Posture and fluids for preventing post-dural puncture headache

  • Review
  • Intervention

Authors

  • Ingrid Arevalo-Rodriguez,

    Corresponding author
    1. Fundación Universitaria de Ciencias de la Salud, Hospital de San José/ Hospital Infantil de San José, Division of Research, Bogotá D.C., Colombia
    • Ingrid Arevalo-Rodriguez, Division of Research, Fundación Universitaria de Ciencias de la Salud, Hospital de San José/ Hospital Infantil de San José, Bogotá D.C., 11001, Colombia. inarev7@yahoo.com. iarevalo@fucsalud.edu.co.

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  • Agustín Ciapponi,

    1. Southern American Branch of the Iberoamerican Cochrane Centre, Argentine Cochrane Centre IECS, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Capital Federal, Argentina
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  • Luis Munoz,

    1. Hospital de San Jose, Fundacion Universitaria de Ciencias de la Salud, Department of Anaesthesia, Bogotá D.C., Colombia
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  • Marta Roqué i Figuls,

    1. CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), Barcelona, Catalunya, Spain
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  • Xavier Bonfill Cosp

    1. CIBER Epidemiología y Salud Pública (CIBERESP), Spain - Universitat Autònoma de Barcelona, Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), Barcelona, Catalonia, Spain
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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. Therefore, it is necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used as a therapeutic measure once PDPH has started, but it is unknown if it can be 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.

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 Controlled Trials Register, MEDLINE, EMBASE, and LILACS up to June 2013.

Selection criteria

We identified randomized controlled trials (RCTs) that compared the effects of bed rest versus early/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 solved 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.

Main results

We included 23 trials (2477 participants) in this review. There was no beneficial effect associated with bed rest compared with immediate mobilization on the incidence of PDPH (risk for bed rest 26.4%; risk for mobilization 20.5%; risk ratio (RR) 1.30; 95% confidence interval (CI) 1.09 to 1.55), severe PDPH (risk for bed rest 10.6%; risk for mobilization 10.7%; RR 1.00; 95% CI 0.75 to 1.32), and presence of any headache after lumbar puncture (risk for bed rest 33.6%; risk for mobilization 28.6%; RR 1.18; 95% CI 1.05 to 1.32). Analyses restricted to the most methodologically rigorous trials gave similar results. Likewise, the two trials that assessed fluid supplementation did not find this preventive measure to be useful in the prevention of PDPH.

Authors' conclusions

There is no evidence from RCTs that suggests 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.

摘要

預防硬腦膜穿刺後頭痛之姿勢與水分補充

背景

硬腦膜穿刺後頭痛(PDPH)是一種常見的腰椎穿刺併發症,許多理論將腦脊髓液(CSF)由硬腦膜上的洞滲漏視為造成此副作用的原因。因此,採取預防措施來避免此併發症是必要的。當PDPH開始時,延長臥床平躺就被用來做為治療措施,但它是否也能用來預防PDPH則是未知。同樣的,在正常飲食攝取之外給予水分補充,對於修復因穿刺造成CSF流失的幫助也是未知。

目的

評估在腰椎穿刺後延長臥床平躺, 結合身體與頭部不同的姿勢以及給予補充水分,是否能預防PDPH在因為診斷或治療而經歷腰椎穿刺的人們身上發生。

搜尋策略

我們搜尋了至2013年6月以前的Cochrane Controlled Trials Register、MEDLINE、EMBASE以及LILACS等資料庫。

選擇標準

我們找出比較以臥床平躺相較於早期/立即活動、頭部下傾相較於水平姿勢、在臥床期間傾斜相較於仰臥姿勢以及給予補充水分相較於沒有/較少的補充品,做為預防PDPH在經歷腰椎穿刺的人們身上發生的措施之隨機對照試驗(RCTs)。

資料收集與分析

兩位作者以web-based軟體EROS(Early Review Organizing Software)獨立地評估研究的合適性。兩位不同的文獻作者使用Cochrane Handbook for Systematic Reviews of Interventions中概述的準則,獨立地評估偏誤風險。我們以共識來化解任何的不一致,由PDPH、嚴重PDPH及任何腰椎穿刺後頭痛的案例中摘錄資料,且以偏誤風險進行治療意向分析與敏感度分析。

主要結果

在本文獻中,我們收錄了23個試驗(2,477位受試者)。在PDPH(臥床平躺的風險26.4%;活動的風險20.5%;風險率比(RR) 1.30; 95% 信賴區間(CI) 1.09至1.55)、嚴重的PDPH(臥床平躺的風險10.6%;活動的風險10.7%;RR 1.00; 95% CI 0.75至1.32)以及腰椎穿刺後出現任何頭痛的發生率上(臥床平躺的風險33.6%;活動的風險28.6%; RR 1.18; 95% CI 1.05至1.32),臥床平躺相較於立即活動並沒有相關的效益,只限於方法最嚴密的試驗分析也有相似的結果。同樣的,兩個評估水分補充的試驗發現此預防措施對於PDPH的預防是沒有用的。

作者結論

RCTs中沒有證據顯示腰椎穿刺後,常規臥床平躺對預防PDPH的發生是有效益的;而水分補充在預防PDPH的作用上仍不明確。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Plain language summary

Postures and fluids for preventing post-dural puncture headache

Some doctors advise their patients to remain in bed after a lumbar puncture and to increase fluid intake to prevent the occurrence of a complication called post-dural puncture headache (PDPH). PDPH limits a person's mobility and daily activities while presenting additional efforts for both the patient and the health institution. This review found that bed rest does not prevent the onset of headaches after lumbar puncture procedures, regardless of the duration of rest, or the body or head positions assumed by the patient. We also found few data on the usefulness of additional fluid intake, which showed no preventive effect on the onset of headaches. We believe that these practices should no longer be routinely recommended to patients for the prevention of headaches after lumbar puncture.

淺顯易懂的口語結論

預防硬腦膜穿刺後頭痛之姿勢與水分補充

有些醫師建議他們的病人在腰椎穿刺後繼續臥床並且增加水分的攝取,以預防一種叫做硬腦膜穿刺後頭痛(PDPH)的併發症發生。PDPH會限制一個人的行動與日常活動,同時對患者及健康機構也代表了額外的照護工作。本文獻發現不論患者休息的時間、身體或頭的姿勢,臥床平躺皆無法預防腰椎穿刺後頭痛的發生。我們也發現少量關於額外水分攝取有效性的資料,顯示它對於頭痛的發生沒有預防的效果。我們相信,不應該再為了預防腰椎穿刺後頭痛而常規性地將這些措施推薦給患者。

譯註

翻譯者:臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)

本翻譯計畫由臺北醫學大學考科藍臺灣研究中心(Cochrane Taiwan)、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行
聯絡E-mail:cochranetaiwan@tmu.edu.tw

Summary of findings(Explanation)

Summary of findings for the main comparison. Bed rest compared with ambulation for preventing post-dural puncture headache
  1. 1 Blinding of outcome assessment (detection bias) as well as randomization features (selection bias) are unclear in several trials.

Bed rest compared with ambulation for preventing post-dural puncture headache
Patient or population: participants undergoing lumbar puncture
Intervention: bed rest
Comparison: ambulation
OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed riskCorresponding risk
Ambulation Bed rest
Post-dural puncture headache
participant's report
Follow-up: 0-15 days
205 per 1000 267 per 1000
(224 to 318)
RR 1.30
(1.09 to 1.55)
1519
(12 studies)
⊕⊕⊕⊝
moderate 1
 
Severe post-dural puncture headache
participant's report
Follow-up: 0-15 days
107 per 1000 107 per 1000
(81 to 142)
RR 1
(0.76 to 1.33)
1568
(9 studies)
⊕⊕⊕⊝
moderate 1
 
Any cephalea
participant's report
Follow-up: 0-15 days
Study population RR 1.18
(1.05 to 1.32)
2477
(18 studies)
⊕⊕⊕⊝
moderate 1
 
287 per 1000 339 per 1000
(301 to 379)
Moderate
231 per 1000 273 per 1000
(243 to 305)
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Summary of findings 2 Fluids compared with less or no fluids for preventing post-dural puncture headache

Summary of findings 2. Fluids compared with less or no fluids for preventing post-dural puncture headache
  1. 1 High risk of detection bias (blinding of outcome assessment) plus unclear risk related to randomization features.
    2 High risk of detection bias in one study; unclear risk of selection bias in both trials included.

Fluids compared with less or no fluids for preventing post-dural puncture headache
Patient or population: participants undergoing lumbar puncture
Intervention: fluids
Comparison: less or no fluids
OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed riskCorresponding risk
Less or no fluids Fluids
Post-dural puncture headache
participant's report
360 per 1000 360 per 1000
(212 to 608)
RR 1
(0.59 to 1.69)
100
(1 study)
⊕⊕⊕⊝
moderate 1
 
Severe post-dural puncture headache
participant's report
180 per 1000 121 per 1000
(47 to 311)
RR 0.67
(0.26 to 1.73)
100
(1 study)
⊕⊕⊕⊝
moderate 1
 
Any cephalea
participant's report
396 per 1000 372 per 1000
(265 to 531)
RR 0.94
(0.67 to 1.34)
200
(2 studies)
⊕⊕⊕⊝
moderate 2
 
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Background

Description of the condition

Post-dural (post-lumbar or post-spinal) puncture headache (PDPH) is one of the most common complications of diagnostic, therapeutic, or inadvertent lumbar punctures (Bezov 2010; Davignon 2002). PDPH is defined as any headache after a lumbar puncture that worsens within 15 minutes of sitting or standing and that is relieved within 15 minutes of lying down (IHS 2004). Ninety per cent of PDPHs occur within three days of the procedure and 66% start within the first 48 hours (Turnbull 2003).

