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3.

Tests for Meningeal Irritation


Neck stiffness
What to do
N.B. Not to be performed if there could be cervical instabilityfor
example, following trauma or in patients with rheumatoid arthritis.
The patient should be lying flat.
Place your hands behind the patients head.
1.

Gently rotate the head, moving the head as if the patient was
indicating no. Feel the stiffness.
2.

Gently lift the head off the bed. Feel the tone in the neck.
3.

1.

Watch the legs for hip and knee flexion.

What you find and what it means


Neck moves easily in both planes, with the chin easily
reaching the chest on neck flexion: normal.
2.

Neck rigid on movement: neck stiffness.


1.

Indicates meningeal irritation. Common causes: viral and


bacterial meningitis, subarachnoid haemorrhage. Rarer
causes: carcinomatous, granulomatous, fungal meningitis.
2.

May also occur in severe cervical spondylosis, parkinsonism,


with tonsillar herniation.
3.
N.B. Proceed to test for Kernigs sign.
3.

Hip and knee flexion in response to neck flexion: Brudzinskis


sign (Fig. 25.1). This indicates meningeal irritation.
FIGURE 25.1
Brudzinskis sign

TIP
Cervical lymphadenopathy and severe pharyngitis may simulate neck
stiffness, but stiffness is usually only on flexion and appropriate physical
signs of these pathologies are easily found.

Testing for Kernigs sign


What to do
The patient is lying flat on the bed.
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2.

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1.

2.

Flex the leg at the hip with the knee flexed.


Then try to extend the knee.
Repeat on the other side (Fig. 25.2).
FIGURE 25.2
Kernigs sign

What you find and what it means


Knee straightens without difficulty: normal.
Resistance to knee straightening: Kernigs signbilateral
indicates meningeal irritation; if unilateral, may occur with
radiculopathy (cf. straight leg raising).
1.
N.B. Kernigs sign is absent with other causes of
neck stiffness.

Head jolt test


A newer sensitive (but not very specific) test for meningeal irritation.

What to do
Ask the patient to turn his head horizontally at a frequency of two or
three times a second.

What you find


1.

2.

1.

No effect: normal.
Worsening of baseline headache: positive test.

What it means
Positive test suggests meningeal irritation is possible.
2.

Negative test makes meningeal irritation very unlikely.