Posture and fluids for preventing post‐dural puncture headache Stable (no update expected for reasons given in 'What's new')

Abstract

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.

Author(s)

Ingrid Arevalo‐Rodriguez, Agustín Ciapponi, Marta Roqué i Figuls, Luis Muñoz, Xavier Bonfill Cosp

Abstract

Plain language summary

Body position and intake of fluids for preventing headache after a lumbar puncture

Background

A lumbar puncture is a medical procedure performed with a needle and syringe used to take a sample of cerebrospinal fluid or to inject medications. Some people experience a side effect afterwards called post‐dural puncture headache (PDPH). This can be made worse by movement, sitting or standing, and can be relieved by lying down. PDPH limits people's mobility and daily activities, as well as causing unplanned expenses for both the patient and the health institution. Doctors sometimes advise their patients to remain in bed after a lumbar puncture and to drink a lot to prevent PDPH.

Key findings

This is an update of the original review published in 2013. We found one new study in a search of the published literature in February 2015. This review includes 24 studies with 2996 participants. We compared different types of bed rest and extra fluids to see if they prevented PDPH after a lumbar puncture. We found low to moderate quality evidence that bed rest does not prevent the onset of headaches after lumbar puncture, regardless of the duration of rest or the body or head positions assumed by the patient. Furthermore, bed rest probably increases the chances of having PDPH. We found few data on the usefulness of extra fluids, which did not seem to prevent PDPH.

We believe that these practices should no longer be routinely recommended to patients for the prevention of headaches after lumbar puncture since there is no evidence supporting them.

Quality of the evidence

We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate.

Author(s)

Ingrid Arevalo‐Rodriguez, Agustín Ciapponi, Marta Roqué i Figuls, Luis Muñoz, Xavier Bonfill Cosp

Reviewer's Conclusions

Authors' conclusions

Implications for practice

Since the previous version of this review, we found one new study for inclusion (Afshinmajd 2014), but the conclusions remain unchanged. This updated review did not find evidence to support bed rest or fluid supplementation for preventing headache following lumbar puncture (low to moderate quality evidence).

For people who receive a lumbar puncture

People who receive a lumbar puncture for diagnostic or therapeutic reasons should be allowed to move freely in accordance with their ability and medical recommendations. In addition, there are no clear benefits or adverse side effects associated with additional oral fluid supplementation (low quality evidence). People should be free to decide whether or not to increase fluid intake after lumbar puncture, unless medical reasons recommend one or the other.

For clinicians

Clinicians should not routinely recommend rest after lumbar puncture to prevent PDPH. The adoption of this practice against the evidence implies patient discomfort (for example among women who give birth via a Cesarean section), or even complications such as venous stasis in people with risk factors.

For policymakers

Due to its lack of benefits and its implications in hospital and health system costs, rest after lumbar puncture to prevent PDPH should not be routinely recommended as a health policy. The role of fluid supplementation in the prevention of PDPH remains unclear.

For funders

This updated review did not find evidence to support bed rest or fluid supplementation for preventing headache following lumbar puncture. As we mentioned before, given that bed rest does not provide any benefit in the prevention of headache after lumbar puncture, it becomes unnecessary to discuss the position that should be adopted during bed rest as well as modification of head postures. However, fluid supplementation in the prevention of PDPH could have a role in prevention of this adverse event.

Implications for research

Additional research focused on bed rest for prevention of PDPH would not identify additional benefits associated with this intervention, which makes further studies unnecessary. Regarding fluid supplementation, more randomized controlled trials would be desirable given the uncertainty of its role in the prevention of PDPH. However, such research would be limited and costly, and fluid supplementation is harmless and can be adopted freely with no delay of hospital discharge.

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