I. EXAMINATION OF MENINGEAL SIGNS

A. Neck Stiffness (Nuchal Rigidity)

• Procedure:

  • Lay the patient supine.

  • Place your hand behind the patient's occiput.

  • Passively flex the neck, trying to touch the chin to the chest.

• Observation:

  • In meningeal irritation, there will be resistance and stiffness to neck flexion.

  • The head may lift off the pillow as a single unit with the trunk when the patient is asked to sit up (inability to flex the neck).

B. Kernig's Sign

• Procedure:

  • Lay the patient supine.

  • Flex one hip to 90 degrees and then flex the knee to 90 degrees.

  • Now, try to extend the knee passively while keeping the hip flexed at 90 degrees.

• Observation:

  • Kernig's sign is positive if there is pain and resistance to extension of the knee beyond 135 degrees.

  • The patient may also complain of back pain during this maneuver.

C. Brudzinski's Sign

• Procedure:

  • Lay the patient supine.

  • Passively flex the patient's neck, bringing the chin towards the chest.

• Observation:

  • Brudzinski's sign is positive if there is involuntary flexion of the hips and knees in response to passive neck flexion.

II. EXAMINATION OF THE AUTONOMIC NERVOUS SYSTEM

A. Pupillary Light Reflex

• Procedure: Shine a light into each pupil and observe the direct and consensual pupillary constriction.

• Observation: Assess for pupillary size, shape, symmetry, and reaction to light (direct and consensual).

B. Lacrimation

• Observation: Assess for the presence or absence of tearing.

C. Sweating

• Observation: Observe for patterns of sweating (e.g., anhidrosis, hyperhidrosis, localized vs. generalized).

D. Postural Hypotension (Orthostatic Hypotension)

• Procedure:

  • Measure blood pressure (BP) with the patient supine after resting for at least 5 minutes.

  • Then, have the patient stand up.

  • Measure BP again after 3 minutes of standing.

• Observation:

  • A sustained drop in systolic BP of ≥ 20 mmHg or diastolic BP of ≥ 10 mmHg after 3 minutes of standing indicates orthostatic hypotension.

E. Micturition and Defecation Status

• Inquiry: Ask the patient about:

  • Bladder control (incontinence, retention, frequency, hesitancy).

  • Bowel control (constipation, diarrhea, fecal incontinence).

F. Sexual Function

• Inquiry: Inquire about any changes or difficulties in sexual function (e.g., erectile dysfunction in males, anorgasmia).

III. EXAMINATION OF SKULL AND SPINE

A. Examination of the Skull

• Inspection:

  • Size and Shape: Observe for microcephaly, macrocephaly, hydrocephalus, or any abnormal bulges or depressions.

  • Symmetry: Check for facial asymmetry.

  • Scalp and Hair: Look for lesions, scars, rashes, hair loss, or signs of inflammation.

• Palpation:

  • Palpate the entire skull for tenderness, lumps, or bony deformities.

  • Percuss the skull to elicit any localized tenderness.

B. Examination of the Spine

• Inspection (Patient standing, preferably undressed to reveal the back):

  • Curvatures: Observe the normal physiological curvatures (cervical and lumbar lordosis, thoracic kyphosis). Look for abnormal curvatures such as:

    • Kyphosis: Exaggerated thoracic curve (hunchback).

    • Lordosis: Exaggerated lumbar curve.

    • Scoliosis: Lateral curvature of the spine (often with rotation), which can be C-shaped or S-shaped.

  • Alignment: Check if the spine is straight.

  • Symmetry: Observe for symmetry of shoulders, hips, and gluteal folds.

  • Skin and Subcutaneous Tissue: Look for any skin lesions, scars, hairy patches, dimples, or sinuses that may indicate underlying spinal dysraphism.

  • Muscle Wasting/Bulk: Observe for muscle atrophy or hypertrophy along the paravertebral muscles.

• Palpation:

  • Spinous Processes: Palpate along the spinous processes for tenderness, gaps (e.g., spina bifida), or displacement.

  • Paravertebral Muscles: Palpate the muscles on either side of the spine for tenderness, spasm, or hypertrophy.

  • Sacroiliac Joints: Palpate for tenderness over the sacroiliac joints.

• Movements:

  • Active Movements: Ask the patient to perform:

    • Flexion: Touch chin to chest (cervical), bend forward to touch toes (thoracolumbar).

    • Extension: Bend head backward (cervical), lean backward (thoracolumbar).

    • Lateral Flexion: Bend head to each shoulder (cervical), bend sideways (thoracolumbar).

    • Rotation: Turn head to each side (cervical), twist trunk to each side (thoracolumbar).

  • Observation: Note the range of motion, any pain elicited, and any guarding or compensatory movements.

• Special Tests (as indicated):

  • Straight Leg Raise Test: For lumbar disc pathology.

  • Femoral Stretch Test: For upper lumbar nerve root involvement.

  • Gaenslen's Test: For sacroiliac joint dysfunction.