今日の臨床サポート

項部硬直

著者: 堀進悟 イムス富士見総合病院 総合診療科

監修: 永山正雄 国際医療福祉大学大学院医学研究科 脳神経内科学

著者校正済:2022/05/25
現在監修レビュー中
参考ガイドライン:
  1. 日本神経学会日本神経治療学会日本神経感染症学会:細菌性髄膜炎の診療ガイドライン.
  1. 日本蘇生協議会:JRC蘇生ガイドライン2020
患者向け説明資料

概要・推奨   

  1. 項部硬直を認めたら、他の身体所見や神経所見に他の異常がないかを確認する。クモ膜下出血の可能性が高ければ、頭部CTあるいはMRI検査を実施する。髄膜炎の可能性が高ければ、頭部CTやうっ血乳頭などから脳圧亢進の可能性を除外し、髄液検査を行う。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
堀進悟 : 特に申告事項無し[2022年]
監修:永山正雄 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 項部硬直は、髄膜炎、クモ膜下出血などで認められる髄膜刺激症候で、髄膜が炎症や出血などにより被刺激性になった状態を示す「身体所見」である。
  1. 項部硬直に関連する代表疾患として、髄膜炎やクモ膜下出血は、頻度の高い緊急症である。しかし、これらのすべてで項部硬直が出現するわけではない。したがって、項部硬直自体の疫学は不明である。
  1. 項部硬直を認めたら、他の身体所見や神経所見に他の異常がないかを確認する。クモ膜下出血の可能性が高ければ、頭部CTあるいはMRI検査を実施する。髄膜炎の可能性が高ければ、頭部CTやうっ血乳頭などから脳圧亢進の可能性を除外し、髄液検査を行う。
問診・診察のポイント  
 
  1. 問診のポイント:突然発症で、以前には経験しない頭痛、嘔吐を伴う頭痛。発熱、意識障害。

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文献 

M L Durand, S B Calderwood, D J Weber, S I Miller, F S Southwick, V S Caviness, M N Swartz
Acute bacterial meningitis in adults. A review of 493 episodes.
N Engl J Med. 1993 Jan 7;328(1):21-8. doi: 10.1056/NEJM199301073280104.
Abstract/Text BACKGROUND AND METHODS: To characterize acute bacterial meningitis in adults, we reviewed the charts of all persons 16 years of age or older in whom acute bacterial meningitis was diagnosed at Massachusetts General Hospital from 1962 through 1988. We included patients who were admitted after initial treatment at other hospitals.
RESULTS: During the 27-year period, 445 adults were treated for 493 episodes of acute bacterial meningitis, of which 197 (40 percent) were nosocomial. Gram-negative bacilli (other than Haemophilus influenzae) caused 33 percent of the nosocomial episodes but only 3 percent of the community-acquired episodes. In the 296 episodes of community-acquired meningitis, the most common pathogens were Streptococcus pneumoniae (37 percent), Neisseria meningitidis (13 percent), and Listeria monocytogenes (10 percent); these organisms accounted for only 8 percent of the nosocomial episodes. Only 19 of the 493 episodes of meningitis (4 percent) were due to H. influenzae. Nine percent of all patients had recurrent meningitis; many had a cerebrospinal fluid leak. Seizures occurred in 23 percent of patients with community-acquired meningitis, and 28 percent had focal central nervous system findings. Risk factors for death among those with single episodes of community-acquired meningitis included older age (> or = 60 years), obtunded mental state on admission, and seizures within the first 24 hours. Among those with single episodes, the in-hospital mortality rate was 25 percent for community-acquired and 35 percent for nosocomial meningitis. The overall case fatality rate was 25 percent and did not vary significantly over the 27 years.
CONCLUSIONS: In our large urban hospital, a major proportion of cases of acute bacterial meningitis in adults were nosocomial. Recurrent episodes of meningitis were frequent. The overall mortality rate remained high.