The pathophysiology of PDPH has not been fully described. It is well known that puncture in the dura allows cerebrospinal fluid (CSF) to leak from the subarachnoid space, resulting in a decrease in CSF volume and pressure (Grande 2005). This CSF volume loss may cause a downward pull on pain-sensitive structures resulting in a headache (Ahmed 2006; Baumgarten 1987; Davignon 2002; Denny 1987; Harrington 2004). Alternatively, the loss of CSF may cause an increase in blood flow, resulting in arterial and venous vasodilation and PDPH. A third explanation involves the role of substance P (a neurotransmitter/neuromodulator involved in pain perception) and the regulation of neurokinin 1 receptors (NK1R) (Clark 1996).

Occurrence of PDPH varies from 1% to 40%, according to needle gauge, needle orientation, operator skill level, and presence of risk factors such as patient's age or history of PDPH (Turnbull 2003). During anaesthetic procedures (e.g. epidural anaesthesia), PDPH is most commonly caused by an unintentional dural puncture (Thew 2008; Turnbull 2003). In contrast, during diagnostic or therapeutic lumbar punctures, the need for adequate CSF flow requires an intentional lesion that may give rise to PDPH (Kuczkowski 2006). Estimated frequencies vary from less than 10% following spinal anaesthesia (Hafer 1997; Vallejo 2000), to 36% following diagnostic lumbar punctures (Lavi 2006; Vallejo 2000) and up to 81% in women with inadvertent dural puncture during active labour. Reported risk of inadvertent dural puncture placement during epidural anaesthesia in women ranges from 0.04% to 6% (Berger 1998; Choi 2003). A significant number of mothers cannot provide adequate care for their newborn because of the headache (Sprigge 2008).

The features of PDPH are often variable. PDPH may be accompanied by neck stiffness, tinnitus, hearing loss, photophobia, or nausea. Other features, such as the localization and duration of the headache, are less predictable (Grande 2005). Although PDPH is not a life-threatening condition, it often restricts physical activity. Likewise, length of hospital stay and medical monitoring increases, especially because patients are usually required to stay in bed for an entire day after the intervention (Angle 2005), as well as direct and indirect costs.

The variability of symptoms makes PDPH a diagnosis of exclusion. Alternative diagnoses, such as viral meningitis, sinus headache, or intracranial haemorrhage should be ruled out first (Turnbull 2003). Once PDPH is diagnosed, the initial treatment involves conservative measures such as bed rest and analgesics. If PDPH continues for more than 72 hours, a more specific treatment is indicated (Ahmed 2006). Severe PDPH may respond to some therapeutic drugs and administration of an epidural blood patch (Boonmak 2010; Lavi 2006). Two Cochrane reviews on drug therapy for the prevention and treatment of PDPH are currently under way (Basurto Ona 2009a; Basurto Ona 2009b).

Description of the intervention

Many publications and reviews of PDPH have focused on treatment after the onset of symptoms. However, the prevention of PDPH is an equally important topic. Immobilization and fluid intake are the two proposed preventive methods that may foster recovery or even prevent PDPH following lumbar puncture.

Sicard first recommended bed rest after lumbar puncture in 1902. He asserted that patients should rest for 24 hours to prevent onset of PDPH (Armon 2005; Coriat 1903). Although the effectiveness of resting for symptom relief is well known, it is debatable whether bed rest prevents the development of symptoms (Davignon 2002). In addition, there is disagreement over the appropriate length of bed rest; some authors suggest that around four hours is sufficient, whereas others suggest 24 hours or more (Thoennissen 2001). It is also believed that certain body postures after lumbar puncture, such as a prone position with or without head-down tilt, may help in the prevention of PDPH onset.

The effectiveness of fluid intake on PDPH prevention has not been investigated thoroughly. Basic characteristics, such as amount of fluid intake and time of treatment, have not been established, although some studies suggest that three additional litres per day for five days is appropriate (Ahmed 2006). Despite lack of evidence, Vanzetta et al. found that hydration is a common recommendation for patients after a dural procedure. Ninety per cent of centres interviewed reported implementing it to prevent the onset of headache (Vanzetta 2005).

How the intervention might work

Prophylactic bed rest may have a mechanism of action similar to the one that has been proposed for therapeutic immobilization after the development of PDPH. CSF leakage is thought to be fundamental in the development of PDPH. Therefore, postures such as prone position after a lumbar puncture may reduce hydrostatic pressure. This may in turn reduce pressure in the subarachnoid space and allow a seal to form over the dura, thus enabling CSF leakage repair. As such, this posture may be effective in preventing PDPH onset.

Additional fluid intake may work by replacing lost corporal fluid and increasing CSF production (Ahmed 2006), thus preventing a hydrostatic pull on pain-sensitive structures and vasodilation (Janssens 2003). By this mechanism, hydration may prevent the development of PDPH.

Why it is important to do this review

Lumbar puncture is a common clinical practice despite its potential adverse effects (Evans 2009; Grande 2005). The morbidity associated with CSF loss, besides PDPH, includes peripartum seizures, cranial subdural hematomas, and subdural fluid collection (Arendt 2009). PDPH may be the first step in a chain of adverse events that can be avoided by following a series of simple recommendations (Janssens 2003). Patient immobilization and oral intake of fluids may be valuable to avoid deleterious complications. Even though most cases of PDPH resolve within a few days, a significant number of people have at least one week of disability, while others require prolonged or recurrent hospitalization (van Kooten 2008).

A 2002 Cochrane Review on strategies to prevent PDPH included published and unpublished literature up to the year 2000 (Sudlow 2002). It is imperative to update these results in order to generate relevant recommendations for consumers, patients, and health practitioners.

Objectives

To assess the effects of posture (bed rest and different positions after lumbar puncture) and administration of supplementary fluids on the prevention of PDPH in people who underwent dural puncture for diagnostic or therapeutic purposes.

Methods

Criteria for considering studies for this review

Types of studies

We included randomized controlled trials (RCTs) in any clinical/research setting where dural puncture was conducted. Quasi-RCTs were not included.

Types of participants

Studies that recruited males and females of all ages who had undergone lumbar puncture for medical reasons (therapeutic or diagnostic).

Types of interventions

The studies on participants undergoing lumbar puncture must have assessed one of the following interventions:

  1. a period of bed rest after lumbar puncture alone or in combination with a head-down/up tilt strategy, with or without a specific body position, or even a combination of several postural strategies with immobilization, versus early mobilization;

  2. head-down/up tilt versus no head-down/up tilt in participants prescribed with a period of bed rest;

  3. prone versus supine posture in participants assigned to immobilization;

  4. administration of supplementary fluids (oral or intravenous) after lumbar puncture versus no/less administration; and

  5. any combination of points 1 to 4.

Types of outcome measures

Primary outcomes

We assessed the presence of PDPH defined as each headache that worsened within 15 minutes of sitting or standing and that was relieved within 15 minutes of lying down as the primary outcome (IHS 2004). We used the valid PDPH diagnosis criteria specified by the International Headache Society (IHS) (IHS 2004), as well as the definition used in each study.

Secondary outcomes

We assessed the presence of severe PDPH using the definition used in each study, which could be based on specific features (e.g. duration of PDPH), a visual analogue score (VAS), or other criteria, such as need of specialized treatments to relieve the headache (e.g. epidural blood patch). Likewise, we assessed information on any headache subsequent to the lumbar puncture procedure in order to incorporate any possible data that had not been catalogued as PDPH.

Search methods for identification of studies

Electronic searches

We used the Cochrane Central Register of Controlled Trials (CENTRAL) as the primary source where all relevant RCTs could be identified (The Cochrane Library 2013, Issue 6). We used a modified version of the CENTRAL search for searching MEDLINE (1966 June week 4, 2013), EMBASE (1974 to 2013 week 4) and LILACS (inception to June 2013). The search terms were a combination of thesaurus-based and free-text terms, both related to the intervention (lumbar puncture in neurological, anaesthesia or myelography settings) and the outcome. We applied no language restrictions.

See Appendix 2, Appendix 3, Appendix 4 and Appendix 5 for details of the CENTRAL, MEDLINE, EMBASE, and LILACS search strategies.

Searching other resources

We handsearched reference lists from retrieved studies as well as information from clinical trial registration web-sites. We used unpublished information collected by previous authors of a systematic review that assessed strategies aimed at preventing PDPH to gather information on allocation and blinding of outcomes (Sudlow 2002).

