Special techniques in neurological assessment

After completing the neurological assessment, three specific techniques must be used should you suspect that a patient can have meningitis: nuchal stiffness, Brudzinski’s sign, and Kernig’s sign (Bickley et al., 2021). Let’s analyze all three.

Stiff neck

Neck stiffness is the stiffness of the neck that resists flexion or passive stretching. This is a typical finding in patients with severe meningitis in conditions corresponding to acute bacterial meningitis and subarachnoid hemorrhage. Before assessing a patient for neck stiffness, be certain that the cervical vertebrae or cervical cord haven’t been injured or damaged, as confirmed by radiographic examination (computed tomography or magnetic resonance imaging). With the patient within the supine position, place your hand behind the patient’s head and bend the neck forward if possible until the patient’s chin touches the chest. The neck must be flexible and the patient should not have any trouble tilting the top and neck forward. Stiffness or resistance to flexion is a positive symptom of neck stiffness.

Brudziński’s sign

When testing for neck stiffness, also observe the patient’s hips and knees, which should remain relaxed and still. Any flexion of the hips and knees when the patient’s neck is passively flexed is a positive Brudzinski sign. Furthermore, when the lower limb of 1 side is passively flexed, an analogous movement is observed within the contralateral limb (Hinkle, 2021). Brudzinski’s sign is a more sensitive indicator of meningeal irritation than Kernig’s sign.

Kernig’s sign

To perform the Kernig sign, bend the patient’s leg on the hip and knee, then slowly straighten the leg and straighten the knee. Although the patient may feel slight discomfort, the movement mustn’t cause pain. Pain and increased resistance when straightening the knee indicate a positive Kernig’s sign. If Kernig’s sign is positive on each side, suspect meningeal irritation.

Inflammation of the subarachnoid space may cause resistance to stretching movements of the spinal nerves and meninges. Although these special techniques should not specific, they could indicate meningitis if other symptoms corresponding to fever and headache are present. Please note that these maneuvers could also be less sensitive in elderly patients, very young patients, patients who’ve received pain medications, and patients with viral meningitis (Bickley et al., 2021).

Remember…

• Before performing these special maneuvers, be sure that that the patient has not suffered any injury to the cervical vertebrae or cervical cord.
• These three symptoms should not specific to meningeal irritation, but may help make the diagnosis when combined with fever and headache.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s guide to physical examination and interviewing (thirteenth ed.). Wolters Kluwer Health: Philadelphia.

Hinkle, J. (2021). Brunner and Suddarth’s textbook of medical-surgical nursing (15^vol ed.). Wolters Kluwer Health. https://wolterskluwer.vitalsource.com/books/9781975161057