PMID 8416268
Jan de Gans, Diederik van de Beek, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators
Dexamethasone in adults with bacterial meningitis.
N Engl J Med. 2002 Nov 14;347(20):1549-56. doi: 10.1056/NEJMoa021334.
Abstract/Text BACKGROUND: Mortality and morbidity rates are high among adults with acute bacterial meningitis, especially those with pneumococcal meningitis. In studies of bacterial meningitis in animals, adjuvant treatment with corticosteroids has beneficial effects.
METHODS: We conducted a prospective, randomized, double-blind, multicenter trial of adjuvant treatment with dexamethasone, as compared with placebo, in adults with acute bacterial meningitis. Dexamethasone (10 mg) or placebo was administered 15 to 20 minutes before or with the first dose of antibiotic and was given every 6 hours for four days. The primary outcome measure was the score on the Glasgow Outcome Scale at eight weeks (a score of 5, indicating a favorable outcome, vs. a score of 1 to 4, indicating an unfavorable outcome). A subgroup analysis according to the causative organism was performed. Analyses were performed on an intention-to-treat basis.
RESULTS: A total of 301 patients were randomly assigned to a treatment group: 157 to the dexamethasone group and 144 to the placebo group. The base-line characteristics of the two groups were similar. Treatment with dexamethasone was associated with a reduction in the risk of an unfavorable outcome (relative risk, 0.59; 95 percent confidence interval, 0.37 to 0.94; P=0.03). Treatment with dexamethasone was also associated with a reduction in mortality (relative risk of death, 0.48; 95 percent confidence interval, 0.24 to 0.96; P=0.04). Among the patients with pneumococcal meningitis, there were unfavorable outcomes in 26 percent of the dexamethasone group, as compared with 52 percent of the placebo group (relative risk, 0.50; 95 percent confidence interval, 0.30 to 0.83; P=0.006). Gastrointestinal bleeding occurred in two patients in the dexamethasone group and in five patients in the placebo group.
CONCLUSIONS: Early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.

Copyright 2002 Massachusetts Medical Society
PMID 12432041
Diederik van de Beek, Jan de Gans, Lodewijk Spanjaard, Martijn Weisfelt, Johannes B Reitsma, Marinus Vermeulen
Clinical features and prognostic factors in adults with bacterial meningitis.
N Engl J Med. 2004 Oct 28;351(18):1849-59. doi: 10.1056/NEJMoa040845.
Abstract/Text BACKGROUND: We conducted a nationwide study in the Netherlands to determine clinical features and prognostic factors in adults with community-acquired acute bacterial meningitis.
METHODS: From October 1998 to April 2002, all Dutch patients with community-acquired acute bacterial meningitis, confirmed by cerebrospinal fluid cultures, were prospectively evaluated. All patients underwent a neurologic examination on admission and at discharge, and outcomes were classified as unfavorable (defined by a Glasgow Outcome Scale score of 1 to 4 points at discharge) or favorable (a score of 5). Predictors of an unfavorable outcome were identified through logistic-regression analysis.
RESULTS: We evaluated 696 episodes of community-acquired acute bacterial meningitis. The most common pathogens were Streptococcus pneumoniae (51 percent of episodes) and Neisseria meningitidis (37 percent). The classic triad of fever, neck stiffness, and a change in mental status was present in only 44 percent of episodes; however, 95 percent had at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status. On admission, 14 percent of patients were comatose and 33 percent had focal neurologic abnormalities. The overall mortality rate was 21 percent. The mortality rate was higher among patients with pneumococcal meningitis than among those with meningococcal meningitis (30 percent vs. 7 percent, P<0.001). The outcome was unfavorable in 34 percent of episodes. Risk factors for an unfavorable outcome were advanced age, presence of otitis or sinusitis, absence of rash, a low score on the Glasgow Coma Scale on admission, tachycardia, a positive blood culture, an elevated erythrocyte sedimentation rate, thrombocytopenia, and a low cerebrospinal fluid white-cell count.
CONCLUSIONS: In adults presenting with community-acquired acute bacterial meningitis, the sensitivity of the classic triad of fever, neck stiffness, and altered mental status is low, but almost all present with at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status. The mortality associated with bacterial meningitis remains high, and the strongest risk factors for an unfavorable outcome are those that are indicative of systemic compromise, a low level of consciousness, and infection with S. pneumoniae.

