Learn all about nuchal rigidity, the impaired neck flexion resulting from muscle spasm (not actual rigidity) of the extensor muscles of the neck; usually attributed to meningeal irritation, its symptoms, causes and treatment.
A stiff neck refers to a tightness or rigidity in the muscles supporting the neck. Nuchal rigidity refers to a stiffness that prevents bending of the neck. Nuchal rigidity occurs in 70% of bacterial meningitis in adults.
The symptoms of viral meningitis are indistinguishable from those of bacterial meningitis or aseptic causes of meningitis. Classic symptoms are fever, headache, and neck stiffness (nuchal rigidity). Young children or infants may simply present with fever and irritability. Other symptoms include photophobia, myalgia, nausea and vomiting, diarrhea, lethargy, and even upper respiratory symptoms (which may precede or occur concomitantly with the classic symptoms).
Physical exam maneuvers for nuchal rigidity include the Kernig’s and Brudzinski’s signs. Kernig’s is performed by having the supine patient, with hips and knees flexed, extend the leg passively. The test is positive if the leg extension causes pain. The Brudzinski’s sign is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion. Despite their historical significance, a positive result from either test has not been shown to be reliable indicators of meningitis.
Another test, known as the “jolt accentuation maneuver” helps determine whether meningitis is present in those reporting fever and headache. A person is asked to rapidly rotate the head horizontally; if this does not make the headache worse, meningitis is unlikely.
Nuchal rigidity Symptoms
The first symptoms are usually fever, vomiting, headache and feeling unwell. Red ticks show symptoms more specific to meningitis and septicaemia and less common in milder illnesses. Limb pain, pale skin, and cold hands and feet often appear earlier than the rash, neck stiffness, dislike of bright lights and confusion. Symptoms of neck stiffness can vary greatly. Symptoms may be mild, causing a slight problem in moving or turning the head and neck. Or the symptoms may be severe, causing great difficulty in moving, turning, or bending the neck. If the neck stiffness is due to a major injury or head trauma or if there is severe nuchal rigidity, emergency treatment may be needed. The healthcare provider will want to know more about the person’s symptoms, such as:
• High blood pressure
• Head injury
• Blood clots or aneurysm
• Recent infection
• Recent dental work
• Swelling in the hands or any tender joints
• Pain and tenderness in the neck
• Stiff Neck
• Subarachnoid Hemorrhage
Nuchal rigidity Causes
Nuchal rigidity causes include the following:
• Subarachnoid Hemorrhage
• Posterior fossa tumor
• Increased Intracranial Pressure
• Dental abscess
• Spinal cord tumor
• Juvenile rheumatoid arthritis
• Acute meningitis
• Bacterial meningitis
• Extradural hematoma
• Wernicke’s encephalopathy
Nuchal rigidity Treatment
Nuchal rigidity treatment is primarily supportive, especially in the case of enterovirus. Some patients require hospitalization for fluid administration and pain relief, while others can be safely treated at home. Exceptions include varicella and herpes simplex virus meningitis, which, if severe, are treated with antiviral agents such as acyclovir. Short-term antibiotic prophylaxis is another method of prevention, particularly of meningococcal meningitis. In cases of meningococcal meningitis, preventative treatment in close contacts with antibiotics (e.g. rifampicin, ciprofloxacin or ceftriaxone) can reduce their risk of contracting the condition, but does not protect against future infections.
Nuchal rigidity Test
CSF (cerebrospinal fluid) analysis should include a gram stain, acid-fast stain, and culture to further aid in diagnosis. If available, polymerase chain reaction PCR (polymerase chain reaction) for presence of genomic material from likely viral pathogens can quickly assist in determining whether a patient’s meningitis is bacterial or viral. PCR tests are currently available for enterovirus, cytomegalovirus, herpes simplex virus, and HIV pathogens. A positive PCR test for enterovirus in the emergency room can save a patient with mild symptoms from an unnecessary hospital admission, assuming proper support and provisions at home.
Kernig’s sign is assessed with the person lying supine, with the hip and knee flexed to 90 degrees. In a person with a positive Kernig’s sign, pain limits passive extension of the knee. A positive Brudzinski’s sign occurs when flexion of the neck causes involuntary flexion of the knee and hip. Although Kernig’s sign and Brudzinski’s sign are both commonly used to screen for meningitis, the sensitivity of these tests is limited. They do, however, have very good specificity for meningitis: the signs rarely occur in other diseases