Journal Reading

Sensitivity and Specificity of Meningeal Signs In Patients With

Meningitis

Adinda putri
Airin shabrina elta
Annisa permatasari
Jihan vadilla
Kholilah

Pembimbing:

dr. R.A Neilan Amroisa, Sp.S, M.Kes

KEPANITERAAN KLINIK NEUROLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI
RUMAH SAKIT PERTAMINA BINTANG AMIN
BANDAR LAMPUNG
2020
Received: 26 March 2019 | Revised: 30 May 2019 | Accepted: 24 June 2019

DOI: 10.1002/jgf2.268

O R I G IN AL AR T I C L E

Sensitivity and specificity of meningeal signs in patients with

meningitis

Tetsuya Akaishi MD, PhD1,2 | Junpei Kobayashi MD, PhD2,3 | Michiaki Abe MD, PhD1 | Kota
Ishizawa MD, PhD1 | Ichiro Nakashima MD, PhD4 | Masashi Aoki MD, PhD2 | Tadashi Ishii MD, PhD1

1
Department of Education and Support for Regional
Medicine, Tohoku University Hospital, Sendai, Japan
2
Department of Neurology, Tohoku University School of
Medicine, Sendai, Japan
3
Department of Neurology, National Hospital Organization
Yonezawa National Hospital, Yonezawa, Japan
4
Department of Neurology, Tohoku Medical and
Pharmaceutical University, Sendai, Japan
Correspondence
Tetsuya Akaishi, Department of Education and Support for
Regional Medicine, Tohoku University Hospital, Seiryo‐machi
1‐1, Aoba‐ ku, Sendai, 980‐8574 Miyagi, Japan.
Email: t‐akaishi@med.tohoku.ac.jp
Abstract
Background: Several types of physical examinations are used in the diagnosis of men‐ ingitis,
including nuchal rigidity, jolt accentuation, Kernig's sign, and Brudzinski's sign. Jolt
accentuation was reported to have sensitivity of nearly 100% and to be highly efficient for
excluding meningitis, but more recent studies showed that a number of patients with
meningitis may present negative in this test.
Methods: We systematically reviewed studies on the above‐mentioned physical ex‐
amination tests and performed meta‐analysis of their diagnostic characteristics to evaluate
the clinical usefulness. Nine studies, comprising a total of 599 patients with pleocytosis in
the cerebrospinal fluid (CSF) and 1216 patients without CSF pleocyto‐ sis, were enrolled in
the analysis.
Results: Jolt accentuation showed a decent level of odds ratio (3.62; 99% confi‐ dence
interval (CI): 1.13‐11.60, P = 0.004) comparable to that in nuchal rigidity (2.52; 1.21‐5.27, P
= 0.001) for the correct prediction of CSF pleocytosis among subjects with suspected
meningitis. The estimated sensitivity was relatively high (40%‐60%) in nuchal rigidity or jolt
accentuation tests. On the other hand, Kernig's and Brudzinski's signs exhibited relatively
low sensitivity (20%‐30%). The estimated specificity was higher in Kernig's and Brudzinski's
signs (85%‐95%) than in nuchal rigidity or jolt ac‐ centuation tests (65%‐75%).
Conclusion: Approximately half of the patients with meningitis may not present typi‐ cal
meningeal signs upon physical examination. Combining several examinations for the
detection of meningeal signs may decrease the risk of misdiagnosis.

K E Y WO R D S
jolt accentuation, Kernig's sign, meningitis, meta‐analysis, nuchal rigidity

This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited and is not used for commercial purposes.
© 2019 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.

