Tools
Brudzinski Sign
Definition/Introduction
Bacterial meningitis affects more than 1 million people per year globally and ranks as one of the top ten most deadly infectious diseases.[1] 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.[2] 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.[3] 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.[2]
Issues of Concern
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Issues of Concern
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%.[4][5] 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.[6][7] Brudzinski's sign may be unreliable in these populations due to the presence of an open fontanelle or weakened immune response.
Clinical Significance
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.
References
Peterson ME,Li Y,Bita A,Moureau A,Nair H,Kyaw MH,Meningococcal Surveillance Group (in alphabetical order).,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 PMID: 30603079]
Level 3 (low-level) evidenceMehndiratta 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:15(4):287-8. doi: 10.4103/0972-2327.104337. Epub [PubMed PMID: 23349594]
Ward MA, Greenwood TM, Kumar DR, Mazza JJ, Yale SH. Josef Brudzinski and Vladimir Mikhailovich Kernig: signs for diagnosing meningitis. Clinical medicine & research. 2010 Mar:8(1):13-7. doi: 10.3121/cmr.2010.862. Epub [PubMed PMID: 20305144]
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:32(1):24-8. doi: 10.1016/j.ajem.2013.09.012. Epub 2013 Oct 16 [PubMed PMID: 24139448]
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:17(1):29-31. doi: 10.1016/j.tjem.2016.11.001. Epub 2016 Nov 24 [PubMed PMID: 28345071]
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:31(10):590-2 [PubMed PMID: 6619465]
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:25(1):107-15 [PubMed PMID: 7824999]
Level 2 (mid-level) evidence