being hospitalized for a fall. He reports that his left leg suddenly gave out and he fell down. His left arm and leg were weak for a day but now has returned to normal. He also had slurred speech and a left facial droop, which have also resolved. He reports no sensory loss, and his general examination is normal. Also, his neurological examination shows 5/5 strength on both sides. He has no sensory disturbance. He is noted to have a Babinski reflex present on the left side but absent on the right. The presence of the Babinski reflex suggests damage to which of the following structures?



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What is the technique for eliciting the Babinski sign?

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A 30-year-old male with severe head injury is in a coma in the intensive care unit. He is intubated and sedated and has no withdrawal to painful stimulation in the upper extremities. In both lower extremities, when the lateral aspect of the foot is scratched with a dull instrument, one observes a slow upward contraction (dorsiflexion) of the big toe, fanning of the other toes, ankle dorsiflexion, as well as hip and knee flexion. This occurs in a stereotyped pattern each time the stimulation is administered. What is the best way to interpret this finding?



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A 17-year-old male is brought in to the emergency department after a motor vehicle accident in which he was an unrestrained passenger. He has no significant past medical history. He reports that he is having difficulty moving his right leg and has pain in his lower back. Examination reveals 3/5 strength in the right lower extremity. His strength is otherwise 5/5. Which of the following exam findings would suggest injury to the central nervous system as the cause of his right lower extremity weakness?

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A one-month-old infant is brought in for a well-child visit to the clinic. The infant has normal head circumference and weight gain. Her physical examination is unremarkable except for the plantar reflex. The provider uses a blunt object to stroke the sole of the infant and finds that her big toe moves upward with other toes fanning out. Her mother suffered from pr-eclampsia during pregnancy, and her previous baby passed away due to the complications caused by spina bifida. What does this finding indicate about the child's development?



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A 70-year-old female with right hemiparesis and aphasia presents to the clinic for a routine checkup. She had a stroke one year ago and now complains of persistent memory difficulties. Examination reveals some difficulty with recall and word finding. The pain sensation is decreased on the right side in comparison to the left. She has 2/4 reflexes on the left with 5/5 strength and 4/4 reflexes with 4/5 strength on the right side. Babinski reflex is absent on the left and present on the right. She walks with a quad cane. Which of the following signs or symptoms suggest damage to her cortical spinal tract?



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Babinski Reflex - References

References

Loo SF,Justin NK,Lee RA,Hew YC,Lim KS,Tan CT, Differentiating Extensor Plantar Response in Pathological and Normal Population. Annals of Indian Academy of Neurology. 2018 Apr-Jun     [PubMed]
Janecek J,Kushlaf H, Gordon Reflex null. 2018 Jan     [PubMed]
Khadilkar SV,Chheda AH, A systematic and quantitative evaluation of plantar stimulation: The effect of type, pattern, force of stimulation in eliciting an accurate plantar response. Clinical neurology and neurosurgery. 2018 May     [PubMed]
Drouin E,Drouin G,Péréon Y, The Babinski sign. The Lancet. Neurology. 2017 Mar     [PubMed]
Araújo R,Firmino-Machado J,Correia P,Leitão-Marques M,Carvalho J,Silva M,Nogueira A,Nunes C, The plantar reflex: A study of observer agreement, sensitivity, and observer bias. Neurology. Clinical practice. 2015 Aug     [PubMed]
Dafkin C,Green A,Kerr S,Veliotes D,Olivier B,McKinon W, The Interrater Reliability of Subjective Assessments of the Babinski Reflex. Journal of motor behavior. 2016     [PubMed]
Sumner AJ, The Babinski sign. Journal of the neurological sciences. 2014 Aug 15     [PubMed]

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