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Meta-Analysis
. 2016 Mar 7;3(3):CD009199.
doi: 10.1002/14651858.CD009199.pub3.

Posture and fluids for preventing post-dural puncture headache

Ingrid Arevalo-Rodriguez  1 , Agustín Ciapponi, Marta Roqué i Figuls, Luis Muñoz, Xavier Bonfill Cosp
Affiliations
Meta-Analysis

Posture and fluids for preventing post-dural puncture headache

Ingrid Arevalo-Rodriguez et al. Cochrane Database Syst Rev. .

Abstract

Background: Post-dural puncture headache (PDPH) is a common complication of lumbar punctures. Several theories have identified the leakage of cerebrospinal fluid (CSF) through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 7, 2013) on "Posture and fluids for preventing post-dural puncture headache".

Objectives: To assess whether prolonged bed rest combined with different body and head positions, as well as administration of supplementary fluids after lumbar puncture, prevent the onset of PDPH in people undergoing lumbar puncture for diagnostic or therapeutic purposes.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, as well as trial registries up to February 2015.

Selection criteria: We identified randomized controlled trials that compared the effects of bed rest versus immediate mobilization, head-down tilt versus horizontal position, prone versus supine positions during bed rest, and administration of supplementary fluids versus no/less supplementation, as prevention measures for PDPH in people who have undergone lumbar puncture.

Data collection and analysis: Two review authors independently assessed the studies for eligibility through the web-based software EROS (Early Review Organizing Software). Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We resolved any disagreements by consensus. We extracted data on cases of PDPH, severe PDPH, and any headache after lumbar puncture and performed intention-to-treat analyses and sensitivity analyses by risk of bias. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

Main results: We included 24 trials with 2996 participants in this updated review. The number of participants in each trial varied from 39 to 382. Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear. The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH.There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.68 to 1.41; participants = 1568; studies = 9) and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 1.16; 95% CI 1.02 to 1.32; participants = 2477; studies = 18). Furthermore, bed rest probably increased PDPH (RR 1.24; 95% CI 1.04 to 1.48; participants = 1519; studies = 12) compared with immediate mobilization. An analysis restricted to the most methodologically rigorous trials (i.e. those with low risk of bias in allocation method, missing data and blinding of outcome assessment) gave similar results. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73; participants = 100; studies = 1) and PDPH (RR 1; 95% CI 0.59 to 1.69; participants = 100; studies = 1), and moderate quality evidence on the incidence of any headache after lumbar puncture (RR 0.94; 95% CI 0.66 to 1.34; participants = 200; studies = 2). We did not expect other adverse events and did not assess them in this review.

Authors' conclusions: Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate. As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear.

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Conflict of interest statement

Ingrid Arevalo‐Rodriguez has no conflicts of interest to declare.

Agustín Ciapponi has no conflicts of interest to declare.

Marta Roqué i Figuls has no conflicts of interest to declare.

Luis Muñoz has no conflicts of interest to declare.

Xavier Bonfill Cosp has no conflicts of interest to declare.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 Bed rest versus ambulation, outcome: 1.1 Post‐dural puncture headache.
5
5
Forest plot for reason for puncture: bed rest versus ambulation, outcome: 2.1 Post‐dural puncture headache.
1.1
1.1. Analysis
Comparison 1: Bed rest versus immediate ambulation, Outcome 1: PDPH
1.2
1.2. Analysis
Comparison 1: Bed rest versus immediate ambulation, Outcome 2: Severe PDPH
1.3
1.3. Analysis
Comparison 1: Bed rest versus immediate ambulation, Outcome 3: Any headache
2.1
2.1. Analysis
Comparison 2: Reason for puncture: bed rest versus immediate ambulation, Outcome 1: PDPH
2.2
2.2. Analysis
Comparison 2: Reason for puncture: bed rest versus immediate ambulation, Outcome 2: Severe PDPH
2.3
2.3. Analysis
Comparison 2: Reason for puncture: bed rest versus immediate ambulation, Outcome 3: Any headache
3.1
3.1. Analysis
Comparison 3: Supine versus prone, Outcome 1: Any headache
4.1
4.1. Analysis
Comparison 4: Supine versus supine with head tilt, Outcome 1: Any headache
5.1
5.1. Analysis
Comparison 5: Fluids versus less or no fluids, Outcome 1: Any headache
6.1
6.1. Analysis
Comparison 6: Sensitivity analysis/low risk of bias: bed rest versus ambulation, Outcome 1: PDPH
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References

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Publication types