A1. Examination of the skull, spine, and meningeal signs

Skull
- Skull intact?
- Bruises or bumps?
Spine
- Spine straight? Lordosis/kyphosis/scoliosis?
- No bruises
- Paraspinal muscles have normal tone?
- Spinal movements normal?
Meningeal signs
- Not examined in people with suspected cervical spinal injury!
  - May cause myelopathy
- These tests are based on the fact that in meningitis, stretching the meninges are painful
  - These examinations stretch the meninges, causing pain and reflex movements which reduce the stretch of the meninges
- Positive in:
  - Meningitis
  - Subarachnoid haemorrhage
  - Meningism
    - = presence of meningeal signs in systemic diseases without CNS involvement
- Nuchal rigidity
  - Procedure
    - Patient lies supine
    - Passively lift patient’s head
  - Negative:
    - No resistance when lifting head
    - Pain may or may not be present
  - Positive:
    - Resistance when lifting head
    - Placing chin on chest is impossible
- Kernig sign
  - Method 1
    - Procedure
      - Patient lies supine and bends their hips and knees to 90 degrees
      - Extend one leg passively while keeping the hip flexed
      - Repeat for other leg
    - Negative:
      - No pain or resistance when extending leg
    - Positive:
      - Pain or resistance when extending leg on both sides
  - Method 2 (similar to Lasègue)
    - Procedure
      - Patient lies supine with legs straight
      - Passively raise one leg while keeping knee straight
      - Repeat for other leg
    - Negative:
      - No pain, and patient doesn’t bend the knee on their own
    - Positive:
      - Pain, and patient bends the knee on their own
- Brudzinski sign
  - Procedure
    - Patient lies supine with legs straight
    - Passively bend patient’s head forward
  - Negative
    - No flexion on the knees or hip
  - Positive
    - Patient flexes knees and hip