Data collection and analysis

Selection of studies

Two review authors (IA and LM) independently conducted a selection of eligible studies through the web-based software EROS (Early Review Organizing Software) (Ciapponi 2011; Ciapponi 2011a; Glujovsky 2010). The review authors reviewed titles and abstracts of all identified studies to determine if they fulfilled the inclusion criteria. Full-text publications of the selected studies were assessed to confirm their relevance for inclusion. We solved any disagreements through discussion with a third review author (AC). Review authors were not blinded to name and affiliation of study authors, journal of publication, or study results at any stage of the review.

Data extraction and management

Two review authors (IA and LM) used pre-designed and tested data extraction forms to extract information on participants, methods of randomization, blinding, comparisons of interest, number of participants originally randomized by arm, people lost to follow-up, and outcomes. Reasons for exclusion of potential studies were recorded in the Characteristics of excluded studies table. We clarified any disagreements by discussion with a third review author (MR). We entered extracted data into Review Manager 5 for analysis (RevMan 2011).

Assessment of risk of bias in included studies

Two review authors (MR and AC) independently assessed risk of bias of the included studies using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We considered five domains (sequence generation, allocation concealment, blinding in outcomes assessment, incomplete outcome data and selective reporting bias); each one of them was classified as low risk of bias, high risk of bias, or unclear risk of bias. We resolved any disagreements by discussion or by consulting a third review author (XB).

Measures of treatment effect

We presented results as summary risk ratios (RR) with 95% confidence intervals (CIs). We used the numbers needed to treat for an additional harmful outcome (NNTH) statistic as an absolute measure of harm. We calculated NNTH as the reciprocal of risk differences (RD) (McQuay 1998).

Dealing with missing data

We retrieved levels of attrition data when available. We conducted sensitivity analyses to explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect. When possible, we carried out analyses on an intention-to-treat (ITT) basis (i.e. we attempted to include all participants randomized to each group). We assumed that any participant lost to follow-up had not experienced the respective outcome.

Assessment of heterogeneity

We assessed heterogeneity of effect sizes by means of the I2 statistic. An I2 greater than 30% was indicative of heterogeneity.

Data synthesis

We carried out statistical analysis using the Cochrane Review Manager 5 software (RevMan 2011). If we detected homogeneity of effects sizes (I2 < 30%), we combined the data using the fixed-effect model. For I2 ranging from 30% to 60%, we planned to use a random-effects model after a full assessment of clinical similarity among the studies (Higgins 2003). If clinical heterogeneity was present, we did not combine the studies.

Subgroup analysis and investigation of heterogeneity

For included studies that provided the necessary data (> 200 people), we assessed the following subgroup analyses:

  1. participants undergoing dural puncture for anaesthesia only, diagnosis only, or myelography only;

  2. subgroup analysis for gender;

  3. subgroup analysis for age;

  4. subgroup analysis for posture during the lumbar puncture (e.g. lateral or sitting up);

  5. subgroup analysis for needle gauge (e.g. 22, 29);

  6. subgroup analysis for needle tips (e.g. pencil-point, diamond, double bevel); and

  7. subgroup analysis for amount of CSF aspirated.

Sensitivity analysis

Sensitivity analyses included assessment of the effect on the primary outcome by excluding any study with high or unclear risk of bias in any of the following:

  1. allocation features;

  2. levels of missing data; or

  3. blinding of outcome assessment.

Results

Description of studies

Results of the search

We identified 29 studies for possible inclusion: 26 on postures and bed rest, and three on supplementary fluids (Figure 1). Most of the studies were published in the 1980s (Andersen 1986; Carbaat 1981; Congia 1985; Cook 1989; Dieterich 1985; Dieterich 1988; Gulati 1981; Handler 1982a; Hilton-Jones 1982; Jensen 1987; Macpherson 1983; Macpherson 1984; Macpherson 1985; Robertson 1980; Smith 1980; Teasdale 1983; Thornberry 1988; Vilming 1988), one was published in 1978 (Eldevik 1978), and nine were published after 1990 (Cucereanu 2010; Ebinger 2004; Fassoulaki 1991; Hafer 1997a; Hallam 1993; Johannsson 1992; Murata 2003; Spriggs 1992; Tejavanija 2006; Vimala 1998).

Figure 1.

Study flow diagram.

We excluded five of the 29 trials assessed for inclusion because they were not fully randomized (Carbaat 1981; Gulati 1981; Hafer 1997a; Hallam 1993; Spriggs 1992). One study was available only in abstract form, which had been submitted for a European Congress (Cucereanu 2010). This study was included as an ongoing trial, awaiting future full-text publication. One study was published in two different articles (Andersen 1986). Details of excluded and ongoing studies are shown in the Characteristics of excluded studies and Characteristics of ongoing studies tables.

Consequently, 23 RCTs were included. Their main features are shown in the Characteristics of included studies table. Eighteen trials with 2477 people compared either bed rest versus immediate mobilization or a longer versus a shorter period of bed rest (Andersen 1986; Congia 1985; Cook 1989; Dieterich 1985; Ebinger 2004; Fassoulaki 1991; Jensen 1987; Johannsson 1992; Macpherson 1983; Macpherson 1984; Macpherson 1985; Murata 2003; Robertson 1980; Teasdale 1983; Tejavanija 2006; Thornberry 1988; Vilming 1988; Vimala 1998). Nine of these trials involved 723 people undergoing diagnostic lumbar puncture (Congia 1985; Dieterich 1985; Ebinger 2004; Handler 1982a; Hilton-Jones 1982;Johannsson 1992;Smith 1980; Tejavanija 2006; Vilming 1988); four trials involved 381 people undergoing spinal anaesthesia for orthopaedic, urological, or obstetric procedures (Andersen 1986; Cook 1989; Fassoulaki 1991; Thornberry 1988); and seven involved 1165 people undergoing myelography (Jensen 1987; Macpherson 1983; Macpherson 1984; Macpherson 1985; Murata 2003; Robertson 1980; Teasdale 1983). One trial involved 208 people undergoing lumbar puncture for any reason (Vimala 1998).

Three trials compared the effects of a head-tilt versus no head-tilt in addition to bed rest among 106 people undergoing diagnostic lumbar puncture (Hilton-Jones 1982; Robertson 1980; Smith 1980). One of these trials also compared the effects of prone versus supine position during bed rest (Hilton-Jones 1982), while another compared prone positioning versus head-tilt followed by supine positioning (Handler 1982a). Two trials assessed the effects of supplementary fluids among 200 people undergoing either diagnostic lumbar puncture or myelography (Dieterich 1988; Eldevik 1978).

Risk of bias in included studies

Summary details of methods used in the studies are shown in the Characteristics of included studies table and illustrated in Figure 2 and Figure 3.

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Random sequence generation and allocation concealment (selection bias)

All 23 included trials were described as randomized, although only seven contained published or unpublished information about the methodology used to allocate treatments (Andersen 1986; Hilton-Jones 1982; Tejavanija 2006; Thornberry 1988; Vilming 1988; Vimala 1998). Similarly, only six trials provided published or unpublished information about allocation concealment (Cook 1989; Jensen 1987; Macpherson 1985; Smith 1980; Thornberry 1988; Vilming 1988). Fifteen trials had an unclear risk of bias for allocation concealment (selection bias). Only two trials had low risk of bias both for random sequence generation and allocation concealment (Thornberry 1988; Vilming 1988).

Blinding (detection bias)

We did not evaluate blinding of participants and researchers in our review due to the nature of the intervention (bed rest or supplementary fluids). Outcome assessment was blinded in 13 trials (Eldevik 1978; Fassoulaki 1991; Handler 1982a; Hilton-Jones 1982; Jensen 1987; Macpherson 1983; Macpherson 1985; Murata 2003; Smith 1980; Teasdale 1983; Thornberry 1988; Vilming 1988). These trials reported assessment of cephalea by another physician or researcher who did not know the results of the randomization scheme. Seven trials did not report information about blinding or the reported information was classified as high risk of bias (Andersen 1986; Congia 1985; Dieterich 1988; Ebinger 2004; Robertson 1980; Tejavanija 2006; Vimala 1998).

Incomplete outcome data

The duration of follow-up varied between five hours to one month after lumbar puncture. In one trial, 27 of the 129 participants included for randomization were either excluded subsequently due to protocol violations or were lost to follow-up without mention of randomization group (Cook 1989). Three other trials documented minor exclusions (Handler 1982a; Murata 2003; Vimala 1998). No participants were reported as lost to follow-up in the remaining trials. Thirty-one patients who were excluded from the different analyses due to protocol violations were included in accordance to ITT analysis.

Selective reporting

High risk of reporting bias was identified in three trials given that no results were found for variables included in the methodology section (Congia 1985; Dieterich 1988; Handler 1982a). Fourteen of the 23 trials included did not provide sufficient information to assess risk of bias and were classified as having an unclear risk of bias.

Other potential sources of bias

Trials were generally small. The number of participants in each trial varied from 39 to 382. Ten trials included fewer than 100 people (Congia 1985; Fassoulaki 1991; Handler 1982a; Hilton-Jones 1982; Jensen 1987; Johannsson 1992; Robertson 1980; Smith 1980; Tejavanija 2006; Thornberry 1988). Only one trial used a power calculation to determine the number of people that had to be recruited (Vimala 1998).

