Nuchal rigidity
Commonly an early sign of meningeal irritation, nuchal rigidity refers to neck stiffness that prevents flexion. To elicit this sign, attempt to passively flex the patient’s neck and touch his chin to his chest. If nuchal rigidity is present, this maneuver triggers pain and muscle spasms. (Make sure that there’s no cervical spinal misalignment, such as a fracture or dislocation, before testing for nuchal rigidity. Severe spinal cord damage could result.) The patient may also notice nuchal rigidity when he attempts to flex his neck during daily activities. This sign isn’t reliable in children and infants.
Nuchal rigidity may herald life-threatening subarachnoid hemorrhage or meningitis. It may also be a late sign of cervical arthritis, in which joint mobility is gradually lost.
Emergency interventions
After eliciting nuchal rigidity, attempt to elicit Kernig’s and Brudzinski’s signs. Quickly evaluate the patient’s level of consciousness (LOC). Take his vital signs. If you note signs of increased intracranial pressure (ICP), such as increased systolic pressure, bradycardia, and a widened pulse pressure, start an I.V. line for drug administration and deliver oxygen as necessary. Keep the head of the bed at least as low as 30 degrees. Draw a specimen for routine blood studies such as a complete blood count with a white blood cell count and electrolyte levels.
History and physical examination
Obtain a patient history, relying on family members if an altered LOC prevents the patient from responding. Ask about the onset and duration of neck stiffness. Were there precipitating factors? Also ask about associated signs and symptoms, such as a headache, a fever, nausea and vomiting, and motor and sensory changes. Check for a history of hypertension, head trauma, cerebral aneurysm or arteriovenous malformation, endocarditis, recent infection (such as sinusitis or pneumonia), or recent dental work. Then, obtain a complete drug history.
If the patient has no other signs of meningeal irritation, ask about a history of arthritis or neck trauma. Can the patient recall pulling a muscle in his neck? Inspect the patient’s hands for swollen, tender joints, and palpate the neck for pain or tenderness.
Medical causes
Cervical arthritis
With cervical arthritis, nuchal rigidity develops gradually. Initially, the patient may complain of neck stiffness in the early morning or after a period of inactivity. Stiffness then becomes increasingly severe and frequent. Pain on movement, especially with lateral motion or head turning, is common. Typically, arthritis also affects other joints, especially those in the hands.
Encephalitis
Encephalitis is a viral infection that may cause nuchal rigidity accompanied by other signs of meningeal irritation, such as positive Kernig’s and Brudzinski’s signs. Usually, nuchal rigidity appears abruptly and is preceded by a headache, vomiting, and a fever. The patient may display a rapidly decreasing LOC, progressing from lethargy to coma within 24 to 48 hours of onset. Associated features include seizures, ataxia, hemiparesis, nystagmus, and cranial nerve palsies, such as dysphagia and ptosis.
Listeriosis
If listeriosis spreads to the nervous system, meningitis may develop. Signs and symptoms include nuchal rigidity, a fever, a headache, and a change in the LOC. Initial signs and symptoms include a fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea.
Gender Cue:Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or still birth.
Meningitis
Nuchal rigidity is an early sign of meningitis and is accompanied by other signs of meningeal irritation — positive Kernig’s and Brudzinski’s signs, hyperreflexia and, possibly, opisthotonos. Other early features include a fever with chills, a headache, photophobia, and vomiting. Initially, the patient is confused and irritable; later, he may become stuporous and seizure-prone or may slip into a coma. Cranial nerve involvement may cause ocular palsies, facial weakness, and hearing loss. An erythematous papular rash occurs in some forms of viral meningitis; a purpuric rash may occur in meningococcal meningitis.
Subarachnoid hemorrhage
Nuchal rigidity develops immediately after bleeding into the subarachnoid space. Examination may detect positive Kernig’s and Brudzinski’s signs. The patient may experience an abrupt onset of a severe headache, photophobia, a fever, nausea and vomiting, dizziness, cranial nerve palsies, and focal neurologic signs, such as hemiparesis or hemiplegia. His LOC deteriorates rapidly, possibly progressing to coma. Signs of increased ICP, such as bradycardia and altered respirations, may also occur.
Special considerations
Prepare the patient for diagnostic tests, such as computed tomography scans, magnetic resonance imaging, and cervical spinal X-rays.
Monitor the patient’s vital signs, intake and output, and neurologic status closely. Avoid routine administration of opioid analgesics because these may mask signs of increasing ICP. Enforce strict bed rest; keep the head of the bed elevated at least 30 degrees to help minimize ICP.
Assist the patient in finding a comfortable position to obtain adequate rest.
Pediatric pointers
Tests for nuchal rigidity are generally less reliable in children, especially in infants. In younger children, move the head gently in all directions, observing for resistance. In older children, ask the child to sit upright and touch his chin to his chest. Resistance to this movement may indicate meningeal irritation.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Neck swelling
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Neck swelling
» Next page: Acceleration-deceleration cervical injuries (Professional Guide to Diseases (Eighth Edition))
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