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References
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214.e4
CHAPTER
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26
Meninges
KEY TEACHING POINTS
• There are three traditional meningeal signs: neck stiffness, Kernig sign, and Brudzinski
sign. Each of these signs reflects the patient’s natural rejection of any movement that
stretches the spinal nerves passing through a spinal subarachnoid space irritated by
inflammation, hemorrhage, or tumor.
• In studies of subarachnoid hemorrhage, neck stiffness has been defined as inability to
either touch the chin to the chest or lift the head 8 cm off the bed when supine.
• Neck stiffness is found in 74% to 92% of patients with bacterial meningitis.
• In patients presenting to emergency departments with either acute atraumatic headache
or stroke, the finding of neck stiffness markedly increases the probability of intracranial
hemorrhage.
I. The Findings
e terms meningeal signs and meningismus refer to the physical ndings that develop after meningeal irritation from inammation, tumor, or hemorrhage. ose most widely known are neck
stiness (or nuchal rigidity), Kernig sign, and Brudzinski sign.
A. NECK STIFFNESS
Neck stiness denotes involuntary resistance to neck exion, which the clinician perceives when
trying to bend the patient’s neck, bringing the chin down to the chest. One specic denition of
neck stiness (from studies of patients with subarachnoid hemorrhage) is the inability to either
touch the chin to the chest or lift the head 8 cm o the bed when supine.1 Occasionally, the
aggravated extensor tone of the neck and spine is so severe that the patient’s entire spine is hyperextended, leaving the torso of the supine patient supported by only occiput and heels, an extreme
posture called opisthotonus.
B. KERNIG SIGN
e Kernig sign was rst described by Vladimir Kernig in 1882. With the patient’s hip and knee
exed, Kernig sign is positive when the patient resists extension of the knee. Kernig called this a
“contracture” of the hamstrings, because the knee would not extend beyond 135 degrees (with hip
exed), even though the knee extended fully if the hip was rst positioned in the fully extended
position (Fig. 26.1).2 Most clinicians perform this test in the supine patient, although Kernig
described the test being performed in the seated patient.
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216
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5—HEAD AND NECK
Kernig sign
Difficulty fully extending
knee if hip flexed
Brudzinski sign
Neck flexion causes knee flexion
Fig. 26.1 Kernig and Brudzinski signs. In Kernig sign (top), the patient resists full extension of the knee
when the knee and hip are first flexed (patient’s left leg), although the knee extends normally if the hip is
extended (patient’s right leg). In Brudzinski sign (bottom), flexion of the patient’s neck causes the hips and
knees to flex, pulling both legs up toward the chest (see the text).
C. BRUDZINSKI SIGN
Jozef Brudzinski described several meningeal signs between 1909 and 1916. In his most popular sign, exion of the supine patient’s neck causes the patient to ex both hips and knees, thus
retracting the legs toward the chest (see Fig. 26.1).
2
D. JOLT ACCENTUATION HEADACHE
First proposed in 1991, jolt accentuation headache was felt to be a sensitive sign of meningitis
in patients with headache and fever.3 To perform the test, the clinician asks the patient to rotate
the head side to side 2 to 3 times per second. Exacerbation of the patient’s baseline headache is
dened as the positive result.
II. Pathogenesis of Meningeal Signs
e basis for all meningeal signs is the patient’s natural rejection of any movement that stretches
spinal nerves, all of which pass through the irritated subarachnoid space. Experiments with cadavers show that exion of the neck pulls the spinal cord toward the head, thus stretching spinal
nerves, whereas exion of the hips with knees extended pulls on the sciatic nerve, thus displacing
26—MENINGES
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217
the conus of the spinal cord downward toward the sacrum.4 Flexion of the hips with knees exed,
in contrast, does not stretch the sciatic nerve.
ese experiments explain why patients with meningeal irritation have neck stiness and a
positive Kernig sign, and they also show that Kernig sign does not dier from the straight leg
raising test for sciatica (see Chapter 64). Brudzinski sign, however, is more dicult to understand.
At rst, it seems logical that patients with meningeal irritation would want to extend their hips
and ex their knees when their neck is exed. Although this position removes tension from the
sciatic nerve, it stretches the femoral nerve,4 explaining why Brudzinski test causes the patient to
ex both hips and knees, thus relieving tension on both nerves.
III. Clinical Significance
A. ACUTE BACTERIAL MENINGITIS
Table 26.1 summarizes the frequency of individual ndings of 3100 adults with acute bacterial
meningitis (principally from Streptococcus pneumoniae, Neisseria meningitidis, and Listeria monocy-
togenes; cases of tuberculosis were excluded). is table reveals that the most frequent ndings in
bacterial meningitis are neck stiness, fever, and altered mental status. Neck stiness is a more
frequent sign than Kernig or Brudzinski sign (sensitivity is 74% to 92% for neck stiness vs. 61%
for Kernig or Brudzinski sign), although this dierence is not statistically signicant and may
reect in part the clinician’s diligence in looking for these ndings. Of the patients with petechial
rash, 73% to 92% have infection with Neisseria meningiditis.
Nonetheless, the accuracy of these traditional physical signs is meager in studies of patients
presenting with headache and fever. EBM Box 26.1 summarizes 8 studies of over 1500 patients.
