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 patient’s neck, bringing the chin down to the chest. Occasionally,

the aggravated extensor tone of the neck and spine is so severe that the patient’s 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 patient’s 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.

Brudzinski’s

contralateral leg 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

Flexion of the opposite

hip and knee

Brudzinski’s reciprocal

contralateral leg sign

One knee and hip are flexed with the

other leg extended; then the flexed

limb is lowered

Contralateral extended leg goes

into flexion

Brudzinski’s cheek sign Pressure against the cheeks on or just

below the zygoma

Flexion at the elbows with an

upward jerking of the arms

Brudzinski’s symphysis

sign

Pressure on the symphysis pubis Flexion of both lower

extremities

Brudzinski’s Neck Sign flexion of the supine patient’s neck Flexion of both the hips and

the knees, thus retracting the

legs toward the chest

Brudzinski's Elbow sign With elbow flexed, shoulder abducted,

elevated, and externally rotated,

examiner attempts to passively extend

the elbow

Resistance to elbow extension

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

Hoyne’s, or tripod sign 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

Guilland’s sign Pinching the skin over the

quadriceps femoris

muscle or squeezing the

muscle

on one side

Flexion of contralateral

hip and knee

Edelmann great

toe phenomenon

Edelmann great

toe phenomenon

Extension of the great toe

Their Statistical Significance is Evaluated in multiple Studies13-18

Clinical Sign Sensitivity

(%)

Specificity

(%)

Likelihood Ratio if sign is

Present Absent

Detecting Meningitis

Neck Stiffness

Kernig's Sign

Brudzinski's Neck Sign

41-52

9-18

9-14

69-71

93-96

94-96

1.5 NS

2.4 NS

NS NS

Detecting Intracranial

Hemorrhage

Neck Stiffness

Kernig's Sign or

Brudzinski's Neck Sign

16-48

3-15

81-98

98

5.4 0.7

NS NS

* Diagnostic standard: for meningitis, cerebrospinal fluid pleocytosis ≥100 WBC / microliter.

for intracranial hemorrhage: Neuroimaging