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Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. Review Free to read. PDPH is defined as any headache occurring after a lumbar puncture that worsens within 15 minutes of sitting or standing and is relieved within 15 minutes of the patient lying down. Researchers have suggested many types of interventions to help prevent PDPH. It has been suggested that aspects such as needle tip and gauge can be modified to decrease the incidence of PDPH.

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Several theories have identified the leakage of cerebrospinal fluid CSF through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication.

Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown.

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. Two different review authors independently assessed risk of bias using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.

We resolved any disagreements by consensus. We included 24 trials with participants in this updated review. The number of participants in each trial varied from 39 to Most of the included studies compared bed rest versus immediate mobilization, and only two assessed the effects of supplementary fluids versus no supplementation. We judged the overall risk of bias of the included studies as low to unclear.

The overall quality of evidence was low to moderate, downgraded because of the risk of bias assessment in most cases. The primary outcome in our review was the presence of PDPH. There was low quality evidence for an absence of benefits associated with bed rest compared with immediate mobilization on the incidence of severe PDPH risk ratio RR 0.

An analysis restricted to the most methodologically rigorous trials i. There was low quality evidence for an absence of benefits associated with fluid supplementation on the incidence of severe PDPH RR 0.

We did not expect other adverse events and did not assess them in this review. Since the previous version of this review, we found one new study for inclusion, but the conclusion remains unchanged. We considered the quality of the evidence for most of the outcomes assessed in this review to be low to moderate.

As identified studies had shortcomings on aspects related to randomization and blinding of outcome assessment, we therefore downgraded the quality of the evidence. In general, there was no evidence suggesting that routine bed rest after dural puncture is beneficial for the prevention of PDPH onset. The role of fluid supplementation in the prevention of PDPH remains unclear. Body position and intake of fluids for preventing headache after a lumbar puncture.

A lumbar puncture is a medical procedure performed with a needle and syringe used to take a sample of cerebrospinal fluid or to inject medications. This can be made worse by movement, sitting or standing, and can be relieved by lying down.

PDPH limits people's mobility and daily activities, as well as causing unplanned expenses for both the patient and the health institution. Doctors sometimes advise their patients to remain in bed after a lumbar puncture and to drink a lot to prevent PDPH. This is an update of the original review published in We found one new study in a search of the published literature in February This review includes 24 studies with participants.

We compared different types of bed rest and extra fluids to see if they prevented PDPH after a lumbar puncture. We found low to moderate quality evidence that bed rest does not prevent the onset of headaches after lumbar puncture, regardless of the duration of rest or the body or head positions assumed by the patient.

Furthermore, bed rest probably increases the chances of having PDPH. We found few data on the usefulness of extra fluids, which did not seem to prevent PDPH. We believe that these practices should no longer be routinely recommended to patients for the prevention of headaches after lumbar puncture since there is no evidence supporting them. 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 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 See a glossary of terms in Appendix 1. During anesthetic procedures for example epidural anesthesia , PDPH is most commonly caused by an unintentional dural puncture Thew ; Turnbull 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 Reported risk of inadvertent dural puncture placement during epidural anesthesia in women ranges from 0.

A significant number of mothers cannot provide adequate care for their newborn because of the headache Sprigge 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 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 , 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 hemorrhage should be ruled out first Turnbull Once PDPH is diagnosed, the initial treatment involves conservative measures such as bed rest and analgesics.

Severe PDPH may respond to some therapeutic drugs and administration of an epidural blood patch Boonmak ; Lavi 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 Although the effectiveness of resting for symptom relief is well known, it is debatable whether bed rest prevents the development of symptoms Davignon 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 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 liters per day for five days is appropriate Ahmed Despite lack of evidence, Vanzetta et al. Ninety per cent of centers interviewed reported implementing it to prevent the onset of headache Vanzetta 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.

As CSF leakage is thought to be fundamental in the development of PDPH, 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. By this mechanism, hydration may prevent the development of PDPH.