J Gen Fam Med. 2019;20:193–198. wileyonlinelibrary.com/journal/jgf2 | 193

AKAISHI
.
1 | INTRODUC TION
Correct diagnosis of meningitis based on physical examinations is one of
the most difficult and important topics in the field of clini‐ cal neurology.
Most cases of viral meningitis are usually self‐remit‐ ting and not fatal,
but severe cases, such as bacterial, tuberculous, and fungal meningitis,
can be fatal if the proper antibiotics are not timely administered. 1,2
Therefore, whether the clinicians in the pri‐ mary care setting can
correctly diagnose meningitis with CSF pleo‐ cytosis by performing
diagnostic physical examination or not is very important.
At present, physical examination tests for meningitis mainly
comprise the following four maneuvers: nuchal rigidity (neck stiffness),
jolt accentuation, Kernig's sign, and Brudzinski's sign. 3 Though the
nuchal rigidity test is the most famous and prevailing physical
examination, correctly assessing the rigidity can be quite difficult in
the clinical scene, even by well‐trained clinicians. As an alternative
diagnostic maneuver with relatively high sensitivity, jolt accentuation
4
was introduced in the late 20th century. The ma‐ neuver of jolt
accentuation involves head rotation at a frequency of 2‐3 times per
second and examining whether the headache ex‐ acerbates or not. Due
to its simplicity, jolt accentuation became popular and prevailed in
Asian and Middle East countries, but not in Western countries. Besides,
most of the follow‐up studies for the validation of the original data
showed that the sensitivity of jolt accentuation was much lower than
5‒9
originally reported. As a result, the usefulness of jolt accentuation
for diagnosing menin‐ gitis in the primary care setting has been
doubted and unsettled.
194
However, the easiness in the performance and interpretation of jolt
accentuation, even by physicians other than neurologists, is attractive and
desired to be reconsidered. Therefore, the objec‐ tive assessment of the
usefulness of jolt accentuation based on previous clinical studies
worldwide is required.
In this report, after systematically reviewing articles studying the
diagnostic characteristics (ie, sensitivity and specificity) of physical
examination tests applied for the detection of meningeal signs, in‐ cluding
jolt accentuation, we evaluated and compared the clinical usefulness of
each test by performing a meta‐analysis of the eligible studies.
2 | MATERIAL S AND METHODS
2.1 | Search method
We searched MEDLINE, PubMed, Cochrane Library, Embase, and
Google Scholar in December 2018. Search terms were as fol‐ lows:
“meningitis,” “physical examination,” “jolt accentuation,” “nuchal
rigidity,” “Kernig,” “Brudzinski,” “sensitivity,” “odds ratio,” and “review.”
These search terms were suitably combined in re‐ peated searches not to
overlook eligible studies; for example, the following combination was used
in PubMed: ("meningitis"[MeSH Terms]) AND ("nuchal rigidity"[All Fields]
OR "neck stiffness[All Fields]") AND ("Jolt accentuation"[All Fields] OR
"Kernig"[All Fields]) AND ("sensitivity"[All Fields] OR "specificity"[All
Fields]) NOT ("Case"[TITLE] OR "review"[TITLE]). Reviews or letters to the
edi‐ tor that did not contain original data were manually excluded after
F I G U R E 1 Overview of the study design.
After the initial search, reviews and letters
without original datasets were excluded
from the following meta‐analysis. As a
result, a total of nine case‐control studies
were enrolled in the subsequent meta‐
analysis
AKAISHI 195
.

the initial search. As a result, a total of nine studies were consid‐ ered as
eligible for the subsequent meta‐analysis.4‒12 Moreover, we confirmed
that there was no report of meta‐analysis that assessed or compared the
usefulness of nuchal rigidity and jolt accentuation tests. The overview of
the above‐described study design is illus‐ trated in Figure 1. Details of the
enrolled nine case‐control studies are summarized in Table 1.
2.2 | Statistical analyses and software
We performed a systematic review of the nine selected studies
regarding their eligibility for being enrolled in the meta‐analysis with
observational studies.13,14 To perform the meta‐analysis of the eligible
nine case‐control studies with respect to the accuracy of the tests in
meningitis diagnosis, the Review Manager 5.3 soft‐ ware was used.15,16
Since a considerable heterogeneity among the enrolled studies was
suspected in advance, the random‐effects model was applied.
Heterogeneity among the enrolled studies for each of the studied
variables was assessed with the Higgins I2 (heterogeneity statistic) and
τ 2 (between‐study heterogeneity variance), both of which are
parameters of between‐study disper‐ sion.17,18 The PRISMA checklist
was referenced in the process of meta‐analysis. 19 Statistical analyses in
other parts of this study were performed using the SPSS Statistics Base
22 software (IBM) and MATLAB R2015a. Because of the simultaneous
comparisons, we considered a P‐value lower than 0.01 to be significant
in this study.
3 | RESULTS
3.1 | Results of the meta‐analysis with forest plots
The results of the meta‐analysis (forest plots) for each physi‐ cal
examination are presented in Figure 2. The heterogeneities in nuchal
rigidity test, jolt accentuation, and Kernig's sign were
high for unknown reasons. As causes of these heterogeneities,
ethnicity or meningitis subtypes were unlikely. Differences in the
thresholds to judge positivity in these physical examinations among
the clinicians might be one of the candidate causes, but not conclusive.
Though there was high heterogeneity in 3 out of the 4 physical
examinations, nuchal rigidity test (2.52; 99% confidence interval (CI): 1.21‐
5.27, P = 0.001), jolt accentuation (3.62; 1.13‐11.60, P = 0.004),
and Brudzinski's sign (2.91; 1.23‐6.87, P = 0.001) were suggested to have
significant odds ratio to differentiate meningitis patients with CSF
pleocytosis from other nonmeningitis patients without CSF pleocytosis.
On the other hand, Kernig's sign method did not reach statistical
significance with odds ratio of 2.37 (99% CI: 0.76‐7.36, P = 0.05).
The calculated scores for the heterogeneity of the enrolled stud‐ ies
and the calculated odds ratios with their 99% CIs are summa‐ rized in
Table 2. The calculated positive likelihood ratio was best for Kernig's sign
(2.61; 1.83‐3.71), and the negative likelihood ratio was best for jolt
accentuation (0.67; 0.58‐0.77).
3.2 | Estimated sensitivity and specificity for each
physical examination test
The provisional overall sensitivity, by simply summing up the cases
from the enrolled nine studies, was 46.1% (242/525) for nuchal rigidity,
52.4% (229/437) for jolt accentuation, 22.9% (106/462) for Kernig's sign,
and 27.5% (103/375) for Brudzinski's sign. The estimated 99% CI of the
summed provisional sensitiv‐ ity was 40.5%‐51.7% for nuchal rigidity,
46.2%‐58.6% for jolt ac‐ centuation, 17.9%‐28.0% for Kernig's sign, and
21.5%‐33.4% for Brudzinski's sign. Regarding the specificity of the
physical examina‐ tion tests, the provisional overall specificity was
71.3% (727/1020) for nuchal rigidity, 71.1% (505/710) for jolt
accentuation, 91.2% (819/898) for Kernig's sign, and 88.8% (663/747)
for Brudzinski's sign. As a conclusion, nuchal rigidity and jolt
accentuation tests

