Neck stiffness in suspected meningitis is a difficult thing to elicit and its definition varies. One doctor may call a slight difficulty or pain in neck bending, stiffness, whilst another will want a totally stiff neck.
The problem arises when there is no real neck stiffness in a patient that presents with headache and fever. What part of the clinical examination might assist us in deciding who needs a lumbar puncture?
HOW CAN WE TEST FOR MENINGEAL IRRITATION?
There is the Kernig’s Sign and Brudzinski’s Sign.
In Kernig’s Sign, the patient is supine with the knee bent at right angles. As the leg as straightened, it causes leg pain.
In Brudzinski’s Sign, when the neck is flexed, it causes flexion of the hips and knees.
These tests have good specificity, but poor sensitivity.
WHAT IS THE JOLT TEST AND HOW DOES IT HELP?
The JOLT test is potentially helpful in determining which patients with FEVER and HEADACHE, need a lumbar puncture.
A prospective study in Headache March 1991, looked at 54 patients with fever and a headache.
34 had pleocytosis on LP. Of these, 33 had a JOLT +ve test. 5 had neck stiffness, or a Kernig’s sign.
The results of this study were suggested that if there is a JOLT +ve and fever and headache, even if no neck stiffness, the patient needed a lumbar puncture.
LET’S DO THE JOLT.
In this test, the patient is asked to quickly move their head from side to side in a horizontal plane. If there is meningeal irritation, the headache will get worse. If the headache does get worse following this movement, it is an indication for a lumbar puncture, regardless of the fact that neck stiffness may not be present.