Neck stiness, Kernig sign, Brudzinski sign, and jolt accentuation headache all have positive likelihood ratios (LRs) of only 1.5 to 2.4 (meningitis in these studies was dened as cerebrospinal
6,8,13–15
TABLE 26.1 ■ Acute Bacterial Meningitis and Subarachnoid Hemorrhage*
Finding Frequency (%)
Acute Bacterial Meningitis
Neck stiffness 74–92
Fever 66–97
Altered mental status 55–95
Kernig or Brudzinski sign 61
Focal neurologic signs 9–37
Seizures 5–28
Petechial rash 3–52
Subarachnoid Hemorrhage
Neck stiffness 21–86
Seizures 7–32
Altered mental status 29–64
Focal neurologic findings 10–36
Fever 6
Preretinal hemorrhages 4
Diagnostic standard: For meningitis, cerebrospinal fluid pleocytosis and microbiologic or postmortem data
supporting bacterial meningitis; for subarachnoid hemorrhage, computed tomography or lumbar puncture.
*Data obtained from 3100 patients with meningitis from references 5–15. 692 patients with subarachnoid
hemorrhage from references 16–19.
†
Results are overall mean frequency or, if statistically heterogeneous, the range of values.
†
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5—HEAD AND NECK
EBM BOX 26.1 Meningitis*
Likelihood Ratio†
Finding (Reference)
Neck stiffness
Kernig sign
Brudzinski sign
Jolt accentuation headache
*Diagnostic standard: for meningitis, cerebrospinal fluid pleocytosis ≥5 white blood cells per microliter.
†
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
20–27
20–25,27
20–25
Sensitivity
(%)
13–78 56–80 1.5 0.7
2–56 73–97 2.1 NS
2–64 74–98 2.4 NS
3,21–27
6–97 33–99 1.8 0.7
Specificity
(%)
if Finding Is
Present Absent
5 WHITE BLOOD CELLS/µL)
Probability
Decrease Increase
+45%+30%+15%–15%–30%–45%
LRs
Brudzinski sign
Kernig sign
Neck stiffness
LRs
MENINGITIS (≥
0.1 0.2 0.5 12510
uid white blood cell count [CSF WBC] ≥5/μL). Jolt accentuation headache turns out to have
widely varying sensitivities (in one study, as low as 6%, EBM Box 26.1). No physical nding signicantly decreases the probability of meningitis in patients with headache and fever. ere are
at least 2 explanations for the dierences between the patients in Table 26.1 (where sensitivity
of neck stiness is 74% to 92%) and EBM Box 26.1 (sensitivity of neck stiness is 13% to 78%):
(1) relatively few of the patients in EBM Box 26.1 had bacterial meningitis (on average, only 1
of 6 with meningitis in these studies had bacterial meningitis; most had aseptic meningitis), and
(2) almost all studies reviewed in EBM Box 26.1 excluded patients with altered mental status,
which is one of the most prominent ndings in observational studies of patients with bacterial
meningitis (sensitivity 55% to 95%; Table 26.1). Even so, after applying a more rigorous deni-
tion of meningitis to the patients studied in EBM Box 26.1 (i.e., CSF WBC ≥100/μL instead of
≥5/μL), the diagnostic accuracy of the traditional meningeal signs is unchanged (neck stiness,
LR = 1.5; Kernig sign, LR = 2.5; Brudzinski sign, LR = 2.2).
20–22
When present, Kernig sign should be symmetric. In one study of 51 consecutive comatose patients
with Kernig sign, asymmetry of the sign indicated that the patient would have hemiparesis after
awakening, the side with the less prominent Kernig sign indicating the side with subsequent paresis.
28
B. SUBARACHNOID HEMORRHAGE AND INTRACEREBRAL
HEMORRHAGE
Table 26.1 summarizes the ndings of almost 700 patients with subarachnoid hemorrhage, 70% to 95%
of whom presented with a severe precipitous headache. e most common physical nding in these
patients was neck stiness (sensitivity, 21% to 86%). In studies of more than 4000 patients presenting
to emergency departments with acute atraumatic severe headache, the nding of neck stiness signicantly increased the probability of subarachnoid hemorrhage (LR = 6.7, EBM Box 26.2).
26—MENINGES
LRs
MENINGEAL SIGNS
fness, detecting subarachnoid
hemorrhage in patients with acute stroke
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EBM BOX 26.2 Intracranial Hemorrhage*
Likelihood Ratio‡
Finding (Reference)
Neck stiffness, detecting subarachnoid
hemorrhage in patients with sudden
atraumatic headache
Neck stiffness, detecting intracranial
hemorrhage in patients with stroke
*Diagnostic standard: for intracranial hemorrhage, neuroimaging; for subarachnoid hemorrhage,
neuroimaging, lumbar puncture, or both.
†
Definition of findings: for neck stiffness, undefined or inability to touch chin to sternum or lift the head 8 cm.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
†
1,29–31
Sensitivity
(%)
22–67 89–97 6.7 0.7
16–48 81–98 5.4 0.7
32–37
Specificity
(%)
Probability
Decrease Increase
+45%+30%+15%–15%–30%–45%
0.1 0.2 0.5 12510
Neck stif
hemorrhage in patients with acute
atraumatic headache
Neck stiffness, detecting intracranial
if Finding Is
Present Absent
LRs
219
Signicant intracerebral hemorrhage may also produce subarachnoid bleeding and neck stiness (i.e., intraventricular blood may pass through the median and lateral apertures of the fourth
ventricle into the subarachnoid space at the base of the brain). In studies of almost 1000 patients
presenting to emergency departments with stroke (i.e., acute neurologic decits believed to be
vascular in origin), the nding of neck stiness increased the probability of intracranial blood,
either subarachnoid or intracerebral hemorrhage (LR = 5.4). Subarachnoid hemorrhage was more
likely in these patients if there were no focal ndings (sensitivity of 64%, specicity of 89%, positive LR = 5.9).
18
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
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