TA B L E 1 Overview of the enrolled data

for the meta‐analysis Pleocytosis:
Author Published year Location pos./neg. (n) NR JA KS BS
Afhami5 2017 Iran 64/163 (+) (+) (+) (+)
Ala10 2018 Iran 45/75 (+) (+) (+) (+)
Mofidi6 2017 Iran 33/15 (+) (+) (+) (+)
Nakao7 2013 U.S.A. 47/183 (+) (+) (+) (+)
Sato11 2017 Japan 58/60 (+) (+) (+) (−)
Tamune8 2013 Japan 139/392 (+) (+) (+) (+)
Thomas12 2002 U.S.A. 80/217 (+) (−) (+) (+)
Uchihara4 1991 Japan 34/20 (+) (+) (+) (−)
Waghdhare9 2010 India 99/91 (+) (+) (+) (+)

Note: Superscripts on the upper right of author names correspond to the numbers in the reference
list.
Abbreviations: BS, Brudzinski's sign; JA, jolt accentuation; KS, Kernig's sign; NR, nuchal rigidity; (+),
evaluated; (−), not evaluated.
AKAISHI
.
F I G U R E 2 Forest plots of physical examination tests in meningitis. Examinations other than Kernig's sign showed a significant odds ratio for the
prediction of pleocytosis in the cerebrospinal fluid
showed higher sensitivity and lower specificity than Kernig's and
Brudzinski's signs.
4 | DISCUSSION
In this meta‐analysis, we compared the clinical significance and re‐ liability
of nuchal rigidity test, jolt accentuation, Kernig's sign, and Brudzinski's sign
in the prediction of CSF pleocytosis. Our results suggested that jolt
accentuation has similar levels of sensitivity,
196
specificity, and odds ratio with the nuchal rigidity test in differenti‐ ating
patients with CSF pleocytosis from the others.
The protocol of jolt accentuation (ie, head rotation, 2‐3 times per
second) is simple, and the results are much more consistent among
clinicians than those of the nuchal rigidity test. Undoubtedly, the most
popular and prevailing physical examination is nuchal rigidity. In contrast
to jolt accentuation, nuchal rigidity can be applied even in the patients
with disturbed consciousness. Neck stiffness can be evaluated in
obtunded or comatose patients, because it is a subjec‐ tive finding,
exclusively judged by the examiner. Thus, if a clinician
AKAISHI 197
.

can correctly assess the nuchal rigidity, this would be the most useful

values
physical examination to diagnose meningitis. Meanwhile, correctly

0.004
0.001

0.05
assessing the nuchal rigidity in cases with only weak neck stiffness is

P‐
not always easy and the diagnosis could vary between examiners.
Considering the above, together with the fact that the suggested

2.52 (1.21‐ 5.27)

2.37 (0.76‐ 7.36)

Odds ratio (99%
sensitivity and odds ratio of jolt accentuation were as high as those of

3.62 (1.13‐
nuchal rigidity, jolt accentuation would be another useful and reli‐ able
diagnostic physical examination test to predict CSF pleocytosis. At this

