|Author, date and country||Patient group||Study type (level of evidence)||Outcomes||Key results||Study Weaknesses|
|Levy et al,|
|Chart review of 650 children who underwent lumbar puncture for presumed diagnosis of meningitis||Retrospective cohort study.||Incidence of neck stiffness in children with/without confirmed meningitis||Neck stiffness was present in 44% children with confirmed meningitis and 20% without meningitis (Sn 44%, Sp80%)||Retrospective study|
Inclusion/exclusion criteria not clearly defined
Small patient numbers in subgroup analysis
CSF proven bacterial meningitis not described
|Incidence of Brudzinskis sign in chidren with/without meningitis||Brudzinskis sign was present in 68% children with confirmed meningitis and 35% children without meningitis (Sn 68%, Sp 65%)|
|Incidence of Kernigs sign in children with/without meningitis||Kernigs sign was present in 15% children with confirmed meningitis and 4% children without meningitis (Sn 15%, Sp 96%)|
|Rothrock et al,|
|258 children (0–24 months) hospitalised with bacterial meningitis over a 12-year period.|
Considered to have bacterial meningitis if: +CSF culture, gram stain, immune electrophoresis/antigen OR +blood culture with raised CSF WBCs
|Retrospective cohort study||Incidence of neck stiffness in children with confirmed bacterial meningitis||Neck stiffness was present in 54-59% children with bacterial meningitis||Retrospective study.|
Absent documentation - only 20% children had Kernigs or Brudzinskis sign documented.
Analysed cohort restricted to under 2s
|Incidence of positive Brudzinskis sign in children with confirmed bacterial meningitis||Brudzinskis sign was positive in 10-13% children with bacterial meningitis|
|Incidence of positive Kernigs sign in children with confirmed meningitis||Kernigs sign was positive in 9-11% children with bacterial meningitis|
|Oostenbrink et al,|
|326 consecutive ED patients (aged 1 month-15 years) with signs of meningeal irritation|
Bacterial meningitis defined as >5WCC in CSF and positive culture of CSF and/or blood.
|Retrospective cohort study||Incidence of bacterial meningitis in children presenting with neck stiffness||Bacterial meningiis was present in 42%(CI: 35-49%) of children with neck stiffness||Retrospective study.|
Absent documentation - 40% cases Brudzinski's/Kernig's signs not documented.
Subgroup analysis based on small patient numbers.
LPs(gold standard) not performed on all children.
Weak inclusion criteria (some atypical meningitis presentations missed).
Frequency of meningeal irritation signs not assessed in children without meningitis.
|Incidence of bacterial meningitis||Bacterial meningitis was present in 30%(CI: 16-49%) of children with positive Kernigs sign|
|Incidence of bacterial meningitis in children with positive Brudzinskis sign||Bacterial meningitis was present in 36%(CI: 22-52%) of children with positive Brudzinskis sign|
|Curtis et al,|
|10 studies included|
CSF analysis as gold standard for diagnosing meningitis
18 symptom descriptors and 48 sign descriptors were extracted for meta-analysis
|Systematic review||Sensitivity, specificity, likelihood ratios for: |
|Neck stiffness: Sn51%, Sp89%, +LR 4.0|
(95% CI 2.6 to 6.3),
(95% CI 0.43 to 0.72)
Kernig's sign: Sn53%, Sp85%, +LR 3.5
(95% CI 2.1 to 5.7),
(95% CI 0.41 to 0.75)
Brudzinski's sign: Sn66%, Sp74%, +LR 2.5
(95% CI 1.8 to 3.6),
−LR 0.46 (95% CI 0.31 to 0.68)
|Heterogeneous studies and patient groups|
br>Results not age defined
Imprecise definitions of signs
|Amarilyo et al,|
|108 children aged 2 months to 16 years with clinically suspected meningitis|
Meningitis defined as >6WBC/mcl microliter of CSF
|Prospective cohort study||Nuchal rigidity||Sensitivity 65% (95% CI 50% to 77%)|
|Small sample size|
28% of patients lacked documentation about presence or absence of eningeal signs
|Kernig's sign||Sensitivity, 27% (95% CI 15% to 41%)|
Specificity, 87% (95% CI 68% to 96%)
|Brudzinski's sign||Sensitivity, 51% (95% CI 36% to 65%)|
Specificity 80% (95% CI, 63 to 92)