3.Tests for Meningeal IrritationNeck stiffnessWhat to doN.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. Watch the legs for hip and knee flexion.What you find and what it means1. 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.FIGURE25.1Brudzinskis signTIPCervical 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 signWhat to doThe patient is lying flat on the bed.1. Flex the leg at the hip with the knee flexed.2. Then try to extend the knee.3. Repeat on the other side (Fig. 25.2).FIGURE25.2Kernigs signWhat you find and what it means1. Knee straightens without difficulty:normal.2. 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 testA newer sensitive (but not very specific) test for meningeal irritation.What to doAsk the patient to turn his head horizontally at a frequency of two or three times a second.What you find1. No effect:normal.2. Worsening of baseline headache:positive test.What it means1. Positive test suggests meningeal irritation is possible.2. Negative test makes meningeal irritation very unlikely.