Copyright 2004 Massachusetts Medical Society.
PMID 15509818
Swati Waghdhare, Ashwini Kalantri, Rajnish Joshi, Shriprakash Kalantri
Accuracy of physical signs for detecting meningitis: a hospital-based diagnostic accuracy study.
Clin Neurol Neurosurg. 2010 Nov;112(9):752-7. doi: 10.1016/j.clineuro.2010.06.003. Epub 2010 Jul 7.
Abstract/Text OBJECTIVES: To evaluate accuracy of physical signs for detecting meningitis.
PATIENTS AND METHODS: We enrolled patients aged 12 years or more, admitted with acute encephalitis syndrome (fever, headache, altered mental status, vomiting, seizures, neurodeficit) to a rural teaching hospital. The design was a double-blind, cross-sectional analysis of consecutive patients, independently comparing signs of meningeal inflammation (nuchal rigidity, head jolt accentuation of headache, Kernig's sign and Brudzinski's sign) elicited by internal medicine residents against an established reference standard (cerebrospinal fluid white cell count >5 white cells/μL). Diagnostic accuracy was measured by computing sensitivity, specificity and likelihood ratios (LRs) and their 95% confidence interval (CI) values.
RESULTS: Of 190 patients (119 men, 71 women; ages 13-81 years; mean 38(SD 18) years) CSF analysis identified meningitis in 99 (52%; 95% CI 44, 59%) patients. No physical sign of meningeal irritation could accurately distinguish those with and without meningitis: nuchal rigidity (LR+ 1.33 (0.89, 1.98) and LR- 0.86 (0.70, 1.06)), head jolt accentuation of headache (LR+ 5.52 (0.67, 44.9) and LR- 0.95(0.89, 1.00)), Kernig's sign (LR+ 1.84 (0.77, 4.35) and LR- 0.93(0.84, 1.03)) and Brudzinski's sign (LR+ 1.69 (0.65, 4.37) and LR- 0.95 (0.87, 1.04)).
CONCLUSION: Physical signs of meningeal inflammation do not help clinicians rule in or rule out meningitis accurately. Patients suspected to have meningitis should undergo a lumbar puncture regardless of the presence or absence of physical signs.

Copyright © 2010 Elsevier B.V. All rights reserved.
PMID 20615607
Karen E Thomas, Rodrigo Hasbun, James Jekel, Vincent J Quagliarello
The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis.
Clin Infect Dis. 2002 Jul 1;35(1):46-52. doi: 10.1086/340979. Epub 2002 Jun 5.
Abstract/Text To determine the diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity for meningitis, 297 adults with suspected meningitis were prospectively evaluated for the presence of these meningeal signs before lumbar puncture was done. Kernig's sign (sensitivity, 5%; likelihood ratio for a positive test result [LR(+)], 0.97), Brudzinski's sign (sensitivity, 5%; LR(+), 0.97), and nuchal rigidity (sensitivity, 30%; LR(+), 0.94) did not accurately discriminate between patients with meningitis (>/=6 white blood cells [WBCs]/mL of cerebrospinal fluid [CSF]) and patients without meningitis. The diagnostic accuracy of these signs was not significantly better in the subsets of patients with moderate meningeal inflammation (>/=100 WBCs/mL of CSF) or microbiological evidence of CSF infection. Only for 4 patients with severe meningeal inflammation (>/=1000 WBCs/mL of CSF) did nuchal rigidity show diagnostic value (sensitivity, 100%; negative predictive value, 100%). In the broad spectrum of adults with suspected meningitis, 3 classic meningeal signs did not have diagnostic value; better bedside diagnostic signs are needed.

PMID 12060874
T Uchihara, H Tsukagoshi
Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis.
Headache. 1991 Mar;31(3):167-71.
Abstract/Text We prospectively examined the clinical signs of 54 febrile patients associated with recent-onset headache. They underwent lumbar puncture (LP) on suspicion of meningitis. The relation of each sign to cerebrospinal fluid (CSF) pleocytosis was estimated. Among 34 patients with pleocytosis, 33 had jolt accentuation (sensitivity: 97.1%), while only 5 of them had neck stiffness or Kernig's sign. Among 20 patients without pleocytosis, 12 had no jolt accentuation (specificity: 60%). We found jolt accentuation to be the most sensitive sign of CSF pleocytosis. If jolt accentuation is noted in a febrile patient associated with recent onset headache, the CSF should be examined even in the absence of neck stiffness or Kernig's sign.

