Nuchal rigidity refers to neck stiffness that prevents flexion, commonly an early sign of meningeal irritation. It can be elicited by attempting to passively flex the patient’s neck, bringing the chin to the chest. Pain and muscle spasms occur if nuchal rigidity is present. Before testing, cervical spinal misalignment (fracture, dislocation) must be excluded to avoid spinal cord injury. Patients may also notice stiffness during daily activities.

Nuchal rigidity may indicate life-threatening conditions such as subarachnoid hemorrhage or meningitis, or a late manifestation of cervical arthritis. It is less reliable as a sign in children and infants.

Emergency interventions

• After eliciting nuchal rigidity, check Kernig’s and Brudzinski’s signs.

• Rapidly assess level of consciousness (LOC) and vital signs.

• Monitor for signs of increased intracranial pressure (ICP): increased systolic pressure, bradycardia, widened pulse pressure.

• Establish an IV line for drug administration and provide oxygen as necessary.

• Keep the head of bed elevated ≥30° to reduce ICP.

• Obtain blood for routine studies, including CBC with WBC and electrolytes.

History and Physical Examination

History

• Onset, duration, and progression of neck stiffness

• Precipitating factors (trauma, infection, recent procedures)

• Associated symptoms: headache, fever, nausea, vomiting, photophobia, motor or sensory changes

• Past history: hypertension, head trauma, aneurysms, AV malformations, endocarditis, recent infections (sinusitis, pneumonia), dental work

• Medication history: drugs affecting CNS, anticoagulants, or antibiotics

Physical Examination

• Inspect for arthritis signs: swollen, tender joints

• Palpate neck for pain, tenderness, or restricted motion

• Evaluate for meningeal irritation: Kernig’s and Brudzinski’s signs

• Neurologic assessment: cranial nerves, motor strength, reflexes, sensory deficits

Medical causes

Special considerations

• Prepare the patient for diagnostic imaging: CT scan, MRI, cervical spine X-rays.

• Monitor vital signs, intake/output, and neurologic status closely.

• Avoid routine opioid administration as it may mask increasing ICP.

• Enforce strict bed rest, with head elevation ≥30° to minimize ICP.

• Ensure the patient finds a comfortable position to rest adequately.

Patient counseling

• Explain the cause of nuchal rigidity and its seriousness.

• Inform the patient and family about planned diagnostic tests and treatment procedures.

• Provide reassurance while emphasizing the need for urgent medical evaluation in suspected infections or hemorrhage.

Pediatric pointers

• Testing for nuchal rigidity is less reliable in children, particularly infants.

• For younger children, gently move the head in all directions, observing for resistance.

• Older children can be asked to touch their chin to the chest; resistance may indicate meningeal irritation.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008. pp. 444–447.

3. Colyar MR. Well-child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

4. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.