11.60)
point, we should acknowledge that the sensitivity of jolt accentuation in
CI)

meningitis diagnosis is much lower than originally reported.4 In the

clinic, several patients with meningitis are negative in jolt accentuation.
Based on the present study, the suggested sen‐ sitivity of jolt
LR− (99% CI)

accentuation in meningitis diagnosis would be around 40%‐60%, far

0.67 (0.58‐

0.84 (0.79‐
0.76 (0.67‐

lower than originally reported. Jolt accentuation is, un‐ doubtedly, a useful
0.77)

and reliable diagnostic physical examination test for meningitis, but it

0.85)

must be performed and interpreted together with other meningeal

signs, accompanying symptoms, and clinical history. Otherwise, patients
with meningitis could be misdiagnosed. As a perspective for future
LR+ (99% CI)

research, it would be useful to as‐ sess the characteristics of each

1.81 (1.50‐

2.61 (1.83‐
1.60 (1.35‐

diagnostic physical examination test after classifying the patients based

on the detected meningitis‐caus‐ ing microorganisms, that is, viruses or
1.91)

2.20)

bacteria. Because bacterial meningitis is usually more urgent and fatal

than viral meningitis,20,21 knowing the sensitivity and specificity of each
physical examination for each type of the causative microorganism may
71.3% (67.6‐

71.1% (66.7‐

help clinicians to estimate the risk for bacterial meningitis in the primary
Specificity
(99% CI)

care setting. Likewise, subgroup analyses for the characteristics of each

physi‐ cal examination test with variables other than the microorganism,
75.5)
74.9)

such as disease severity or the level of CSF pleocytosis, would be also

important. Another perspective for future research would be to
Sensitivity (99%

evaluate the overlapping pattern of the four physical examina‐ tion

Abberviations: CI, confidence interval; LR+, positive likelihood ratio; LR−,

tests in the detection of meningeal signs. If the meningeal signs are

52.4% (46.2‐
46.1% (40.5‐
TA B L E 2 Calculated effect sizes for each of the studied diagnostic examinations

independently detected in each of the four tests, performing all four

physical examinations in combination would lower the risk of
58.6)
51.7)

misdiagnosing cases with meningitis. On the other hand, if there are

CI)

overlaps in the detection of meningeal signs among the four tests, their
combination would not significantly decrease the risk of
[%]

78
77

85
I2

misdiagnosis.
There are some limitations in this study. First, most of the pre‐ vious
studies that assessed the usefulness of jolt accentuation were reported
1.2
1.2
0.5

mainly from groups in Japan and Iran. Further data from Western
1

countries are needed to conclude the usefulness of jolt ac‐ centuation in

the diagnosis of meningitis. Another limitation is that the heterogeneity
Datasets

among the enrolled studies was high in nuchal ri‐ gidity, jolt accentuation,
and Kernig's sign due to unknown causes. The threshold of positivity in
(n)

negative likelihood ratio.

9

each of the four physical examination tests could have varied among the
clinicians and affected the results. Further accumulation of clinical data,
followed by systematic review and meta‐analysis of the new datasets, will
accentuation

Kernig's sign

be necessary to conclude the superiority among the four physical

rigidity Jolt

examinations.
Nuchal

In conclusion, odds ratio, sensitivity, and specificity in predict‐ ing CSF

pleocytosis are almost similar between jolt accentuation and nuchal
rigidity tests. Because the correct assessment of nuchal
AKAISHI
.
rigidity is not always easy for the clinicians, jolt accentuation would be a
helpful supplementary physical examination to avoid misdiag‐ nosing
meningitis. However, sensitivities in both nuchal rigidity and jolt
accentuation tests are lower than 40%‐60%. Thus, the clinicians need to
remember that a number of patients with meningitis may not present with
meningeal signs. A careful review of clinical history and symptoms, together
with the meningeal signs, is necessary to decrease the risk of misdiagnosis.
ACKNOWLEDG EMENT
We thank Dr Satoshi Miyata (Department of Cardiovascular Medicine,
Tohoku University Hospital) for his professional com‐ ments about the
statistical method in the meta‐analysis.
CONFLIC T OF INTEREST
The authors have stated explicitly that there are no conflicts of inter‐ est in
connection with this article.
ORCID
Tetsuya Akaishi https://orcid.org/0000‐0001‐6728‐4966
R EFER EN CE S
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How to cite this article: Akaishi T, Kobayashi J, Abe M, et al. Sensitivity
and specificity of meningeal signs in patients with meningitis. J Gen
Fam Med. 2019;20:193–198. https://doi. org/10.1002/jgf2.268c
Sensitivitas dan spesifisitas tanda-tanda meningeal pada pasien dengan
meningitis

Tetsuya Akaishi MD, PhD 1,2 | Junpei Kobayashi MD, PhD 2,3 | Michiaki Abe MD, PhD 1 | Kota

Ishizawa MD, PhD 1 | Ichiro Nakashima MD, PhD 4 | Masashi Aoki MD, PhD 2 | Tadashi Ishii MD,

