One specific element in the motor exam that often creates confusion for the examiner (and the family) is the interpretation of the patient’s response to a painful stimulus in the lower extremity. The confusion relates to the issue of differentiating between a purposeful withdrawal response to pain versus a simple spinal reflex withdrawal to pain. The importance of this differentiation is that a purposeful withdrawal response to pain may be a good prognostic sign in patients with hypoxic-ischemic injury, whereas a spinal reflex withdrawal may be seen in brain-dead patients. It is important to realize that brain-dead patients may exhibit a variety of movements that are spinally mediated and do not imply intact brain-stem or cortical function. Among the possible movements are extensor plantar responses, jerks of the fingers, toe flexion, and a Lazarus sign, which involves flexion of the arms at the elbow, adduction of the shoulders, lifting of the arms, dystonic posturing of the hands, and crossing of the hands. Furthermore, a triple-flexion response with dorsiflexion at the ankle, knee, and hip may be seen with distal lower-extremity pain stimulation, which may appear at first glance to be a purposeful withdrawal response but is actually a spinal cord reflex.