NUCHAL RIGIDITY

Finding nuchal rigidity on examination has almost invariably prompted the diagnosis of meningitis and lumbar puncture, but the astute clinician will want to consider other possibilities to avoid a potentially hazardous procedure. Anatomy is the key. Visualize the structures of the neck and the many causes come quickly to mind. Cellulitis of the back of the neck or a carbuncle may be the cause in the skin. The muscles of the neck may be rigid from parkinsonism or pyramidal tract disease. Diseases of the spine such as cervical spondylosis, rheumatoid spondylitis, and tuberculosis may cause nuchal rigidity. An acute fracture of the cervical spine should be considered if no history can be obtained. The respiratory tree recalls retropharyngeal abscess, mediastinal emphysema, and endotracheal intubation. Finally, the spinal cord and meninges may be involved by meningitis, epidural abscess, subarachnoid hemorrhage, and primary and metastatic tumors, resulting in nuchal rigidity.

Approach to the Diagnosis

The workup of nuchal rigidity requires a good history, but if one is unobtainable, no spinal tap should be performed until the cervical spine is x-rayed and the eyegrounds are examined. Even with a good history, a spinal tap should be withheld if there is papilledema: A neurosurgeon should be consulted immediately under these circumstances. In a patient with fever, nuchal rigidity, no papilledema, and no focal neurologic signs (particularly a dilated pupil), a spinal tap can be performed for diagnosis and immediate therapy. It is preferable, however, to have CT scan results in hand first. Meningitis or a subarachnoid hemorrhage is frequently found in these circumstances. CT scans and x-rays of the cervical spine and skull will still be indicated in cases where the diagnosis remains obscure.

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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