PhD1
Kedokteran dan
Universitas Farmasi, Sendai, Je1 Departemen
Pendidikan dan Dukungan untuk Daerah Medicine,
Rumah Sakit Universitas Tohoku, Sendai, Jepang
2 Departemen Neurologi, Tohoku University School of

Medicine, Sendai, Jepang

3 Departemen Neurologi, Rumah Sakit National
Hospital Organisasi Yonezawa Nasional, Yonezawa,
Jepang
4
Departemen Neurologi, Tohoku pang

Korespondensi
Tetsuya Akaishi, Departemen Pendidikan dan
Dukungan untuk Daerah Medicine, Rumah Sakit
Universitas Tohoku, Seiryo-machi 1-1, Aoba- ku,
Sendai, Miyagi 980-8574, Jepang. Email: t
akaishi@med.tohoku.ac.jp

Ini adalah akses artikel terbuka di bawah ketentuan Creat ive Commo ns Attri butio n-NonCo Lisensi mmercial, yang memungkinkan penggunaan, distribusi dan reproduksi dalam media apapun, asalkan karya asli benar
dikutip dan tidak digunakan untuk tujuan komersial. © 2019 The Authors. Journal of General dan Kedokteran Keluarga diterbitkan oleh John Wiley & Sons Australia, Ltd atas nama Asosiasi Perawatan Primer Jepang.

