Posture and fluids for preventing post-dural puncture headache

 

Abstract

Background

Potentially disabling postural headache occurs after dural puncture in 1-70% of patients. It has been suggested that such headaches may be less common if patients routinely have a period of bed rest or receive supplementary fluids after the procedure.

Objectives

To assess the effects on post dural puncture headache of a period of bed rest versus early mobilisation, of different positions during a period of bed rest, and of administering supplementary fluids after the procedure.

Search methods

We searched the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2000), MEDLINE (January 1994-December 1998), and EMBASE (January 1980-December 1998). We also searched the reference lists of articles identified electronically, and contacted trial authors for information about other potentially relevant studies. Date of the most recent search: December 2000.

Selection criteria

We sought randomised, unconfounded trials, among all types of patients, that compared the effects on post-dural puncture headache of: bed rest versus early mobilisation; head-down tilt versus horizontal or prone versus supine positions during bed rest; or the administration of supplementary fluids versus control.

Data collection and analysis

One reviewer extracted data from the reports of all trials considered eligible for inclusion. The authors of included studies were invited to check the information extracted and provide any details that were unavailable in the published reports. Intention-to-treat analyses were performed.

Main results

Eleven trials among 1723 patients compared either bed rest with immediate mobilisation or a longer versus a shorter period of bed rest. There was a non-significant relative increase in the odds of the primary outcome of postural headache among patients allocated more rather than less bed rest (196/639 [31%] bed rest versus 169/615 [27%] early mobilisation; odds ratio [OR] 1.21; 95% confidence interval [CI] 0.94 to 1.55). Analyses confined to the methodologically most rigorous trials gave similar results. Only two trials among 126 patients compared different positions during bed rest. No statistically significant differences were found, but small numbers made the comparisons imprecise. One trial among 100 patients assessed fluid supplementation. Again, the numbers of patients and outcome events were small, and indicated the possibility of both reduced and increased postural headache with additional fluids.

Authors' conclusions

There is no good evidence from randomised trials to suggest that routine bed rest after dural puncture is beneficial. The role of fluid supplementation in the prevention of post-dural puncture headache remains uncertain.

 

Plain language summary

Posture and fluids for preventing post-dural puncture headache

Routine bed rest after dural puncture does not prevent the headache that may follow this procedure, but any role for fluid supplements remains unclear. Dural (usually lumbar) puncture involves passing a needle into the fluid-filled space around the spinal cord and nerve roots. This common procedure is used to obtain spinal fluid for laboratory tests or to give a spinal anaesthetic. To prevent the headache that can result from leakage of fluid though the defect created by the needle, patients may be advised to lie flat for several hours, or receive supplementary fluids afterwards. Randomised trials showed no evidence of benefit from bed rest. Too few patients have been randomised in relevant trials to allow a reliable assessment of the effects of fluid supplements.

 

摘要

背景

姿勢和增加體內水份來預防脊椎硬膜穿刺後頭痛

在脊椎硬膜穿刺後的1 – 70%的病人中會有潛在性失能姿勢性頭痛約。有人建議這種頭痛若常規地在做完步驟後,臥床休息一段時間或補充液體會較少見。

目標

評估臥床休息一段期間和早期活動,在臥床休息期間不同的姿勢, 和在執行完此步驟之後體內水份的補充對脊椎硬膜穿刺後頭痛的比較。

搜尋策略

我們搜尋Cochrane Controlled Trials Register(Cochrane Library, Issue 4, 2000), MEDLINE (January1994December 1998), and EMBASE (January 1980December 1998)。我們並且以資訊方式尋找文章參考目錄, 並聯繫實驗作者關於其它潛在地相關研究的報告。最近搜尋的日期: 2000 年12月。

選擇標準

我們尋找了隨機化,沒有混淆的實驗並包括各類型的病人, 來比較對脊椎硬膜穿刺後頭痛的影響: 臥床休息與早期的動作來比較; 在休息期間的比較頭低與水平或趴著與平躺; 或給予補充體內水份與控制組的比較。

資料收集與分析

一個評論者從所有被認為可納入的試驗報告中擷取了資料。納入研究的作者被邀請來檢查所擷取資料及提供已發表但細節部分無法獲得的資料。實施Intentiontotreat analyses 。

主要結論

11項試驗包含1723 名患者比較臥床休息與立即活動,並比較較長與較短的臥床休息期間。姿勢性頭痛病人在較少臥床休息並無顯著增加頭痛的機會(196/639 [31%]臥床休息與169/615 [27%]早期活動;odds ratio [OR] 1.21; 95% confidence interval [CI] 0.94 to 1.55)。若採取最嚴格的分析的方法的試驗,結果也是類似。只有2項試驗在126 名患者之中做了在休息期間不同姿勢的比較。統計上並未發現有重大區別, 但是病例數較小,使的此結果比較較不精確。1項試驗在100 名患者做補充水份的比較。同樣的, 患者的數量和結果事件太少, 無法指出增加水份可以減少姿勢性頭疼。

作者結論

在隨機化的實驗中,沒有有利的證據建議常規臥床休息對硬脊膜穿刺後是有利的。身體體液補充的角色在硬脊膜穿刺後頭痛的預防依然是不明的。

翻譯人

本摘要由三軍總醫院詹舜名翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在硬脊膜穿刺後,常規臥床休息無法預防這種步驟後之頭疼, 但補充水份的角色依然是不清楚。硬脊膜穿刺(通常是腰部) 包含一根針進入在脊髓和神經根附近充滿液體的空間。這個常見的步驟被使用來獲得脊髓液來做為實驗室檢驗或給脊椎麻醉劑。為防止可能起因於針穿刺後脊髓液流出所造成頭痛, 患者被勸告平躺幾個小時,或之後多補充水分。隨機化的試驗顯示在臥床休息後沒有好處。隨機化的相關試驗病人太少，以致無法可靠的評估補充水分的影響。