Effects of interventions

See: Summary of findings for the main comparison Bed rest compared with ambulation for preventing post-dural puncture headache; Summary of findings 2 Fluids compared with less or no fluids for preventing post-dural puncture headache

Bed rest versus early mobilization (Comparison 1)

Post-dural puncture headache (Analysis 1.1)

Information on PDPH was available from 12 of the 18 trials that had compared either bed rest versus immediate mobilization or a longer versus a shorter period of bed rest, comprising 61% of the people randomized in these trials (Analysis 1.1). There was no statistical heterogeneity between the results of individual trials for the primary outcome (I2 = 0%). Bed rest resulted in more cases of PDPH compared with early ambulation (RR 1.30; 95% CI 1.09 to 1.55), corresponding to an NNTH of 17 (95% CI 10 to 50).

Severe post-dural puncture headache (Analysis 1.2)

Nine trials had data on severe PDPH, comprising 63% of people. Approximately 47% of PDPHs recorded were considered to be severe (Analysis 1.2). There were no differences between bed rest and early mobilization. In this analysis, it is unclear whether bed rest was associated with an increase or a decrease in PDPH onset due to the 95% CI (RR 1.00; 95% CI 0.75 to 1.32).

Any headache (Analysis 1.3)

All 18 trials in this comparison had outcome data for 'any headache' (Analysis 1.3). The results were very similar to those of PDPH (RR 1.18; 95% CI 1.05 to 1.32; NNTH 20; 95% CI 13 to 50). The funnel plot for this analysis was presented in Figure 4. In addition, a L'Abbé plot of bed rest versus early mobilization event rates was presented in Figure 5 (L'Abbe 1987).

Figure 4.

Funnel plot of comparison: 1 Bed rest versus ambulation, outcome: 1.3 Any cephalea.

Figure 5.

L'Abbé plot: Bed rest versus ambulation rates.

Bed rest versus bed rest with head-down tilt (Comparison 2)

Only one trial including 29 people had outcome data for 'any headache after lumbar puncture', comprising 1% of people randomized in the 21 included trials (Analysis 2.1). This trial suggested that there was no difference between bed rest with or without head-down tilt regarding incidence of cephalea after lumbar puncture (RR 0.81; 95% CI 0.48 to 1.38).

Prone versus supine posture (Comparison 3)

Only two trials including 120 people had outcome data for 'any headache' comprising 4.4% of people randomized in the 21 included trials (Analysis 3.1). There was no statistical heterogeneity between the results of individual trials for this outcome (I2 = 0%). There was no difference between positions regarding incidence of cephalea after lumbar puncture (RR 0.86; 95% CI 0.54 to 1.37).

Prone or supine posture versus prone or supine posture with head-down tilt (Comparison 4 and 5)

Regarding supine position, only two trials including 87 people had outcome data for 'any headache', comprising 3.2% of people randomized in the 21 included trials (Analysis 4.1). There was no statistical heterogeneity between the results of individual trials for this outcome (I2 = 0%). There were more headaches associated with the supine posture with head-down tilt compared with supine position alone (RR 1.75; 95% CI 1.11 to 2.74).

Regarding prone position, only one trial including 39 people had outcome data for any headache, comprising 1.4% of people randomized in the 21 included trials (Analysis 5.1). There were no differences between prone with head-down tilt versus prone position alone regarding incidence of any cephalea after lumbar puncture (RR 1.18; 95% CI 0.58 to 2.42).

Supplementary fluids (Comparison 6)

Only one trial including 100 people had outcome data for the incidence of PDPH and severe PDPH, comprising 50% of people randomized in the two trials that studied this intervention. Data suggest that there were no differences between fluid supplementation and no supplementation on incidence of PDPH (RR 1; 95% CI 0.59 to 1.69) or incidence of severe PDPH (RR 0.67; 95% CI 0.26 to 1.73) (Analysis 6.1; Analysis 6.2). Similar results were found regarding incidence of any cephalea after lumbar puncture, which was analysed by the two trials that investigated supplementary fluids (RR 0.94; 95% CI 0.67 to 1.34) (Analysis 6.3).

Subgroup analysis

There was insufficient information on age, gender, postures during lumbar puncture, needle gauge, needle tip, and amount of CSF aspirated in order to perform the planned subgroup analysis. Information on reason for puncture was available only for trials comparing bed rest versus early mobilization.

Reason for puncture (Analyses 7.1 to 7.3).

Regarding PDPH (Analysis 7.1), there was no difference between bed rest and early mobilization in three of the four separate categories of lumbar puncture: diagnostic lumbar puncture (RR 1.16; 95% CI 0.94 to 1.43), myelography (RR 1.48; 95% CI 0.67 to 3.27), and mixed (RR 1.27; 95% CI 0.68 to 2.35). There was a small significant difference between bed rest and immediate mobilization on spinal anaesthesia data (RR 1.82; 95% CI 1.20 to 2.78), suggesting an increase in the risk of PDPH with bed rest. However, the number of people included in these trials was small and the validity of these results remains unclear.

There was no difference in severe PDPH between bed rest and early mobilization with regards to reason of lumbar puncture (Analysis 7.2), including: diagnostic lumbar puncture (RR 0.92; 95% CI 0.62 to 1.37), anaesthesia (RR 2.89; 95% CI 1.12 to 7.45), and mixed (RR 0.25; 95% CI 0.05 to 1.15). There was no information on severe PDPH in myelography trials.

There was no difference on 'any headache' after lumbar puncture between bed rest and early mobilization (Analysis 7.3) in three of four separate categories of lumbar puncture: diagnostic lumbar puncture (RR 1.16; 95% CI 0.95 to 1.42), myelography (RR 1.06; 95% CI 0.91 to 1.24), and mixed (RR 1.27; 95% CI 0.68 to 2.35). There were more headaches following spinal anaesthesia after bed rest than after immediate mobilization (RR 1.87; 95% CI 1.28 to 2.73; NNTH 14; 95% CI 4 to 17).

Sensitivity analyses (Analysis 8.1)

Two trials including 380 people had low risk of bias with regards to blinding of outcome assessment, losses to follow-up, adequate randomization and allocation concealment (Analysis 8.1). These trials compared bed rest versus early ambulation. Analysis restricted to these trials showed no difference between bed rest and early ambulation in incidence of PDPH (RR 1.19; 95% CI 0.90 to 1.56). There was no statistical heterogeneity between studies (I2 = 0%).

Discussion

Summary of main results

Regarding bed rest, this systematic review of all available RCTs found no evidence to suggest that a period of bed rest following dural puncture reduces the risk of PDPH, severe PDPH, or any headache. Furthermore, immobilization could even increase the risk of headache in people undergoing lumbar puncture. When we only considered trials with low risk of bias in methodological aspects such as randomization methods and blinding of outcome assessment, again there was no evidence of benefit of bed rest on the incidence of PDPH. Figure 5 shows the proportion of PDPH events in both groups (bed rest and early ambulation) by study and sample size (L'Abbe 1987). The graphics illustrate that the estimated harm could be explained by the studies with smaller sample sizes. Meanwhile studies with sample sizes of 200 or more people showed no effect (benefit or harm) due to intervention, despite the null estimation of heterogeneity. However, it could be misleading since they do not account for sampling error in both observed event rates (Sharp 1996).

A total of 26.4% of people randomized to the bed rest group in the included studies experienced a postural headache, compared with 20.5% randomized to the early mobilization groups. These figures show that 49 additional participants out of 1000 receiving bed rest will have a PDPH (with a minimum of eight and a maximum of 98). Sensitivity analysis considering only trials with low risk of bias consistently showed the lack of benefit of bed rest compared with early mobilization. Subgroup analyses only show differences in the anaesthesia subgroup (four trials), but only one trial in this analysis had low risk of bias in all categories assessed. It is also important to consider that the low number of participants involved in this analysis (381) may not be sufficient to detect differences between interventions.

These results suggest that there is no role for prolonged immobilization in lumbar puncture practice. Given that bed rest does not provide any benefit in the prevention of headaches after lumbar puncture, it becomes unnecessary to discuss the position that should be adopted during bed rest as well as modification of head postures (head-down or head-up tilt). In any case, the results of our review do not suggest any benefits related to specific body and head postures on the incidence of cephalea after lumbar puncture.

Regarding fluid supplements, we identified two trials (200 people) that studied the role of fluid supplementation following lumbar puncture. Only one of these trials provided data on incidence of PDPH and severe PDPH, and found no beneficial effect associated with fluid supplementation. Similar results were found for incidence of any headache, which was assessed by both trials. The wide 95% CIs of these comparisons preclude us from making solid conclusions about fluid supplementation in the prevention of PDPH. Sudlow et al previously estimated that a sample size of 100 to 3000 participants per arm, assuming baseline risks of 20% and 8%, respectively, would be necessary to identify a beneficial effect of this intervention (Sudlow 2002). Recruitment of this number of participants would require the involvement of several centres, as well as a considerable amount of work and resources to conduct the corresponding clinical trial.

