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. 2019 Jul 15;20(5):193-198.
doi: 10.1002/jgf2.268. eCollection 2019 Sep.

Sensitivity and specificity of meningeal signs in patients with meningitis

Tetsuya Akaishi  1   2 , Junpei Kobayashi  2   3 , Michiaki Abe  1 , Kota Ishizawa  1 , Ichiro Nakashima  4 , Masashi Aoki  2 , Tadashi Ishii  1
Affiliations

Sensitivity and specificity of meningeal signs in patients with meningitis

Tetsuya Akaishi et al. J Gen Fam Med. .

Abstract

Background: Several types of physical examinations are used in the diagnosis of meningitis, including nuchal rigidity, jolt accentuation, Kernig's sign, and Brudzinski's sign. Jolt accentuation was reported to have sensitivity of nearly 100% and to be highly efficient for excluding meningitis, but more recent studies showed that a number of patients with meningitis may present negative in this test.

Methods: We systematically reviewed studies on the above-mentioned physical examination tests and performed meta-analysis of their diagnostic characteristics to evaluate the clinical usefulness. Nine studies, comprising a total of 599 patients with pleocytosis in the cerebrospinal fluid (CSF) and 1216 patients without CSF pleocytosis, were enrolled in the analysis.

Results: Jolt accentuation showed a decent level of odds ratio (3.62; 99% confidence interval (CI): 1.13-11.60, P = 0.004) comparable to that in nuchal rigidity (2.52; 1.21-5.27, P = 0.001) for the correct prediction of CSF pleocytosis among subjects with suspected meningitis. The estimated sensitivity was relatively high (40%-60%) in nuchal rigidity or jolt accentuation tests. On the other hand, Kernig's and Brudzinski's signs exhibited relatively low sensitivity (20%-30%). The estimated specificity was higher in Kernig's and Brudzinski's signs (85%-95%) than in nuchal rigidity or jolt accentuation tests (65%-75%).

Conclusion: Approximately half of the patients with meningitis may not present typical meningeal signs upon physical examination. Combining several examinations for the detection of meningeal signs may decrease the risk of misdiagnosis.

Keywords: Kernig's sign; jolt accentuation; meningitis; meta‐analysis; nuchal rigidity.

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Conflict of interest statement

The authors have stated explicitly that there are no conflicts of interest in connection with this article.

Figures

Figure 1
Figure 1
Overview of the study design. After the initial search, reviews and letters without original datasets were excluded from the following meta‐analysis. As a result, a total of nine case‐control studies were enrolled in the subsequent meta‐analysis
Figure 2
Figure 2
Forest plots of physical examination tests in meningitis. Examinations other than Kernig's sign showed a significant odds ratio for the prediction of pleocytosis in the cerebrospinal fluid
See this image and copyright information in PMC

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