As you complete your neurologic assessment, there are three special techniques that you should perform if you suspect your patient might have meningeal inflammation: nuchal rigidity, Brudzinski sign, and Kernig sign (Bickley et al., 2021). Let’s review all three.

Nuchal Rigidity

Nuchal rigidity is neck stiffness that resists flexion or passive stretch. It is a common sign in patients with severe meningeal inflammation in conditions such as acute bacterial meningitis and subarachnoid hemorrhage. Prior to assessing your patient for nuchal rigidity, ensure the the cervical vertebrae or cervical cord are not injured or damaged, confirmed by radiologic studies (computed tomography scan or magnetic resonance imaging). With the patient in the supine position, place your hand behind the patient’s head and flex the neck forward until the patient’s chin touches their chest, if possible. The neck should be supple, and the patient shouldn’t have problems bending the head and neck forward. Stiffness or resistance to flexion is a positive sign of nuchal rigidity.

Brudzinski Sign

As you test for nuchal rigidity, also observe the patient’s hips and knees, which should remain relaxed and still. Any flexion of the hips and knees while passively flexing the patient’s neck is a positive Brudzinski sign. In addition, when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity (Hinkle, 2021). Brudzinkski sign is a more sensitive indicator of meningeal irritation than Kernig sign.

Kernig Sign

To perform Kernig sign, flex the patient’s leg at both the hip and knee, and then slowly extend the leg and straighten the knee. While the patient may experience slight discomfort, the motion should not elicit pain. Pain and increased resistance to extension of the knee indicate a positive Kernig sign. If Kernig sign is positive bilaterally, suspect meningeal irritation.
 
Inflammation in the subarachnoid space can cause resistance to movements that stretch the spinal nerves and meninges. While these special techniques are low in specificity, they can point to meningitis if other signs are present such as fever and headache. Note that these maneuvers may be less sensitive in elderly patients, the very young, patients who have received analgesic medications, and patients with viral meningitis (Bickley et al., 2021). 

Remember…

• Confirm that your patient has not suffered any injury to the cervical vertebrae or cervical cord prior to performing these special maneuvers.
• These three signs alone are not specific for meningeal irritation but may help with the diagnosis when coupled with fever and headache.

References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15^th ed.). Wolters Kluwer Health.  https://wolterskluwer.vitalsource.com/books/9781975161057