J Gen Fam Med. 2019; 20: 193-198. wileyonlinelibrary.com/journal/jgf2 | 193

194 |
1 | PENGANTAR
Diagnosis yang benar dari meningitis berdasarkan pemeriksaan fisik adalah salah satu topik
yang paling sulit dan penting dalam bidang clini- kal neurologi. Kebanyakan kasus
meningitis viral biasanya diri remit- ting dan tidak fatal, tetapi kasus yang parah, seperti
meningitis bakteri, TB, dan jamur, dapat berakibat fatal jika antibiotik yang tepat tidak tepat
waktu diberikan. 1,2 Oleh karena itu, apakah dokter dalam pengaturan perawatan mary
pri- benar dapat mendiagnosa meningitis dengan CSF pleo- cytosis dengan
melakukan pemeriksaan fisik diagnostik atau tidak sangat penting.
Saat ini, tes pemeriksaan fisik untuk meningitis terutama terdiri dari empat manuver
berikut: kaku kuduk (leher kaku), sentakan aksentuasi, tanda Kernig, dan tanda Brudzinski. 3
Meskipun tes kaku kuduk adalah pemeriksaan fisik yang paling terkenal dan berlaku, benar
menilai kekakuan bisa sangat sulit dalam adegan klinis, bahkan oleh dokter terlatih. Sebagai
manuver diagnostik alternatif dengan sensitivitas yang relatif tinggi, sentakan aksentuasi
diperkenalkan pada akhir abad 20. 4 The neuver ma dari sentakan aksentuasi melibatkan rotasi
kepala pada frekuensi 2-3 kali per detik dan memeriksa apakah sakit kepala mantan
acerbates atau tidak. Karena kesederhanaannya, sentakan aksentuasi menjadi populer dan
berlaku di negara-negara Asia dan Timur Tengah, tapi tidak di negara-negara Barat. Selain
itu, sebagian besar studi tindak lanjut untuk validasi data asli menunjukkan bahwa sensitivitas
sentakan aksentuasi itu jauh lebih rendah dari yang dilaporkan.5-9 Akibatnya, kegunaan
sentakan aksentuasi untuk mendiagnosis gitis menin- dalam pengaturan perawatan primer
telah meragukan dan gelisah.
Namun, kemudahan dalam kinerja dan interpretasi sentakan aksentuasi, bahkan oleh dokter
selain ahli saraf, menarik dan diinginkan untuk dipertimbangkan kembali. Oleh karena itu,
penilaian tive objec- dari kegunaan aksentuasi sentakan berdasarkan studi klinis sebelumnya
di seluruh dunia diperlukan.
Dalam laporan ini, setelah sistematis meninjau artikel mempelajari karakteristik
diagnostik (yaitu, sensitivitas dan spesifisitas) dari tes pemeriksaan fisik diterapkan untuk
mendeteksi tanda-tanda meningeal, di- cluding sentakan aksentuasi, kami dievaluasi dan
dibandingkan kegunaan klinis setiap tes dengan melakukan meta-analisis dari studi yang
memenuhi syarat.
2 | BAHAN DAN METODE
2.1 | metode pencarian
Kami mencari MEDLINE, PubMed, Cochrane Library, Embase, dan Google Scholar pada
bulan Desember 2018. Istilah pencarian adalah sebagai terendah fol-: “meningitis,”
“pemeriksaan fisik,” “sentakan aksentuasi,” “kaku kuduk,” “Kernig,” “
Brudzinski,”‘sensitivitas,’‘rasio odds,’dan‘ulasan.’ Istilah penelusuran tersebut sesuai
dikombinasikan dalam pencarian peated ulang untuk tidak mengabaikan studi yang
memenuhi syarat; misalnya, kombinasi berikut digunakan dalam PubMed: (
"meningitis" [MESH Syarat]) DAN ( "nuchal kekakuan" [Semua Fields] ATAU "leher kaku
[Semua Fields]") DAN ( "Jolt aksentuasi" [Semua Fields] OR "Kernig" [Semua Fields]) DAN (
"sensitivitas" [Semua Fields] ATAU "kekhususan" [Semua Fields]) TIDAK ( "Kasus"
[TITLE] OR "ulasan" [TITLE]).
GAMBAR 1 Sekilas desain penelitian. Setelah
pencarian awal, ulasan dan surat-surat tanpa dataset
asli dikeluarkan dari meta-analisis berikut. Akibatnya,
total sembilan studi kasus-kontrol yang terdaftar
dalam meta-analisis selanjutnya
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pencarian awal. Akibatnya, total sembilan studi yang pertimbangan- ered sebagai
memenuhi syarat untuk meta-analisis selanjutnya. 4-12 Selain itu, kami menegaskan bahwa
tidak ada laporan dari meta-analisis yang dinilai atau dibandingkan kegunaan kekakuan dan
sentakan aksentuasi nuchal tes. Ikhtisar dijelaskan di atas desain studi illus- trated pada
Gambar 1. Rincian terdaftar sembilan studi kasus-kontrol diringkas dalam Tabel 1.
2.2 | analisis statistik dan software
Kami melakukan tinjauan sistematis dari sembilan studi yang dipilih mengenai
kelayakan mereka untuk didaftarkan dalam meta-analisis dengan studi observasional. 13,14
Untuk melakukan meta-analisis dari studi yang memenuhi syarat sembilan
kasus-kontrol sehubungan dengan keakuratan tes dalam diagnosis meningitis, Review Manajer
5,3 soft gudang digunakan. 15,16 Karena heterogenitas yang cukup antara studi terdaftar diduga
sebelumnya, model random-efek diterapkan. Heterogenitas antara terdaftar studi untuk
masing-masing variabel yang diteliti dinilai dengan Higgins saya 2 ( heterogenitas statistik)
dan τ 2 ( antara-studi heterogenitas variance), keduanya merupakan parameter antara-studi sion yang positif adalah yang terbaik untuk tanda Kernig (2,61; 1,83-3,71), dan rasio
disper-. 17,18 PRISMA checklist direferensikan dalam proses meta-analisis. 19 analisis statistik di
kemungkinan negatif yang terbaik untuk sentakan aksentuasi (0.67; 0,58-0,77).
bagian lain dari penelitian ini dilakukan dengan menggunakan SPSS Statistik Basis 22 software
(IBM) dan MATLAB R2015a. Karena perbandingan simultan, kami dianggap sebagai P -nilai
menurunkan dari 0,01 menjadi signifikan dalam penelitian ini.
tinggi untuk alasan yang tidak diketahui. Sebagai penyebab heterogeneities ini, etnis atau
meningitis subtipe tidak mungkin. Perbedaan dalam ambang batas untuk menilai positif di ini
pemeriksaan fisik antara dokter mungkin salah satu penyebab calon, tetapi tidak konklusif.
Meskipun ada heterogenitas yang tinggi dalam 3 dari 4 pemeriksaan fisik, tes kaku kuduk
(2,52; 99% confidence interval (CI):
1,21-5,27, P = 0,001), sentakan aksentuasi (3,62; 1,13-11,60, P = 0,004), dan tanda Brudzinski
(2,91; 1,23-6,87, P = 0,001) yang diusulkan untuk memiliki rasio odds signifikan untuk
membedakan pasien meningitis dengan pleositosis CSF dari pasien nonmeningitis lain tanpa
pleositosis CSF. Di sisi lain, metode tanda Kernig tidak bermakna secara statistik dengan
rasio odds 2,37 (99% CI: 0,76-7,36,
P = 0,05).
Skor tersebut dihitung untuk heterogenitas terdaftar ies stud- dan odds rasio dihitung
dengan% CI mereka 99 yang summa- disahkan pada Tabel 2. dihitung rasio kemungkinan
3.2 | sensitivitas dan spesifisitas diperkirakan untuk setiap tes