Overall completeness and applicability of evidence

Included studies evaluated a wide range of bed rest times in order to determine if extended bed rest had any effect on the prevention of PDPH. Rest periods additional to those indicated as a result of the medical/surgical procedure ranged from 4 to 24 hours. Several head and body positions were evaluated taking into account physiological theories about PDPH. Studies that focused on supplementary fluids only assessed additional fluid intake of 1.5 to 2 L, which does not allow extrapolation to other forms of hydration, such as parenteral supplementation. Considering the nature of the medical problem and its interventions, it is likely that the evidence obtained from the included RCTs could be applied to similar populations outside of trials. It seems unlikely that publication bias could have influenced the main findings of this review, since such bias usually involves the preferential publication of trials with differences between groups. Furthermore, the funnel plot generated for the comparison with more RCTs included showed no severe asymmetries (Figure 4).

Quality of the evidence

Lack of information in published reports was a problem when assessing risk of bias. Many trials did not adequately report the study characteristics that are important to evaluate the quality of the evidence. Also, participants included in these trials cannot be blinded to the assigned interventions, which poses a possible source of bias.

Another possible source of bias in these trials arises from the nature of the outcome (headache after lumbar puncture), which depends strongly on the subjective report of participants rather than on an objective assessment. This phenomenon may have influenced the results, especially those related to an excess of PDPH risk in people on bed rest. People with limited mobility may be more susceptible to report minor discomforts or to over-rate its seriousness. Some trials implemented a blinded assessment of outcomes to partially avoid this potential source of bias. However, this assessment was misreported and its quality was unclear in several cases.

Agreements and disagreements with other studies or reviews

The previous version of this review highlighted the lack of benefit of both interventions for the prevention of PDPH of any kind (including those non-postural) (Sudlow 2002). The new evidence identified does not alter the conclusions of the previous review but provides a warning about the probability of deleterious effects associated with bed rest. One review that included 16 trials with 1083 participants also found that extended rest did not prevent the appearance of headaches after lumbar puncture (Thoennissen 2001). No other reviews were identified on the effectiveness of fluid supplementation.

Authors' conclusions

Implications for practice

There is no evidence to support longer bed rest or fluid supplementation for preventing headache following lumbar puncture. The adoption of this practice against the evidence implies unnecessary hospital costs, patient discomfort (e.g. among women who give birth via a caesarean section), or even complications such as venous stasis in people with risk factors. Thus, rest after lumbar puncture to prevent post-dural puncture headache (PDPH) should not be routinely recommended. Instead, people should be allowed to move freely in accordance with their ability and medical recommendations.

There are no clear benefits or adverse side effects associated with additional oral fluid supplementation. People should be free to decide whether or not to increase fluid intake after lumbar puncture, unless there are medical reasons that recommend one or the other.

Implications for research

Additional research focused on longer bed rest for prevention of PDPH would not identify additional benefits associated with this intervention, which makes further studies unnecessary. Regarding fluid supplementation, more research would be desirable given the uncertainty of its role on 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.

Acknowledgements

The review authors would like to thank Daniel Comande (Trials Search Co-ordinator, Argentine Cochrane Centre-IECS) for his support and assistance designing the search strategy for this review, and Hector Pardo (Iberoamerican Cochrane Center) for helping with the final manuscript. In addition, we would like to acknowledge Cathie Sudlow and Charles Warlow, authors of a previous review on strategies aimed at preventing post-dural puncture headache.

Ingrid Arévalo-Rodríguez is a PhD student at the Department of Pediatrics, Obstetrics and Gynecology, and Preventive Medicine of the Universitat Autònoma de Barcelona, Barcelona, Spain.

Data and analyses

Download statistical data

Comparison 1. Bed rest versus ambulation
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 PDPH121519Risk Ratio (M-H, Fixed, 95% CI)1.30 [1.09, 1.55]
2 Severe PDPH91568Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.75, 1.32]
3 Any cephalea182477Risk Ratio (M-H, Fixed, 95% CI)1.18 [1.05, 1.32]
Analysis 1.1.

Comparison 1 Bed rest versus ambulation, Outcome 1 PDPH.

Analysis 1.2.

Comparison 1 Bed rest versus ambulation, Outcome 2 Severe PDPH.

Analysis 1.3.

Comparison 1 Bed rest versus ambulation, Outcome 3 Any cephalea.

Comparison 2. Bed rest versus bed rest with head tilt
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Any cephalea1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
Analysis 2.1.

Comparison 2 Bed rest versus bed rest with head tilt, Outcome 1 Any cephalea.

Comparison 3. Supine versus prone
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Any cephalea2120Risk Ratio (M-H, Fixed, 95% CI)0.86 [0.54, 1.37]
Analysis 3.1.

Comparison 3 Supine versus prone, Outcome 1 Any cephalea.

Comparison 4. Supine versus supine with head tilt
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Any cephalea287Risk Ratio (M-H, Fixed, 95% CI)1.75 [1.11, 2.74]
Analysis 4.1.

Comparison 4 Supine versus supine with head tilt, Outcome 1 Any cephalea.

Comparison 5. Prone versus prone with head tilt
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Any cephalea1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
Analysis 5.1.

Comparison 5 Prone versus prone with head tilt, Outcome 1 Any cephalea.

Comparison 6. Fluids versus less or no fluids
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 PDPH1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
2 Severe PDPH1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
3 Any cephalea2200Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.67, 1.34]
Analysis 6.1.

Comparison 6 Fluids versus less or no fluids, Outcome 1 PDPH.

Analysis 6.2.

Comparison 6 Fluids versus less or no fluids, Outcome 2 Severe PDPH.

Analysis 6.3.

Comparison 6 Fluids versus less or no fluids, Outcome 3 Any cephalea.

Comparison 7. Reason for puncture: bed rest versus ambulation
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 PDPH121519Risk Ratio (M-H, Fixed, 95% CI)1.30 [1.09, 1.55]
1.1 Diagnostic6723Risk Ratio (M-H, Fixed, 95% CI)1.16 [0.94, 1.43]
1.2 Myelography1207Risk Ratio (M-H, Fixed, 95% CI)1.48 [0.67, 3.27]
1.3 Anaesthesia4381Risk Ratio (M-H, Fixed, 95% CI)1.82 [1.20, 2.78]
1.4 Mixed1208Risk Ratio (M-H, Fixed, 95% CI)1.27 [0.68, 2.35]
2 Severe PDPH91568Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.75, 1.32]
2.1 Diagnostic3509Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.62, 1.37]
2.2 Myelography2582Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.59, 1.58]
2.3 Anaesthesia3269Risk Ratio (M-H, Fixed, 95% CI)2.89 [1.12, 7.45]
2.4 Mixed1208Risk Ratio (M-H, Fixed, 95% CI)0.25 [0.05, 1.15]
3 Any cephalea182477Risk Ratio (M-H, Fixed, 95% CI)1.18 [1.05, 1.32]
3.1 Diagnostic6723Risk Ratio (M-H, Fixed, 95% CI)1.16 [0.95, 1.42]
3.2 Myelography71165Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.91, 1.24]
3.3 Anaesthesia4381Risk Ratio (M-H, Fixed, 95% CI)1.87 [1.28, 2.73]
3.4 Mixed1208Risk Ratio (M-H, Fixed, 95% CI)1.27 [0.68, 2.35]
Analysis 7.1.

Comparison 7 Reason for puncture: bed rest versus ambulation, Outcome 1 PDPH.

Analysis 7.2.

Comparison 7 Reason for puncture: bed rest versus ambulation, Outcome 2 Severe PDPH.

Analysis 7.3.

Comparison 7 Reason for puncture: bed rest versus ambulation, Outcome 3 Any cephalea.

Comparison 8. Low risk of bias: bed rest versus ambulation
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 PDPH2380Risk Ratio (M-H, Fixed, 95% CI)1.19 [0.90, 1.56]
Analysis 8.1.

Comparison 8 Low risk of bias: bed rest versus ambulation, Outcome 1 PDPH.

Appendices

Appendix 1. Glossary of terms

Term Definition
 Analgesia, epiduralThe relief of pain without loss of consciousness through the introduction of an analgesic agent into the epidural space of the vertebral canal
Analgesia, obstetricalThe elimination of pain, without the loss of consciousness, during obstetric labour; obstetric delivery; or the postpartum period, usually through the administration of analgesics
Blood patch, epiduralThe injection of autologous blood into the epidural space either as a prophylactic treatment immediately following an epidural puncture or for treatment of headache as a result of an epidural puncture
Cerebrospinal fluid pressureManometric pressure of the cerebrospinal fluid as measured by lumbar, cerebroventricular, or cisternal puncture. Within the cranial cavity it is called intracranial pressure
Dura materThe outermost of the 3 meninges, a fibrous membrane of connective tissue that covers the brain and the spinal cord
FluidsCompounds that permit restore the volume and composition of the body fluids to normal and which are administered orally, intravenously, by intermittent gavage or by hypodermoclysis
MyelographyX-ray visualization of the spinal cord following injection of contrast medium into the spinal arachnoid space
PosturesThe position or attitude of the body
Primary preventionSpecific practices for the prevention of disease or mental disorders in susceptible individuals or populations. These include health promotion, including mental health; protective procedures, such as communicable disease control; and monitoring and regulation of environmental pollutants
Post-dural puncture headacheA secondary headache disorder attributed to low cerebrospinal fluid pressure caused by spinal puncture, usually after dural or lumbar puncture
Spinal punctureTapping fluid from the subarachnoid space in the lumbar region, usually between the third and fourth lumbar vertebrae
Source: www.ncbi.nlm.nih.gov/mesh

