Warning: Jolt At Your Own Risk…

A guest post by Rory Spiegel (@CaptainBasilEM) who blogs on nihilism and the art of doing nothing at emnerd.com.

Jolt accentuation is a means of perturbing the meninges of a patient presenting with a headache, in the hopes of delineating those who have meningitis from those with a more benign cause. Similar to the “rock the gurney” test in appendicitis or the Dix-Hallpike in BPPV, we are exacerbating the patient’s symptoms in the hopes of better understanding their illness. It has been claimed that the jolt accentuation test is the most sensitive physical exam finding available to rule out meningitis. A recent article published in American Journal of Emergency Medicine suggests otherwise.

This elegantly constructed prospectively gathered cohort was performed at two inner city hospitals over a 4-year period. Authors enrolled all neurologically intact patients older than 18 years old presenting with symptoms suspicious for meningitis. Physicians were asked to answer a questionnaire of physical examination findings before receiving CSF results.  Cunningly the authors surreptitiously placed the LP trays at the research staff’s station to ensure capture of eligible candidates.

47 patients (20%) out of 230 total enrolled were found to have CSF pleocytosis (defined as > 5 WBC ). The jolt accentuation test performed poorly at identifying these patients, with a sensitivity of 21% and a specificity of 82%. Kerning sign, Brudzinski sign, and nuchal rigidity performed no better with sensitivities and specificities of 2%, 2%, 13% and 97%, 98%, 80% respectively. Dishearteningly, the Emergency Physicians overall gestalt performed just as poorly with a sensitivity of 44% and a specificity of 40%.

Unfortunately the authors do not tell us how the jolt accentuation test performed in patients diagnosed with bacterial or fungal meningitis.  In this cohort only 3 of the 230 patients had culture positive meningitis, with only 2 from bacterial or fungal sources (one Cryptococcal and one Meningococcal ). The Emergency Physician identified both of these cases as high-risk upon initial evaluation. The authors failed to mention whether the jolt accentuation was positive in either of these patients. To truly examine jolt accentuation’s diagnostic performance, further studies using culture positive bacterial meningitis rather than pleocytosis as our diagnostic criteria are needed. This would require a much larger cohort, including a significantly larger quantity of cases of bacterial meningitis. But until then perturb with caution…

“Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults” www.ncbi.nlm.nih.gov/pubmed/24139448