Recumbency Following Spinal Tap
Abstract & Commentary
Source: Thoennissen J, et al. Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis. CMAJ. 2001;165:1311-1316.
Is even short-term bed rest, for 30 minutes or so, beneficial in preventing headache postcervical or lumbar puncture? A MEDLINE literature search undertaken by the American Academy of Neurology showed no relation between duration of recumbency and the occurrence of headache postlumbar puncture (Evans RW, et al. Neurology. 2000;55:909-914). A more thorough review encompassing the English and non-English literature now shows similar negative results for both lumbar and cervical spinal tap.
EMBASE, MEDLINE, Pascal Biomed, Current Contents, PsycINFO, the Cochrane Controlled Trial Register, textbooks, and references of chosen articles were searched for studies examining the effect of recumbency on headache incidence following spinal tap. Sixteen randomized, controlled trials were found which studied no or short-term (up to 8 hours) bed rest encompassing 1083 patients, or longer bed rest (up to 24 hours) in 1128 patients. Trials were stratified according to reason for puncture: anesthesia (n = 5), myelography (n = 6), or diagnostic purposes (n = 5).
In a single myelography trial, benefit was shown for immediate mobilization whereas in another myelography trial, as well as in an anesthesia trial, headache was more frequent with prolonged bed rest. When data in each subgroup were pooled, no benefit for prolonged or short-term bed rest over immediate mobilization was shown in any of the groups. This is the most comprehensive review to date and clearly indicates that headaches following spinal tap are not affected by bed rest.
Commentary
Postlumbar puncture headaches are best prevented by using thin needles inserted parallel to the long fibers of the dura mater. Caffeine is safe and beneficial once the headache has begun. Blood patch is warranted for intractable headache lasting a week or longer.
Following accidental dural puncture, 10 cc of normal saline injected into the subarachnoid space may reduce the incidence of headache and the need for blood patch (Reg Anesth Pain Med. 2001;26:293-295). Among 28 patients with a dural tear who underwent this procedure, 22 were performed "immediately" through the epidural needle and 6 had intrathecal catheters placed through the epidural needle, with saline injected prior to catheter removal. Twenty-six patients with dural tear who did not receive saline served as controls. Seven (32%) of immediately saline-treated patients developed headache, of which 1 needed blood patch, vs. 16 (62%) and 9, respectively, of controls. None of the 6 intrathecal catheter- treated patients experienced headaches vs. 3 controls, 1 of whom required blood patch. Intrathecal normal saline infusion appears beneficial to prevent headache after dural tear. —Michael Rubin
Dr. Rubin, Associate Professor of Clinical Neurology, New York Presbyterian Hospital-Cornell Campus, is Assistant Editor of Neurology Alert.
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