Meningismus =========== þ Meningismus - The increased sensitivity of testing for the presence of meningismus by flexing the neck in the sitting position has been described in the pediatric literature. [with the knees extended; all controls could get more than 45 degrees of flexion at C7 in this posture --KC] [Vincent J, Thomas K, Mathew O. An improved clinical method for detecting meningeal irritation. Department of Paediatrics, Medical College Hospital, Kerala, India. Arch Dis Child 1993 Feb;68(2):215-8.] Abstract: - Other techinques that have been proposed to elicit the presence of meningismus include testing for the presence of 'jolt' accentuation of headache. [Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Department of Internal Medicine, Asahi General Hospital, Chiba, Japan. Headache 1991 Mar;31(3):167-71.] Abstract: I suppose that the latter is analagous to demonstrating the presence of peritonitis by shaking the bed or observing whether the patient's abdominal pain was accentuated during the trip to the ED during a bumpy car ride. - As an aside, antibiotic pre-treatment does not appear to affect the sensitivity of the physical signs of meningismus in the evaluation for meningitis. [Rothrock SG, Green SM, Wren J, Letai D, Daniel-Underwood L, Pillar E. Pediatric bacterial meningitis: is prior antibiotic therapy associated with an altered clinical presentation? Ann Emerg Med 1992 Feb;21(2):146-52.] Abstract: - We are reminded that the absence of meningismus in cases of documented meningitis may extend well beyond the neonatal period, as well. [Geiseler PJ, Nelson KE. Bacterial meningitis without clinical signs of meningeal irritation. South Med J 1982 Apr;75(4):448-50.] Abstract: It is a generally accepted proposition that meningismus may be absent in the comatose patient in spite of the presence of meningeal irritation. - Conditions other than meningeal irritation can cause meningismus (unless your patient had a metastatic lesion and carcinomatous meningitis as well). Cervical radiculapathy, increased intracranial pressure and posterior fossa tumors may do so as well. --H. Louzon MD þ Review of Meningeal Signs [Verghese A, Gallemore G. Kernig's and Brudzinski's Signs Revisited. Rev Infect Dis 1987;9(6):1187-1192.] þ Kernig's Sign(s) - Vladimir Mihailovich Kernig, born in Latvia in 1840, worked at Obuhorsk hospital in St. Petersburg, and retired in 1911. - Kernig's original description: "In the majority of cases of meningitis, contractures are not present in the extremities when the patient is lying down, whereas if one tries to extend the knee while the patient remains sitting, one succeeds onlyh to an angle of about 135 degrees. In cases in which the phenomenon is pronounced, a right angle is maintained. The phenomenon is sot striking that the difference between the entire absence of this contracture in the reclining position and its presence in the siting position is so readily seen that it is worthwhile to pay particular symptom and look for it in every case." N.B. this does not mention pain, just limitation of extension. [Kernig W III. Ueber ein wenig beerktes Meningitis-Symptom. Berliner Klinische Wochenschrift 1884;21:829-32.] "[this] is especially useful as a quick orientation symptom in a busy hospital setting, if I may say so. At times the neck stiffness in the supine position is hardly noticeable and does not always increase when the patient is seated; the sensorium may at any given moment be very clear, and as is well known, it is not in every case that the first examination will result in suspicion of meningitis. For this reason it is of great value that one may, by merely placing the patient in an upright position, obtain such definite symptoms as a marked bending contracture in the knee joints. If already suspected, this will confirm the diagnosis; if not already suspected, these symptoms will point to meningitis or should indicated that the pia affection should be considered. [Kernig VM. Ueber ein Krankheits Symptom der acuten Meningitis. St. Petersburg Medizinische Wochenschrift 1882;7:398.] þ Brudzinski's Signs - Polish physician who was dean of the University of Warsaw and chief physician at the Hospital of Karl and Maria. - "Nape of the Neck Sign": "The technique of exploration for the symptom of the neck is very simple; one takes the child's head lying horizontally in his left hand, and one makes a flexion of the head and of the neck while applying his right hand on the child's chest to prevent it from raising up." Positive is flexion of the hips and knees. Brudzinski found this to be positive in 96% of his cases of meningitis, but Kernig's sign was present only in 57%. - "Brudzinski's Contralateral Reflex Signs" Described earlier than the nape of the neck sign, and not found as often as the nape of the neck sign. + "Brudzinski's Identical Contralateral Sign" Patient supine. When hip and knee on one sign are flexed by examiner, contralateral leg begins to flex at hip and knee. + "Brudzinski's Reciprocal Contralateral Sign" As one continues flexing the hip and knee, the contralateral leg gives a little kick (extension at the knee). - "Brudzinski's Cheek Sign" Pressure on both cheeks below the bone causes a reflex raising of both upper extremities with flexion of the elbows. (Mostly in those with tuberculous meningitis.) - "Brudzinski's Symphisis Sign" Contracture of both lower extremities from presure over the symphisis. (Mostly in those with tuberculous meningitis.) - "Brudzinski's Arm Sign" Extension of the nape of the neck sign where the arms start flexing, too. þ Lase`gue's sign - straight leg raising þ Guilland's sign - brisk flexion of hip and knee elicited by pushing the contralateral quadriceps muscle [Monrad-Krohn GH, Refsum S. The clinical examination of the nervous system. 12th ed. London: H.K. Lewis, 1964. þ Amoss' sign - inability to sit erect unless the knees were drawn up. [Vincent J, Thomas K, Mathew O. An improved clinical method for detecting meningeal irritation. Department of Paediatrics, Medical College Hospital, Kerala, India. Arch Dis Child 1993 Feb;68(2):215-8.] Abstract: þ How likely to have meningitis is an adult with headache and fever, but without abnormal mental status or nuchal rigidity? - In one study, 13 patients with meningitis had "no overt abnormalities of mental status other than lethargy" (not "delirious or arousable only with constant stimulation") and also had no nuchal rigidity. One of these patients (8%) died of meningitis. The number of patients with similar mental status but with nuchal rigidity was 95; of them, 9 (9%) died. I cannot tell, from the data presented, how many of these were small children; but, there were only 92 patients under age 10 in the entire study, so at least some, and probably a large number, of the 95 with only lethargy but no nuchal rigidity were older children or adults. [Hodges FR, Perkins RL. Acute bacterial meningitis: an analysis of factors influencing prognosis. Am J Med Sci 1975;270(3):427-440.] - In the pediatric group older than one month in this study of bacterial (i.e., not aseptic or viral) meningitis, "Nine patients (56%) without meningeal signs were alert on admission. In contrast, 14% of patients with meningeal signs were alert on admission." [Geiseler PJ, Nelson KE. Bacterial meningitis without clinical signs of meningeal irritation. South Med J 1982 Apr;75(4):448-50.] Abstract: þ Meningismus in the Elderly - In the elderly, especially those who have had a CVA or who are demented, nuchal rigidity may be present without meningitis; abnormal palmomental, grasp and snout reflexes are associated with this finding. [Puxty JA, Fox RA, Horan MA. The frequency of physical signs usually attributed to meningeal irritation in elderly patients. J Am Geriatr Soc 1983; 31:590-2.] Abstract: