Posture and fluids for preventing post‐dural puncture headache

Ingrid Arevalo-Rodriguez; Agustín Ciapponi; Marta Roqué-Figuls; Luis Muñoz; Xavier Bonfill Cosp

doi:10.1002/14651858.CD009199.pub3

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Figure 4

Funnel plot of comparison: 1 Bed rest versus ambulation, outcome: 1.1 Post‐dural puncture headache.

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Figure 5

Forest plot for reason for puncture: bed rest versus ambulation, outcome: 2.1 Post‐dural puncture headache.

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Analysis 1.1

Comparison 1: Bed rest versus immediate ambulation, Outcome 1: PDPH

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Analysis 1.2

Comparison 1: Bed rest versus immediate ambulation, Outcome 2: Severe PDPH

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Analysis 1.3

Comparison 1: Bed rest versus immediate ambulation, Outcome 3: Any headache

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Analysis 2.1

Comparison 2: Reason for puncture: bed rest versus immediate ambulation, Outcome 1: PDPH

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Analysis 2.2

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

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Analysis 2.3

Comparison 2: Reason for puncture: bed rest versus immediate ambulation, Outcome 3: Any headache

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Analysis 3.1

Comparison 3: Supine versus prone, Outcome 1: Any headache

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Analysis 4.1

Comparison 4: Supine versus supine with head tilt, Outcome 1: Any headache

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Analysis 5.1

Comparison 5: Fluids versus less or no fluids, Outcome 1: Any headache

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Analysis 6.1

Comparison 6: Sensitivity analysis/low risk of bias: bed rest versus ambulation, Outcome 1: PDPH

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Summary of findings 1. Bed rest versus ambulation for preventing post‐dural puncture headache

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)
Bed rest versus ambulation for preventing post‐dural puncture headache
Patient or population: Participants undergoing lumbar puncture Intervention: Bed rest Comparison: Ambulation
	Assumed risk	Corresponding risk
	Ambulation	Bed rest
Post‐dural puncture headache Reported by participant Follow‐up: 0 to 15 days	205 per 1000	254 per 1000 (213 to 303)	RR 1.24 (1.04 to 1.48)	1519 (12 studies)	⊕⊕⊕⊝ moderate¹
Severe post‐dural puncture headache Reported by participant Follow‐up: 0 to 15 days	107 per 1000	105 per 1000 (73 to 151)	RR 0.98 (0.68 to 1.41)	1568 (9 studies)	⊕⊕⊝⊝ low²
Any headache Reported by participant Follow‐up: 0 to 15 days	287 per 1000	333 per 1000 (293 to 379)	RR 1.16 (1.02 to 1.32)	2477 (18 studies)	⊕⊕⊕⊝ moderate³
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.
¹ Downgraded (‐1) due to unclear risk of bias related to allocation concealment (9 studies), as well as high risk of bias in blinding of outcome assessment (6 studies). ² Downgraded (‐1) due to unclear risk of bias related to allocation concealment (5 studies), as well as high risk of bias in blinding of outcome assessment (2 studies), and (‐1) due to imprecision since the 95% CI 0.68 to 1.41 could lead to opposite recommendations. ³ Downgraded (‐1) due to unclear risk of bias related to allocation concealment (12 studies), as well as high risk of bias in blinding of outcome assessment (7 studies).

Summary of findings 1. Bed rest versus ambulation for preventing post‐dural puncture headache

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Comparison 1. Bed rest versus immediate ambulation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 PDPH Show forest plot	12	1519	Risk Ratio (M‐H, Random, 95% CI)	1.24 [1.04, 1.48]

1.2 Severe PDPH Show forest plot	9	1568	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.68, 1.41]

1.3 Any headache Show forest plot	18	2477	Risk Ratio (M‐H, Random, 95% CI)	1.16 [1.02, 1.32]

Comparison 1. Bed rest versus immediate ambulation

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Comparison 2. Reason for puncture: bed rest versus immediate ambulation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 PDPH Show forest plot	12	1519	Risk Ratio (M‐H, Random, 95% CI)	1.24 [1.04, 1.48]

2.1.1 Diagnostic	6	723	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.90, 1.37]
2.1.2 Myelography	1	207	Risk Ratio (M‐H, Random, 95% CI)	1.48 [0.67, 3.27]
2.1.3 Anesthesia	4	381	Risk Ratio (M‐H, Random, 95% CI)	1.82 [1.19, 2.78]
2.1.4 Mixed	1	208	Risk Ratio (M‐H, Random, 95% CI)	1.27 [0.68, 2.35]
2.2 Severe PDPH Show forest plot	9	1568	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.68, 1.41]

2.2.1 Diagnostic	3	509	Risk Ratio (M‐H, Random, 95% CI)	0.93 [0.62, 1.38]
2.2.2 Myelography	2	582	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.59, 1.60]
2.2.3 Anesthesia	3	269	Risk Ratio (M‐H, Random, 95% CI)	2.45 [0.89, 6.72]
2.2.4 Mixed	1	208	Risk Ratio (M‐H, Random, 95% CI)	0.25 [0.05, 1.15]
2.3 Any headache Show forest plot	18	2477	Risk Ratio (M‐H, Random, 95% CI)	1.16 [1.02, 1.32]

2.3.1 Diagnostic	6	723	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.94, 1.40]
2.3.2 Myelography	7	1165	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.89, 1.26]
2.3.3 Anesthesia	4	381	Risk Ratio (M‐H, Random, 95% CI)	1.85 [1.27, 2.71]
2.3.4 Mixed	1	208	Risk Ratio (M‐H, Random, 95% CI)	1.27 [0.68, 2.35]

Comparison 2. Reason for puncture: bed rest versus immediate ambulation

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Comparison 3. Supine versus prone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Any headache Show forest plot	3	239	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.68, 1.37]

Comparison 3. Supine versus prone

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Comparison 4. Supine versus supine with head tilt

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Any headache Show forest plot	2	87	Risk Ratio (M‐H, Random, 95% CI)	1.72 [1.10, 2.69]

Comparison 4. Supine versus supine with head tilt

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Comparison 5. Fluids versus less or no fluids

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Any headache Show forest plot	2	200	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.66, 1.34]

Comparison 5. Fluids versus less or no fluids

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Comparison 6. Sensitivity analysis/low risk of bias: bed rest versus ambulation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 PDPH Show forest plot	2	380	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.90, 1.54]

Comparison 6. Sensitivity analysis/low risk of bias: bed rest versus ambulation

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