3 | HASIL pemeriksaan fisik

The sementara keseluruhan sensitivitas, dengan hanya menjumlahkan kasus dari

3.1 | Hasil meta-analisis dengan plot hutan
Hasil meta-analisis (plot hutan) untuk setiap pemeriksaan cal physi- disajikan pada Gambar 2.
heterogeneities di tes kaku kuduk, sentakan aksentuasi, dan tanda Kernig berada
terdaftar sembilan studi, adalah 46,1% (242/525) untuk kaku kuduk, 52,4% (229/437)
untuk sentakan aksentuasi, 22,9% (106/462) untuk tanda Kernig , dan 27,5% (103/375)
untuk tanda Brudzinski. Diperkirakan 99% CI dari ity sensitiv- sementara disimpulkan
adalah 40,5% -51,7% untuk kaku kuduk, 46,2% -58,6% untuk sentakan centuation ac-,
17,9% -28,0% untuk tanda Kernig, dan 21,5% -33,4% untuk Brudzinski tanda.
Mengenai spesifisitas tes tion examina- fisik, secara keseluruhan spesifisitas
sementara adalah 71,3% (727/1020) untuk kaku kuduk, 71,1% (505/710) untuk
sentakan aksentuasi, 91,2% (819/898) untuk tanda Kernig, dan 88,8% (663/747) untuk
tanda Brudzinski. Sebagai kesimpulan, kaku kuduk dan tes aksentuasi sentakan

TABEL 1 Tinjauan tentang terdaftar data untuk

Pleositosis:
meta-analisis Penulis Diterbitkan tahun tempat pos./neg. (N) NR JA KS BS

Afhami 5 2017 Iran 64/163 (+) (+) (+) (+)

Ala 10 2018 Iran 45/75 (+) (+) (+) (+)

Mofidi 6 2017 Iran 33/15 (+) (+) (+) (+)

Nakao 7 2013 Amerika Serikat 47/183 (+) (+) (+) (+)

Sato 11 2017 Jepang 58/60 (+) (+) (+) (-)

Tamune 8 2013 Jepang 139/392 (+) (+) (+) (+)

Thomas 12 2002 Amerika Serikat 80/217 (+) (-) (+) (+)

Uchihara 4 1991 Jepang 34/20 (+) (+) (+) (-)

Waghdhare 9 2010 India 99/91 (+) (+) (+) (+)

catatan: Superskrip di kanan atas nama penulis sesuai dengan nomor dalam daftar referensi.

Singkatan: BS, tanda Brudzinski; JA, sentakan aksentuasi; KS, tanda Kernig; NR, kaku kuduk; (+), Dievaluasi; (-), tidak dievaluasi.
196 |

GAMBAR 2 plot hutan tes pemeriksaan fisik di meningitis. Pemeriksaan selain tanda Kernig menunjukkan rasio odds signifikan untuk prediksi pleositosis dalam cairan serebrospinal

menunjukkan sensitivitas tinggi dan spesifisitas lebih rendah dari Kernig dan tanda- spesifisitas, dan rasio odds dengan tes kaku kuduk pada pasien Ating diferensiasi dengan

tanda Brudzinski. pleositosis CSF dari yang lain.

Protokol dari sentakan aksentuasi (yaitu, rotasi kepala, 2-3 kali per detik)
sederhana, dan hasilnya jauh lebih konsisten antara dokter daripada tes kaku kuduk.
4 | DISKUSI
Tidak diragukan lagi, yang paling populer dan berlaku pemeriksaan fisik adalah kaku
kuduk. Berbeda dengan sentakan aksentuasi, kaku kuduk dapat diterapkan bahkan
Dalam meta-analisis, kami membandingkan signifikansi klinis dan kewajiban ulang tes
pada pasien dengan kesadaran terganggu. Kaku leher dapat dievaluasi pada pasien
kaku kuduk, sentakan aksentuasi, tanda Kernig, dan tanda Brudzinski dalam prediksi
obtunded atau koma, karena merupakan temuan subyektif, secara eksklusif dinilai oleh
pleositosis CSF. Hasil kami menunjukkan bahwa sentakan aksentuasi memiliki tingkat
pemeriksa. Dengan demikian, jika seorang dokter
yang sama dari sensitivitas,
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benar dapat menilai kaku kuduk, ini akan menjadi pemeriksaan berguna paling fisik untuk
mendiagnosis meningitis. Sementara itu, benar menilai kaku kuduk pada kasus dengan