Lumbar puncture is a common clinical practice despite its potential adverse effects Evans ; Grande The morbidity associated with CSF loss, besides PDPH, includes peripartum seizures, cranial subdural hematomas, and subdural fluid collection Arendt PDPH may be the first step in a chain of adverse events that could be avoided by following a series of simple recommendations Janssens 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 hospitalizations van Kooten A Cochrane review on strategies to prevent PDPH included published and unpublished literature up to the year Sudlow It is imperative to update these results in order to generate relevant recommendations for consumers, patients, and health practitioners.

Studies that recruited males and females of all ages who had undergone lumbar puncture for medical reasons therapeutic or diagnostic. The studies on participants undergoing lumbar puncture must have assessed one of the following interventions:. We assessed the presence of severe PDPH using the definition used in each study, which could be based on specific features for example duration of PDPH , a visual analogue score VAS , or other criteria, such as need of specialized treatments to relieve the headache for example 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. We applied no language restrictions. We handsearched reference lists from retrieved studies as well as information from the World Health Organization International Clinical Trials Registry platform www.

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 The review authors evaluated titles and abstracts of all identified studies to determine if they fulfilled the inclusion criteria.

We resolved 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. We recorded reasons for exclusion of potential studies 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 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 We considered five domains sequence generation, allocation concealment, blinding in outcome assessment, incomplete outcome data, and selective reporting bias ; we classified each one of them 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. We used the number needed to treat for an additional harmful outcome NNTH statistic as an absolute measure of harm. We retrieved levels of attrition data when available. We assessed heterogeneity of effect sizes by means of the I 2 statistic.

We carried out statistical analysis using Review Manager 5 software RevMan For included studies that provided the necessary data, we planned to assess the subgroup analyses detailed below. However, due to scarcity of data, we did not perform analyses 2 to We planned to perform sensitivity analyses by excluding any study with high or unclear risk of bias in any of the subgroups detailed below:.

The GRADE system assesses the quality of evidence based on the extent to which users can be confident that an association reflects the item being evaluated Guyatt Assessment of the quality of evidence included risk of bias, heterogeneity, directness of the evidence, risk of publication bias, and precision of effect estimates, among other issues Guyatt ; Guyatt a ; Guyatt b ; Guyatt c ; Guyatt d ; Guyatt e ; Guyatt f ; Guyatt g.

Since publication of the previous version of this review, we identified four studies for possible inclusion Figure 1.

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Posture and fluids for preventing post‐dural puncture headache

Several theories have identified the leakage of cerebrospinal fluid CSF through the hole in the dura as a cause of this side effect. It is therefore necessary to take preventive measures to avoid this complication. Prolonged bed rest has been used to treat PDPH once it has started, but it is unknown whether prolonged bed rest can also be used to prevent it. Similarly, the value of administering fluids additional to those of normal dietary intake to restore the loss of CSF produced by the puncture is unknown. 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.

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Needle gauge and tip designs for preventing post-dural puncture headache (PDPH).

Important User Information: Remote access to EBSCO's databases is permitted to patrons of subscribing institutions accessing from remote locations for personal, non-commercial use. However, remote access to EBSCO's databases from non-subscribing institutions is not allowed if the purpose of the use is for commercial gain through cost reduction or avoidance for a non-subscribing institution. Feb, Vol. Abstract: The intracranial hypotension syndrome IHS is a disorder caused by brain descent due to a CSF leak resulting from diagnostic, therapeutic or spontaneous lesions.

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Intracranial hypotension syndrome: A post dural puncture headache?

Intracranial hypotension syndrome: A post dural puncture headache? Corresponding author at : Calle 48 No apto torre 7. The intracranial hypotension syndrome IHS is a disorder caused by brain descent due to a CSF leak resulting from diagnostic, therapeutic or spontaneous lesions. The pathophysiology, the clinical and the therapeutic approach are similar as in post dural puncture headache, the latter being considered a mild form of IHS.

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