Appendix 2. Cochrane Controlled Trials Register search strategy

#1 MeSH descriptor: [Post-Dural Puncture Headache] this term only

#2 (PLPH or PPH or PDPH or Post dural or Post-dural):ti,ab,kw (Word variations have been searched)

#3 #1 or #2

#4 MeSH descriptor: [Anesthesia, Epidural] explode all trees

#5 MeSH descriptor: [Anesthesia, Spinal] this term only

#6 MeSH descriptor: [Injections, Spinal] explode all trees

#7 MeSH descriptor: [Myelography] this term only

#8 MeSH descriptor: [Spinal Puncture] this term only

#9 (spinal or intraspinal or dural or intradural or epidural or lumbar* or theca* or intrathecal or subarachnoid* or "sub arachnoid*" or Myelograph*):ti,ab,kw (Word variations have been searched)

#10 #4 or #5 or #6 or #7 or #8

#11 (puncture* or inject* or anesth* or anaesth* or needle*):ti,ab,kw (Word variations have been searched)

#12 #10 and #11

#13 MeSH descriptor: [Headache] this term only

#14 (Headach* or cephalea* or cephalalgi*):ti,ab,kw (Word variations have been searched)

#15 #13 or #14

#16 #12 and #15

#17 #3 or #16

#18 MeSH descriptor: [Bed Rest] this term only

#19 (Patient position* or Bed rest or bedrest or recumb* or posture* or rest in bed):ti,ab,kw (Word variations have been searched)

#20 #18 or #19

#21 #17 and #20

#22 MeSH descriptor: [Fluid Therapy] explode all trees

#23 (Fluid Therap* or Rehydrat* or Oral fluid* or Fluid Admin* or Fluid intake* or supplementary fluid* or fluid supplement* or hydrat*):ti,ab,kw (Word variations have been searched)

#24 #22 or #23

#25 #17 and #24

Appendix 3. MEDLINE (OVID) search strategy

1 Post-Dural Puncture Headache/

2 (PLPH or PPH or PDPH or Post dural or Post-dural).tw.

3 or/1-2

4 exp anesthesia, epidural/ or anesthesia, spinal/

5 exp Injections, Spinal/

6 Myelography/

7 Spinal Puncture/

8 (spinal or intraspinal or dural or intradural or epidural or lumbar* or theca* or intrathecal or subarachnoid* or "sub arachnoid*" or Myelograph*).tw.

9 or/4-8

10 (puncture* or inject* or anesth* or anaesth* or needle*).tw.

11 9 and 10

12 Headache/

13 (Headach* or cephalea* or cephalalgi*).tw.

14 or/12-13

15 11 and 14

16 3 or 15

17 Bed Rest/

18 (Patient position* or Bed rest or bedrest or recumb* or posture* or rest in bed).tw.

19 or/17-18

20 16 and 19

21 exp Fluid Therapy/

22 (Fluid Therap* or Rehydrat* or Oral fluid* or Fluid Admin* or Fluid intake* or supplementary fluid* or fluid supplement* or hydrat*).tw.

23 or/21-22

24 16 and 23

25 20 or 24

26 randomized controlled trial.pt.

27 controlled clinical trial.pt.

28 randomized.ab.

29 placebo.ab.

30 drug therapy.fs.

31 randomly.ab.

32 trial.ab.

33 or/28-34

34 exp animals/ not humans.sh.

35 33 not 34

36 25 and 35

Appendix 4. EMBASE (OVID) search strategy

1 Post-Dural Puncture Headache/

2 (PLPH or PPH or PDPH or Post dural or Post-dural).tw.

3 or/1-2

4 exp anesthesia, epidural/ or anesthesia, spinal/

5 exp Injections, Spinal/

6 Myelography/

7 Spinal Puncture/

8 (spinal or intraspinal or dural or intradural or epidural or lumbar* or theca* or intrathecal or subarachnoid* or "sub arachnoid*" or Myelograph*).tw.

9 or/4-8

10 (puncture* or inject* or anesth* or anaesth* or needle*).tw.

11 9 and 10

12 Headache/

13 (Headach* or cephalea* or cephalalgi*).tw.

14 or/12-13

15 11 and 14

16 3 or 15

17 Bed Rest/

18 (Patient position* or Bed rest or bedrest or recumb* or posture* or rest in bed).tw.

19 or/17-18

20 16 and 19

21 exp Fluid Therapy/

22 (Fluid Therap* or Rehydrat* or Oral fluid* or Fluid Admin* or Fluid intake* or supplementary fluid* or fluid supplement* or hydrat*).tw.

23 or/21-22

24 16 and 23

25 20 or 24

26 random$.tw.

27 factorial$.tw.

28 crossover$.tw.

29 cross over$.tw.

30 cross-over$.tw.

31 placebo$.tw.

32 (doubl$ adj blind$).tw.

33 (singl$ adj blind$).tw.

34 assign$.tw.

35 allocat$.tw.

36 volunteer$.tw.

37 Crossover Procedure/

38 double-blind procedure.tw.

39 Randomized Controlled Trial/

40 Single Blind Procedure/

41 or/26-40

42 (animal/ or nonhuman/) not human/

43 41 not 42

44 25 and 43

Appendix 5. LILACS (BIREME) Search strategy

(MH Cefalea Pospunción de la Duramadre OR PLPH OR PPH OR PDPH OR Post dural OR post-dural OR Pós-Punção OR Pospunción) [Words] and (MH Anestesia Epidural OR MH Anestesia Raquidea OR MH Inyecciones Espinales OR MH Mielografía OR MH Punción Espinal OR Extradural OR Peridural OR Raquianestesia OR Mielograf$ OR Myelograph$ OR spinal OR intraspinal OR dural OR intradural OR epidural OR lumbar$ OR theca$ OR intratecal$ OR intrathecal OR subarachnoid$ OR sub arachnoid$ OR subaracnoid$) [Words] and (Punção OR puncion$ OR puncture$ OR inject$ OR Injeçõ$ OR inyec$ OR Anestesi$ OR anesth$ OR needle$ OR aguja$ OR Agulha$)) AND (MH Cefalea OR Cefale$ OR Cefalalgi$ OR Cephalgi$ OR Hemicrani$ OR Enxaqueca$ OR Jaqueca$ OR Cefalgi$) [Words]

Contributions of authors

All review authors contributed to the writing of the protocol. IA, AC, and LM conducted the search and selection of studies. IAR, LM, XB, and MR conducted data extraction and 'Risk of bias' assessment. IA and MR were in charge of all the statistical analyses. All authors contributed to writing the final document. IA entered data into RevMan and will carry out futures updates of this review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Fundación Universitaria de Ciencias de la Salud/ Hospital de San José- Hospital Infantil de San José, Colombia.

  • Institute for Clinical Effectiveness and Health Policy IECS, Argentina.

  • Iberoamerican Cochrane Centre, Spain.

External sources

  • Agencia de Calidad del Sistema Nacional de Salud, Ministry of Health, Spain.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Andersen 1986

MethodsParticipants admitted to urology department who received spinal anaesthesia were randomized by means of random numbers
Participants112 participants included in analysis
InterventionsGroup A: 24-hour flat bed rest postoperatively; Group B: mobilization after anaesthesia
OutcomesPDPH and any headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Immediately after surgery, patients were randomized (random numbers) to group A: 24 hour flat bed rest postoperatively, or Group B: mobilization after anesthesia" - "All patients were assigned under the principle of randomness (drawing lots)"
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
High riskPatient interviews were used to conduct pre- and postanaesthesia assessments. There was no information on whether standardized forms were used or on how incidence of headaches was collected. Follow-up assessments (2 weeks) were completed using autoadministered standardized questionnaires about headaches (quality and duration)
Incomplete outcome data (attrition bias)
All outcomes
Low risk"112 pt [patients] were included in the study". Data on tables and text corresponds to 112 participants
Selective reporting (reporting bias)Low risk

Technical difficulties in spinal anaesthesia: number of attempts, blood in the cerebrospinal fluid

Symptoms: spinal headache (incidence, onset, and duration), visual disturbances, tinnitus, low back pain, paraesthesia, leg cramps, satisfaction with anaesthesia

Congia 1985

MethodsParticipants with indication of LP for neurological diagnostic were randomized to 2 groups. Details about random sequence generation were not provided
Participants39 participants were included in the analysis
InterventionsGroup A: bed rest for 24 hours; Group B: mobilization after LP
OutcomesPDPH
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk "Randomly, 20 patients were invited to get up immediately afterwards and 19 to stay in bed for 24 hours". No details on sequence generation were provided
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
High riskThere was no information on this item
Incomplete outcome data (attrition bias)
All outcomes
Low risk39 participants were included and randomized
Selective reporting (reporting bias)High riskResults concerning nausea, vomiting, and neck stiffness (soon after puncture and at 7 days), as well as electroencephalography results (before and after puncture, at 24 hours and at 7 days) were not provided

