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Contemporary Clinical Signs in Neurology

Jeseph gedshaw MD
Raddek stuart MD
The terms meningeal signs and meningismus refer to the physical findings that develop after
meningeal irritation from inflammation, tumor, or hemorrhage. Those most widely known are
neck stiffness (or nuchal rigidity), Kernig sign, and Brudzinski sign.
A. NECK STIFFNESS1,2
Neck stiffness denotes involuntary resistance to neck flexion, which the clinician perceives
when trying to bend the patients neck, bringing the chin down to the chest. Occasionally,
the aggravated extensor tone of the neck and spine is so severe that the patients entire
spine is hyperextended, leaving the torso of the supine patient supported only by the
occiput and the heels, an extreme posture called opisthotonus.
B. KERNIG SIGN3,6,8
The Kernig sign was first described by Vladimir Kernig in 1882. With the patients hip and
knee flexed, the 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 the hip flexed), even though the knee extended fully if the hip was first
positioned in the fully extended position. Most clinicians perform this test in the supine
patient, although Kernig described the test being performed in the seated patient.
C. BRUDZINSKI SIGNs4,5,,6,7,8
Jozef Brudzinski described several meningeal signs between 1909 and 1916.
Brudzinskis
contralateral leg sign

Brudzinskis reciprocal
contralateral leg sign
Brudzinskis cheek sign
Brudzinskis symphysis
sign
Brudzinskis Neck Sign

Brudzinski's Elbow sign

Passive flexion of one hip, especially


with the knee extended, or passive
knee extension after the hip has been
flexed to a right angle
One knee and hip are flexed with the
other leg extended; then the flexed
limb is lowered
Pressure against the cheeks on or just
below the zygoma
Pressure on the symphysis pubis
flexion of the supine patients neck

With elbow flexed, shoulder abducted,


elevated, and externally rotated,
examiner attempts to passively extend
the elbow

Flexion of the opposite


hip and knee

Contralateral extended leg goes


into flexion
Flexion at the elbows with an
upward jerking of the arms
Flexion of both lower
extremities
Flexion of both the hips and
the knees, thus retracting the
legs toward the chest
Resistance to elbow extension

D. Other less Well Validated and described Signs6,7,10


Hoynes, or tripod sign

Guillands sign

Edelmann great
toe phenomenon

Patient with meningitis may


sit in bed with the hands
placed far behind, the head
thrown back, the hips and
knees flexed, and the back
arched
Pinching the skin over the
quadriceps femoris
muscle or squeezing the
muscle
on one side
Edelmann great
toe phenomenon

Flexion of contralateral
hip and knee

Extension of the great toe

Their Statistical Significance is Evaluated in multiple Studies13-18


Clinical Sign

Sensitivity
(%)

Specificity
(%)

Likelihood Ratio if sign is


Present

Detecting Meningitis
Neck Stiffness
Kernig's Sign
Brudzinski's Neck Sign

Detecting Intracranial
Hemorrhage
Neck Stiffness
Kernig's Sign or
Brudzinski's Neck Sign

Absent

41-52
9-18
9-14

69-71
93-96
94-96

1.5
2.4
NS

NS
NS
NS

16-48
3-15

81-98
98

5.4
NS

0.7
NS

* Diagnostic standard: for meningitis, cerebrospinal fluid pleocytosis 100 WBC / microliter.
for intracranial hemorrhage: Neuroimaging

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