The Nervous System

Question 1

SIGNS OF MENINGITIS

Test for these important signs wheneVer you suspect meningeal inflammation from either meningitis or subarachnoid hemorrhage

Answer 1

1. NECK MOBILITY/NUCHAL RIGIDITY

• Before using this special assessment technique, ensure that the patient has not sustained injury or trauma to the cervical vertebrae or cord–this may mean delaying further assessment until radiographic examination rules out fracture
• Lay the patient supine and flex the head forward using a hand behind the patient’s head–continue to flex until the chin touches the chest, if possible.
  
  • In a normal exam, the patient is able to bend the head and neck easily as it is flexed forward.
  • Neck stiffness with resistance to flexion is found in approximately 84% if oatients with acute bacterial meningitis and 21-86% of patients with subarachnoid hemorrhage
    
    • It is most reliably present in severe meningeal inflammation but its overall diagnostic accuracy is low

2. BRUDZINSKI SIGN

• As you flex the patient’s neck to assess for nuchal rigidity, observe the patient’s hips and knees
  
  • In a normal exam, they will remain relaxed and motionless
  • In an abnormal exam, flexion of both the hips and knees will indicate a positive Brudzinski sign

3. KERNIG SIGN

• In this technique, you will flex the patient’s leg at the hip and the knee while the patient is supine, and then slowly extend the leg to straighten the knee back out.
  
  • In a normal exam, there may be some discomfort behind the knee while full extension is performed, but should not illicit pain
  • In an abnormal exam, increased pain and resistance while extending the knee indicates a positive Kernig sign

**Note that inflammation in the subarachnoid space will cause increased resistance to movements exercised through these techniques. Inflamed, affected nerves will cause resistance and indicate a positive meningeal sign:

• spinal nerves (neck flexion)
• femoral nerve (Brudzinski sign)
• sciatic nerve (Kernig sign)