Cook 1989

MethodsParticipants undergoing potentially minor urological or gynaecological surgery, who received spinal anaesthesia were randomized to 2 groups
Participants129 participants were included, but only 102 were analyzed
InterventionsGroup A: bed rest for 4 hours after operation; group B: bed rest for 24 hours after operation
OutcomesPDPH and severe PDPH scored subjectively by patient
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Patients were allocated randomly after operation to either the 4-hour (Group 1) or 24-hour (Group 2) recumbency groups". No details on sequence generation were provided
Allocation concealment (selection bias)Low riskInformation retrieved by Sudlow 2002: sealed envelopes (sequentially numbered and opaque)
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk

Described as "blinded trial": "Patient follow-up was achieved either by patients returning a questionnaire through the post, or more commonly by direct telephone interview on the fourth day after operation. The telephone interviewer was unaware of the length of the patient's postoperative recumbence"

"No indication was given to the patient at interview of the nature of the investigation"

"No particular emphasis was placed on any one of these symptoms. No indication was given to the patient that a headache was a well recognised complication of spinal anesthesia"

Incomplete outcome data (attrition bias)
All outcomes
Low risk129 participants entered, 9 lost to follow-up, 18 breaches of study protocol. 102 participants were assessed
Selective reporting (reporting bias)Low riskParticipants were asked if they had suffered from any postoperative complaints: cough, dizziness, headache, or backache. Participants were asked to grade subjectively any complaint as mild, moderate, or severe and if any complaint was posture dependent (i.e. worse on standing)

Dieterich 1985

MethodsParticipants with indication of diagnostic LP were randomized to 2 groups. Details about random sequence generation were not provided
Participants160 neurological patients were included and analyzed
InterventionsGroup A: bed rest for 30 minutes with head-down tilt at an angle of 10°. Group B: immediate mobilization
OutcomesPDPH, severe PDPH rated by the participants (major complaints)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"To examine the prophylactic efficacy of this postural manoeuvre in a prospective study, patients were randomly allocated to one of two groups: the members of one group were to lie with their heads tilted down at an angle of 10° for 30 min, the members of the other group were to get up immediately after LP". No details on sequence generation were provided
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
Low riskThere was no information on this item
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)High riskResults about localization and duration of PDPH were not reported

Dieterich 1988

MethodsParticipants with indication of diagnostic LP were randomized to 2 groups. Details about random sequence generation were not provided
Participants100 participants were included and assessed
InterventionsGroup A: participants were asked to drink 1.5 L of fluids per day for 5 days in addition to normal clinic diet; Group B: participants were asked to drink 3 L of fluids per day for 5 days in addition to normal clinic diet
OutcomesPDPH; severe PDPH defined as any headache that started within a few seconds to 10 minutes after mobilization and severe enough to make the patient spend the rest of the day lying in bed (≤ 10 minutes)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Diagnostic LP was performed on 100 age-matched, randomly allocated, neurological patients". No details about sequence generation were provided
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
High riskThere was no information on this item
Incomplete outcome data (attrition bias)
All outcomes
Low risk100 participants randomized and assessed
Selective reporting (reporting bias)Low riskThe intensity, nature, localization, and duration of PDPH. Symptoms were recorded only if they could be convincingly reproduced by a change of position and typically improved by bed rest

Ebinger 2004

MethodsParticipants 2-17 years of age who received diagnostic LP were openly randomized to 1 of 2 groups using a list of randomly assigned numbers
Participants111 neurological participants were included and assessed
InterventionsGroup A: bed rest for 24 hours. Group B: mobilization afterwards
OutcomesPDPH and any headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Those who consented were openly randomized to one of two treatment groups using a list of randomly assigned numbers that were made known only upon consent to study participation"
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome data "were recorded by the patient, his/her parents, or the nursing staff". "Patients discharged from the hospital were contacted by telephone.  Patients' complaints were assessed each day by the same person"
Incomplete outcome data (attrition bias)
All outcomes
Low risk

"A total of 111 patients were included"; "Data analysis on an intent-to-treat basis was performed"

No apparent missing outcome data

Selective reporting (reporting bias)Low risk"For the first 4 days following puncture, reports of positional headache, general headaches, backaches, nausea, or neck stiffness" "Complaints that began or became more severe following lumbar puncture and that were at least of moderate severity, affecting patients' general feeling of well-being were recorded"

Eldevik 1978

MethodsParticipants who received a lumbar myelography were randomly divided into 2 groups. Details about randomization procedure were not provided
Participants100 participants were included and assessed
InterventionsGroup A: participants received 1 L of 0.9% saline and 1 L of 0.5 glucose intravenously for the last 2 hours before myelography. Group B: participants did not receive any supplementary fluids
OutcomesPDPH and any headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Patients were randomly divided into two groups". No details on generation were provided
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Twenty-four and 48 hours after the study, they were interviewed and examined by one of the authors who did not know which patient received fluids"
Incomplete outcome data (attrition bias)
All outcomes
Low risk"One hundred patients were included in the study." 100 participants were randomized and assessed
Selective reporting (reporting bias)Low risk"Each patient was asked to describe side effects, specifically headaches, nausea, vomiting, back pain and dizziness"

Fassoulaki 1991

MethodsParticipants scheduled for transurethral resection of prostate under spinal anaesthesia were randomized to 1 of 2 groups. Details about randomization procedure were not provided
Participants69 participants were included and assessed
InterventionsGroup A: bed rest for 24 hours. Group B: mobilization after 8 hours
OutcomesPDPH, severe PDPH (when patient needed bed rest plus systemic analgesics)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Patients were randomly allocated to either early mobilization or to 24 hours bed rest ". No details on sequence generation were provided
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Each patient was asked blindly about incidence of any headaches 24, 48 and 72 hours postoperatively by one of the authors other than the anesthetist that had performed the subarachnoid anesthesia"
Incomplete outcome data (attrition bias)
All outcomes
Low risk"Sixty-nine patients gave their consent to participate in the study." 69 participants were randomized and assessed
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Handler 1982a

MethodsParticipants scheduled for diagnostic LP were randomized to 1 of 2 groups. Details about randomization procedure were not provided
Participants50 participants were randomized but only 44 were analyzed
InterventionsGroup A: 4 hours of prone bed rest following the procedure. Group B: 30 minutes of 30° head-down tilt followed by 3.5 hours of supine bed rest, following the procedure
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Fifty patients (27 female, 23 male) requiring diagnostic lumbar puncture, admitted as day cases, were randomly allocated to a trial group (four hours prone bed rest) or a control group (30 minutes 30° head-down tilt followed by three and a half hours supine bed rest) following the procedure". No details on sequence generation were provided.
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Low risk

Described as "prospective single blind trial"

"Patients were interviewed blindly by one observer at five hours and again at one week or by postal questionnaire. They were asked 'How do you feel?' and if any symptoms were reported they were asked to rate them on a three-point scale. No mention was made before the procedure of headache or any other symptom"

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk50 participants were randomized. "Forty-four patients were completely assessed; 6 were excluded from the study as they could not be contacted for review at one week". The group that these participants belonged to or the reasons for discontinuation were not clear
Selective reporting (reporting bias)High riskParticipants were asked 'How do you feel?' and if any symptoms were reported they were asked to rate them on a 3-point scale. Any headache, neck stiffness, back pain, nausea, or vomiting was recorded

Hilton-Jones 1982

MethodsParticipants admitted to neurological wards and scheduled for LP were randomized to 1 of 4 groups by drawing a card from a series of sealed envelopes
Participants76 participants were included and assessed
InterventionsGroup A: posture tilted and supine. Group B: posture tilted and prone. Group C: posture horizontal and supine. Group D: posture horizontal and prone
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Patients were randomly allocated to one of four groups by drawing a card from a series of sealed envelopes. Stratification by the three operators was performed prior to randomization"
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Low riskParticipants were asked whether they had developed any pain, discomfort, or any other problems after LP. Headache was not specifically mentioned by the questioner. "In an attempt to exclude bias by the person who had performed the LP, all questioning of the patients was performed by the senior nurse on the ward"
Incomplete outcome data (attrition bias)
All outcomes
Low risk76 participants were randomized and assessed
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Jensen 1987

MethodsParticipants scheduled for lumbar myelography were randomized to 1 of 2 groups. Details about randomization procedure were not provided
Participants81 participants were randomized but only 77 were analyzed
InterventionsGroup A: bed rest for 24 hours, the first 6 hours with elevated headboard. Group B: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskThere was no information on this item
Allocation concealment (selection bias)Low risk"Patients were randomized to two regimens (closed code)"
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"The headache was divided into three degrees by a physician who did not know what regimen the patients had followed"
Incomplete outcome data (attrition bias)
All outcomes
High risk81 participants were randomized (40 + 41), 3 + 1 losses to follow-up. 77 participants (37 + 40) analyzed
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Johannsson 1992

MethodsParticipants scheduled for LP were randomized to 1 of 2 groups. Details about randomization procedure were not provided
Participants52 participants were included and analyzed
InterventionsGroup A: bed rest for 4 hours. Group B: immediate mobilization after 30 minutes
OutcomesPDPH, severe PDPH
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described: "Patients were randomized by age and sex"
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
High risk"A week after the survey asked all active on creation of the position-dependent headache with relief of scheduling"
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear risk"Also asked about neck pain, neck stiffness, nausea, vomiting, tinnitus, photophobia, dizziness, double vision, and possibly other symptoms"

