Bacterial meningitis affects more than 1 million people per year globally and ranks as one of the top ten most deadly infectious diseases. Bacterial meningitis has a high frequency of neurologic sequelae and mortality and is treatable with antibiotics, which makes the diagnosis extremely important and time-sensitive. As compared with other febrile illnesses, bacterial meningitis is relatively rare. Because of this, many clinical tests have been described to help providers differentiate meningitis from other causes of fever and headache. Two of the most commonly used are Kernig's and Brudzinski's signs. The original report of Brudzinski's sign was in the late 1800s by Dr. Josef Brudzinski. At that time, he described four maneuvers to aid in the clinical diagnosis of meningitis. The four maneuvers he described included the Brudzinski's reflex, the cheek sign, the nape of the neck sign and the symphyseal sign. The most popular of the maneuvers is the nape of the neck sign, currently known as Brudzinski's sign.
Brudzinski's sign is characterized by reflexive flexion of the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the patient's chest and the other hand behind the patient's neck. The examiner then passively flexes the neck forward and assesses whether the knees and hips flex. Upon passive neck flexion, a positive test results when the patient flexes his knees and hips. During the process of performing the test, the hand on the chest prevents the patient from reflexively lifting his chest off the bed which decreases the specificity of the test. While the pathophysiology for the hip/knee flexion is not completely understood, the theory is that hip and knee flexion occurs as an involuntary reflex to compensate and help reduce meningeal irritation. Passive neck flexion causes spinal cord movement and stretching of the meninges, resulting in pain for patients with meningitis. The thinking is that the involuntary hip/knee flexion occurs to create maximal relaxation of the meninges, reducing pain.
While Brudzinski's sign is commonly used to assess for meningitis, it has limitations in the diagnosis of meningitis. Brudzinski's sign has low sensitivity but high specificity for detecting meningitis. For Brudzinski's sign, estimates are that the diagnostic sensitivity is between 2 and 43%, and the specificity for meningitis is between 80 to 100%. Given the low sensitivity of the test, the absence of Brudzinski's sign does little to rule out the diagnosis of meningitis and further testing is often necessary.
An additional limitation of Brudzinski's sign is the fact the sign is not useful in certain populations. In very young (less than 2 months), immunocompromised and elderly patients, Brudzinski's sign may be absent despite severe disease. Brudzinski's sign may be unreliable in these populations due to the presence of an open fontanelle or weakened immune response.
Meningitis is a devastating disease that without early treatment can cause lifelong neurologic sequelae or even death. Clinical signs and symptoms to aid in the early diagnosis and initiation of therapy are extremely important to help reduce long-term complications. While Brudzinski's sign may not definitively rule out meningitis, it can increase clinical suspicion of meningitis and trigger early treatment. Given its high specificity for the disease, there is a high likelihood of meningitis if the Brudzinski's sign is present. A positive result can aid providers who have a clinical suspicion of meningitis by allowing them to initiate antibiotics early. However, it is important to note that the absence of the sign does not rule out meningitis due to its poor sensitivity.
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
|Mehndiratta M,Nayak R,Garg H,Kumar M,Pandey S, Appraisal of Kernig's and Brudzinski's sign in meningitis. Annals of Indian Academy of Neurology. 2012 Oct; [PubMed]|
|Nakao JH,Jafri FN,Shah K,Newman DH, Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. The American journal of emergency medicine. 2014 Jan; [PubMed]|
|Mofidi M,Negaresh N,Farsi D,Rezai M,Mahshidfar B,Abbasi S,Hafezimoghadam P, Jolt accentuation and its value as a sign in diagnosis of meningitis in patients with fever and headache. Turkish journal of emergency medicine. 2017 Mar; [PubMed]|
|Puxty JA,Fox RA,Horan MA, The frequency of physical signs usually attributed to meningeal irritation in elderly patients. Journal of the American Geriatrics Society. 1983 Oct; [PubMed]|
|Chotpitayasunondh T, Bacterial meningitis in children: etiology and clinical features, an 11-year review of 618 cases. The Southeast Asian journal of tropical medicine and public health. 1994 Mar; [PubMed]|
|Peterson ME,Li Y,Bita A,Moureau A,Nair H,Kyaw MH,Abad R,Bailey F,Garcia IF,Decheva A,Krizova P,Melillo T,Skoczynska A,Vladimirova N, Meningococcal serogroups and surveillance: a systematic review and survey. Journal of global health. 2019 Jun; [PubMed]|
|Ward MA,Greenwood TM,Kumar DR,Mazza JJ,Yale SH, Josef Brudzinski and Vladimir Mikhailovich Kernig: signs for diagnosing meningitis. Clinical medicine [PubMed]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Infectious Disease. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Infectious Disease, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Infectious Disease, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Infectious Disease. When it is time for the Infectious Disease board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Infectious Disease.