Sato Ryota, Kuriyama Akira, Luthe Sarah Kyuragi
Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan.
Department of General Medicine, Kurashiki Central Hospital, Okayama, Japan.
Headache. 2017 Apr;57(4):586-592. doi: 10.1111/head.13022. Epub 2017 Jan 5.
Jolt accentuation has been considered to be the most sensitive physical finding to predict meningitis. However, there are only a few studies assessing the diagnostic accuracy of jolt accentuation. Therefore, we aimed to evaluate the diagnostic accuracy of jolt accentuation and investigate whether it can be extended to patients with mild altered mental status.
We performed a single center, retrospective observational study on patients who presented to the emergency department in a Japanese tertiary care center from January 1, 2010 to March 31, 2016. Jolt accentuation evaluated in patients with fever, headache, and mild altered mental status with Glasgow Coma Scale no lower than E2 or M4 was defined as "jolt accentuation in the broad sense." Jolt accentuation evaluated in patients with fever, headache, and no altered mental status was defined as "jolt accentuation in the narrow sense." We evaluated the sensitivity and specificity in both groups.
Among 118 patients, the sensitivity and specificity of jolt accentuation in the broad sense were 70.7% (95% confidence interval (CI): 58.0%-80.8%) and 36.7% (95% CI: 25.6%-49.3%). The positive likelihood ratio and negative likelihood ratio were 1.12 (95% CI: 0.87-1.44) and 0.80 (95% CI: 0.48-1.34), respectively. Among 108 patients, the sensitivity and specificity of jot accentuation in the narrow sense were 75.0% (95% CI: 61.8%-84.8%) and 35.1% (95% CI: 24.0%-48.0%). The positive likelihood ratio and negative likelihood ratio were 1.16 (95% CI: 0.90-1.48) and 0.71 (95% CI: 0.40-1.28), respectively.
Jolt accentuation itself has a limited value in the diagnosis of meningitis regardless of altered mental status. Therefore, meningitis should not be ruled out by negative jolt accentuation.
摇头加重试验一直被认为是预测脑膜炎最敏感的体格检查发现。然而，仅有少数研究评估了摇头加重试验的诊断准确性。因此，我们旨在评估摇头加重试验的诊断准确性，并研究其是否可扩展应用于轻度精神状态改变的患者。
我们对2010年1月1日至2016年3月31日期间在日本一家三级医疗中心急诊科就诊的患者进行了一项单中心回顾性观察研究。对发热、头痛且格拉斯哥昏迷量表评分不低于E2或M4的轻度精神状态改变患者进行的摇头加重试验评估被定义为“广义摇头加重试验”。对发热、头痛且无精神状态改变患者进行的摇头加重试验评估被定义为“狭义摇头加重试验”。我们评估了两组的敏感性和特异性。
在118例患者中，广义摇头加重试验的敏感性和特异性分别为70.7%（95%置信区间（CI）：58.0% - 80.8%）和36.7%（95%CI：25.6% - 49.3%）。阳性似然比和阴性似然比分别为1.12（95%CI：0.87 - 1.44）和0.80（95%CI：0.48 - 1.34）。在108例患者中，狭义摇头加重试验的敏感性和特异性分别为75.0%（95%CI：61.8% - 84.8%）和35.1%（95%CI：24.0% - 48.0%）。阳性似然比和阴性似然比分别为1.16（95%CI：0.90 - 1.48）和0.71（95%CI：0.40 - 1.28）。
无论精神状态是否改变，摇头加重试验本身在脑膜炎诊断中的价值有限。因此，不能因摇头加重试验结果为阴性而排除脑膜炎。