P -values
hanya kekakuan leher yang lemah tidak selalu mudah dan diagnosis bisa bervariasi
antara pemeriksa. Mengingat di atas, bersama-sama dengan fakta bahwa disarankan
sensitivitas dan peluang rasio sentakan aksentuasi yang setinggi-orang dari kaku kuduk,
sentakan aksentuasi akan mampu tes diagnostik pemeriksaan fisik lain yang berguna
dan reli- untuk memprediksi pleositosis CSF.
Pada titik ini, kita harus mengakui bahwa sensitivitas sentakan aksentuasi dalam
diagnosis meningitis jauh lebih rendah daripada yang dilaporkan. 4 Di klinik, beberapa pasien
dengan meningitis yang negatif dalam sentakan aksentuasi. Berdasarkan penelitian ini,
sensitifitas sen- disarankan sentakan aksentuasi dalam diagnosis meningitis akan menjadi
sekitar 40% -60%, jauh lebih rendah dari yang dilaporkan. Jolt aksentuasi adalah, un-
doubtedly, tes pemeriksaan yang berguna dan dapat diandalkan diagnostik fisik untuk
LR (99%

meningitis, tetapi harus dilakukan dan ditafsirkan bersama dengan tanda-tanda lain
CI)

meningeal, gejala yang menyertainya, dan sejarah klinis. Jika tidak, pasien dengan
meningitis bisa salah didiagnosis.
Sebagai perspektif untuk penelitian masa depan, itu akan berguna untuk sess
sebagai- karakteristik masing-masing tes pemeriksaan fisik diagnostik setelah
mengelompokkan pasien berdasarkan meningitis-menghasilkan perubahan-ing
mikroorganisme yang terdeteksi, yaitu, virus atau bakteri. Karena meningitis bakteri
biasanya lebih mendesak dan fatal dibandingkan meningitis viral, 20,21

mengetahui sensitivitas dan spesifisitas masing-masing pemeriksaan fisik untuk setiap jenis
mikroorganisme penyebab dapat membantu dokter untuk memperkirakan risiko meningitis
bakteri dalam pengaturan perawatan primer. Demikian juga, analisis subkelompok untuk
karakteristik masing-masing tes pemeriksaan cal physi- dengan variabel lain selain
mikroorganisme, seperti tingkat keparahan penyakit atau tingkat CSF pleositosis, akan juga
penting. Perspektif lain untuk penelitian masa depan akan mengevaluasi pola tumpang tindih
dari empat tes tion examina- fisik dalam deteksi tanda-tanda meningeal. Jika tanda-tanda
Sensitivitas (99%

meningeal secara independen terdeteksi di masing-masingempat tes, melakukan semua

empat pemeriksaan fisik dalam kombinasi akan menurunkan risiko misdiagnosing kasus
dengan meningitis. Di samping itu
Ada beberapa keterbatasan dalam penelitian ini. Pertama, sebagian besar studi
CI)

vious pra yang dinilai kegunaan sentakan aksentuasi dilaporkan terutama dari
saya

kelompok-kelompok di Jepang dan Iran. Data lebih lanjut dari negara-negara Barat yang
diperlukan untuk menyimpulkan kegunaan sentakan centuation ac- dalam diagnosis
meningitis. Keterbatasan lain adalah bahwa heterogenitas antara terdaftar studi tinggi di
gidity nuchal RI-, sentakan aksentuasi, dan tanda Kernig karena penyebab yang tidak
Dataset

diketahui. Ambang positif di masing-masing empat tes pemeriksaan fisik bisa bervariasi
(n)

antara dokter dan mempengaruhi hasil. akumulasi lebih lanjut dari data klinis, diikuti
oleh tinjauan sistematis dan meta-analisis dari dataset baru, akan diperlukan untuk
menyimpulkan keunggulan antara empat pemeriksaan fisik.
Kesimpulannya, rasio odds, sensitivitas, dan spesifisitas di predict- ing pleositosis CSF
hampir sama antara sentakan aksentuasi dan tes kaku kuduk. Karena penilaian yang benar
dari nuchal
198 |
kekakuan tidak selalu mudah untuk dokter, sentakan aksentuasi akan menjadi
membantu pemeriksaan fisik tambahan untuk menghindari misdiag- nosing meningitis.
Namun, kepekaan dalam kedua tes kekakuan dan sentakan aksentuasi nuchal lebih
rendah dari 40% -60%.
Dengan demikian, dokter perlu mengingat bahwa sejumlah pasien dengan meningitis
mungkin tidak hadir dengan tanda-tanda meningeal. Sebuah seksama terhadap
sejarah dan gejala klinis, bersama-sama dengan tanda-tanda meningeal, diperlukan
untuk mengurangi risiko misdiagnosis.
PENGAKUAN
Kami berterima kasih kepada Dr Satoshi Miyata (Departemen Kedokteran Kardiovaskular, Rumah
Sakit Tohoku University) untuk komentar-komentar profesionalnya tentang metode statistik
dalam meta-analisis.
KONFLIK KEPENTINGAN
Para penulis telah menyatakan secara eksplisit bahwa tidak ada konflik est antar
sehubungan dengan artikel ini.
ORCID
Tetsuya Akaishi https://orcid.org/0000-0001-6728-4966
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