PMID 2071396
N van der Wee, G J Rinkel, D Hasan, J van Gijn
Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?
J Neurol Neurosurg Psychiatry. 1995 Mar;58(3):357-9.
Abstract/Text Computed tomography may be normal in up to 5% of patients who are investigated within one or two days after subarachnoid haemorrhage. This study investigated the need for further diagnostic evaluation after a normal CT scan was found very early (within 12 hours) in patients suspected of subarachnoid haemorrhage. A consecutive series of 175 patients with sudden headache and a normal neurological examination who had first CT within 12 hours after the onset of headache were investigated. The patients with normal CT underwent lumbar puncture, but not earlier than 12 hours after the event. Computed tomography showed subarachnoid blood in 117 patients, and was normal in 58. Spectrophotometric analysis of CSF gave evidence for a subarachnoid haemorrhage in two of these 58 patients (3%; 95% confidence interval (95% CI) 0.4-12%); a ruptured aneurysm was found in both. Thus CT was normal in two of 119 patients with a definite subarachnoid haemorrhage (2%; 95% CI 0.2-6%). It is concluded that in patients with sudden headache but normal CT a deferred lumbar puncture is necessary to rule out subarachnoid haemorrhage, even if CT is performed within 12 hours after the onset of symptoms.

PMID 7897421
Jeffrey J Perry, Ian G Stiell, Marco L A Sivilotti, Michael J Bullard, Marcel Emond, Cheryl Symington, Jane Sutherland, Andrew Worster, Corinne Hohl, Jacques S Lee, Mary A Eisenhauer, Melodie Mortensen, Duncan Mackey, Merril Pauls, Howard Lesiuk, George A Wells
Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.
BMJ. 2011 Jul 18;343:d4277. Epub 2011 Jul 18.
Abstract/Text OBJECTIVE: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset.
DESIGN: Prospective cohort study.
SETTING: 11 tertiary care emergency departments across Canada, 2000-9.
PARTICIPANTS: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage.
MAIN OUTCOME MEASURES: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography.
RESULTS: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%).
CONCLUSION: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

PMID 21768192
Abstract/Text OBJECTIVES: To determine the sensitivity of third-generation CT scanners for diagnosed nontraumatic subarachnoid hemorrhage (SAH) and to assess the impact of symptom duration on sensitivity.
METHODS: A retrospective chart review was performed in a university-affiliated tertiary care hospital with an annual ED volume of > 100,000 patients. The target population was all patients who presented to the ED from January 1991 to September 1994 with symptoms suggestive of SAH and who had a final diagnosis of nontraumatic SAH based on either a positive CT scan or positive spinal fluid analysis. Patients referred from outside facilities were included if they had a CT done at the study site. All CT scans were done using third-generation scanners. Official CT scan reports were used to categorize scans as positive or negative.
RESULTS: There were 140 patients identified with SAH, with a mean age of 56 years (range 10-88). The sensitivity of CT in the diagnosis of nontraumatic SAH when performed at or before 12 hours of symptom duration was 100% (80/80), and 81.7% (49/60) after 12 hours of symptom duration (95% CI 95-100% and 69.5-90.4%, respectively; p < 0.0001). Eleven of the 140 patients had a negative CT and positive spinal fluid analysis, yielding an overall sensitivity of 92.1% (129/140).
CONCLUSION: The sensitivity of third-generation CT scans for SAH decreases with time from the onset of symptoms. In this sample population, CT was able to detect all patients scanned < or = 12 hours after symptom onset. Although the study demonstrated good sensitivity of CT scan reports for SAH when the scan was performed after < or = 12 hours of symptom onset, additional real-time experience is needed to better define the potential risk of a missed SAH should this population not receive the customary lumbar puncture examination in the setting of a negative CT scan.

PMID 8870753
T A Sames, A B Storrow, J A Finkelstein, M R Magoon
Sensitivity of new-generation computed tomography in subarachnoid hemorrhage.
Acad Emerg Med. 1996 Jan;3(1):16-20.
Abstract/Text OBJECTIVE: To determine the sensitivity of the initial new-generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a "normal" NGCT scan.
METHODS: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age < 2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration < 24 hours (group 1) and > 24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT scanner was defined as a third-generation scanner or more recent.
RESULTS: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients (n = 144) and 83.8% for the group 2 patients (n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH.
CONCLUSION: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A "normal" NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.

PMID 8749962

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