Macpherson 1983

MethodsParticipants referred to radiculography were randomized to 1 of 2 groups. Details about randomization procedure were not provided
Participants119 participants were included and assessed
InterventionsGroup A: bed rest after procedure. Group B: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described: '..random selection scheme recommended by Gore (1981)'
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Low risk'A radiographer, unaware into which group the patient had been placed, interviewed the patient and nursing staff at approximately 24 hours and 48 hours noting any complications'
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Macpherson 1984

MethodsParticipants who received iopamidol radiculography were randomly allocated into 2 groups. Details about randomization procedure were not provided
Participants200 participants were included and assessed
InterventionsGroup A: bed rest after procedure. Group B: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described: "..Following random allocation (Gore 1981) patients were then either confined to bed overnight (B) or allowed to remain ambulant (A) after the examination"
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk"A radiographer, unaware of the group to which the patient had been assigned, interviewed the patient and nursing staff approximately 24 and 48 hours after the procedure to collect information on any complications"
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Macpherson 1985

MethodsParticipants who received iopamidol myelography were randomly allocated into 2 groups. Details about the randomization procedure were not provided
Participants382 participants were included and assessed
InterventionsGroup A: bed rest after procedure; Group B: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described: "...Following random allocation (Gore, 1981) patients were then either confined to bed overnight (B) or allowed to remain ambulant (A) after the examination"
Allocation concealment (selection bias)Low riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
Low riskA radiographer, unaware of the group to which the patient had been assigned, interviewed the patient and nursing staff approximately 24 and 48 hours after the procedure to collect information on any complications
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Murata 2003

MethodsParticipants undergoing lumbar myelography were randomized in 1 of 2 groups. Details about the randomization procedure were not provided
Participants207 participants were included and randomized, but only 198 were assessed
InterventionsGroup A: bed rest for 20 hours without the head elevated. Group B: immediate mobilization
OutcomesPDPH
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"An observer, who did not know the ambulatory status of the patients, reviewed each patient after myelography and questioned them regarding headaches"
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot strict ITT analysis: "Nine patients (5 men and 4 women) in group B were excluded from the study because they could not maintain bed rest for 20 hours." The incidence of these figures on primary outcomes is low
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Robertson 1980

MethodsParticipants undergoing metrizamide lumbar myelography were randomized to 1 of 3 groups. Details about the randomization procedure were not provided
Participants90 participants were included and assessed
InterventionsGroup A: horizontal position and bed rest for 1-2 hours. Group B: horizontal position and strict bed rest for 1-2 hours (bathroom privileges were denied) + head elevation to 45°/30°. Group C: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described
Allocation concealment (selection bias)Unclear riskThere was no information about this item
Blinding of outcome assessment (detection bias)
All outcomes
High riskNot mentioned: "The patients were followed up by a neurologist and their symptoms were recorded"
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Smith 1980

MethodsParticipants scheduled for LP were randomized to 1 of 2 groups. Details about the randomization procedure were not provided
Participants50 participants were included and assessed
InterventionsGroup A: 30 minutes 30° head-down tilt followed by 3.75 hours of supine bed rest. Group B: 4 hours of supine bed rest
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described: "Fifty patients admitted for day case lumbar puncture were randomly allocated to a control group or a trial group"
Allocation concealment (selection bias)Low riskInformation retrieved by Sudlow 2002: The authors used opaque, numbered and sealed envelopes
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Patients were blindly assessed by one observer, 5 hours and again a week after the intervention, and were asked to rate any headache on a three point scale"
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskInsufficient information to permit judgement of 'high' or 'low' risk of bias

Teasdale 1983

MethodsParticipants scheduled for cervical myelography were randomized to 1 of 2 groups. Details about the randomization procedure were not provided
Participants120 participants were included and assessed
InterventionsGroup A: bed rest for 24 hours with back and head elevation for the first 6 hours. Group B: immediate mobilization
OutcomesAny headache after LP
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskMentioned but not described. Reference to Gore 1981
Allocation concealment (selection bias)High risk"Prior to the LP, randomized, consecutive numbers were allocated to each patient. Those receiving an even number were asked to lie supine in bed for 4 hours and were nursed in that position, while those receiving an odd number were advised to walk around at will"
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"A questionnaire concerning possible side effects was completed immediately after the myelogram by the examining radiologist and again at 24 and 48 hours by a radiographer who was unaware of the category into which the patient had been allocated"
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Tejavanija 2006

MethodsParticipants undergoing diagnostic LP were randomized to 1 of 2 groups by block randomization
Participants96 participants were eligible, but only 65 were included and assessed
InterventionsGroup A: 6 hour - supine recumbence. Group B: early ambulation (< 1 hour - supine recumbence)
OutcomesPDPH
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"After LP, patients were randomized to the standard group (6 hour-supine recumbence) or early ambulation (< 1 hour-supine recumbence) by block randomization"
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
High risk"The authors recorded associated symptoms of PDPH such as nausea, vomiting. Severity, pain scale and treatment were assessed". No information about blinding was provided
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Thornberry 1988

MethodsWomen that received subarachnoid anaesthesia for second- and third-stage procedures, excluding caesarean section, were randomized to 1 of 2 groups
Participants80 women were included and assessed.
InterventionsGroup A: 24 hours bed rest. Group B: 6 hours postspinal rest and later mobilization
OutcomesPDPH, severe PDPH (when the patient described it as such and was obviously distressed, or if it was debilitating, persistent, and associated with additional neurological symptoms such as neck stiffness, blurred vision, or tinnitus)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskInformation retrieved by Sudlow 2002: the authors used opaque, numbered and sealed envelopes
Allocation concealment (selection bias)Low riskInformation retrieved by Sudlow 2002: the authors used opaque, numbered and sealed envelopes
Blinding of outcome assessment (detection bias)
All outcomes
Low riskInformation retrieved by Sudlow 2002: blinding of outcome assessment: yes
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Vilming 1988

MethodsNeurological patients scheduled for LP were randomized to 1 of 2 groups by drawing sealed envelopes
Participants300 participants were included and assessed
InterventionsGroup A: bed rest for 6 hours. Group B: immediate mobilization
OutcomesPDPH; severe PDPH (postural headache that made the patient bedridden part of the day or entire day)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskBefore the study started, 300 forms were prepared, 150 for men and 150 for women. Half the forms were marked "ambulation" and half "bed rest". By drawing 1 of these forms the participants were randomly allocated to 1 of the 2 groups
Allocation concealment (selection bias)Low riskInformation retrieved by Sudlow 2002: "pre-labelled forms stratified by gender, with appropriate pre-allocation concealment"
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Four to 6 days after the LP each patient, on his own and without interference from any other person, answered on a written form whether he as a consequence of the LP had experienced (...). If the patient had experienced headache, further questions were posed by one of us, who did not know the patient's post-LP posture:..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Vimala 1998

  1. a

    LP: lumbar puncture; PDPH: post-dural puncture headache.

MethodsParticipants scheduled to LP for any reason were randomized to 1 of 2 groups by block randomization
Participants208 participants were included, but only 204 were assessed
InterventionsGroup A: bed rest for 24 hours; Group B: immediate mobilization
OutcomesPDPH; severe PDPH (described by the patient)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Patient were randomized in two groups (medical wards and neuro [neurological] wards) to either ambulation or bed rest using a block of four"
Allocation concealment (selection bias)Unclear riskThere was no information on this item
Blinding of outcome assessment (detection bias)
All outcomes
High risk"Patients were interviewed by a single investigator on days 0, 1, 2 and 7 on the presence and nature of headache and associated symptoms". Blinding was not mentioned
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo apparent missing outcome data
Selective reporting (reporting bias)Unclear riskThere was insufficient information to determine 'high' or 'low' risk of bias

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Carbaat 1981Non-randomized comparison of 24 hours of bed rest versus immediate mobilization
Gulati 1981Treatment allocation by alternation inadequately concealed. (Comparison of 24 hours bed rest versus immediate mobilization)
Hafer 1997aTreatment allocation by month of year of surgery inadequately concealed. (Comparison of 24 hours bed rest versus early mobilization)
Hallam 1993Non-randomized comparison of 24 hours bed rest versus early ambulation
Spriggs 1992Treatment allocation by odd/even numbers inadequately concealed. (Comparison of 4 hours of bed rest versus immediate mobilization)

Characteristics of ongoing studies [ordered by study ID]

Cucereanu 2010

Trial name or titleRestrictive versus liberal perioperative fluid administration in spinal anesthesia for arthroscopic surgery
MethodsControlled clinical trial between liberal and restrictive fluid administration in spinal anaesthesia for non-bleeding arthroscopic surgery analysing intra- and postoperative outcome
Participants217 American Society of Anesthesiologists 1-2 participants undergoing arthroscopic surgery under spinal anaesthesia
Interventionsgroup L (112 participants) received liberal fluid administration (1900 ± 300 mL) and group R (105 participants) received
10 mL/kg crystalloids
OutcomesArterial pressure, heart rate, the need for ephedrine infusion, haemodynamic impact after tourniquet release and postoperative incidents such as headache, the need for bladder catheterization, infections
Starting dateNo information about starting date
Contact information 
NotesPublished on Abstracts of the XXIX Annual European Society of Regional Anaesthesia (ESRA) Congress 2010

Ancillary