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Three Part Question

In [patients undergoing diagnostic lumbar puncture] does [a period of bed rest] reduce [the incidence of headache or other complications]?

Clinical Scenario

A 27 year old woman attends the emergency department with a two day history of headache with mild neck stiffness. She appears otherwise well. Her CT scan is normal and you feel that if a lumbar puncture is normal she can be discharged. The duty physician advises you that the patient will require four hours bed rest after the lumbar puncture. The duty anaesthetist overhears and says that the patient will be able to go home immediately. You wonder if either of them is right.

Search Strategy

Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, ACP journal club, Database of Abstracts of Reviews of Effects (DARE), Cochrane Controlled Trial Register up to 04/07 using the OVID interface.
{[exp spinal puncture OR (spinal adj5 tap).af OR (spinal adj5 puncture).af OR (spinal adj5 injection).af OR (lumbar adj5 tap).af OR (lumbar adj5 puncture).af OR (lumbar adj5 injection).af OR (dural adj5 tap).af OR (dural adj5 puncture).af OR (dural adj5 injection).af] AND [exp posture OR posture.af OR supine.af OR flat.af OR immobilis$.af OR recumben$.af OR (bed adj5 rest).af] AND [exp headache OR exp headache disorders OR headache.af]} LIMIT to human AND English Language.

Search Outcome

238 papers were found. One Cochrane review was found which looked at data from 14 papers and mentioned 8 other papers that had been excluded. Another systematic review (Thoennissen, 2001) included 11 papers that were in the Cochrane review, 2 papers that were excluded by the Cochrane review and a further 3 papers not mentioned in the Cochrane review. In addition 2 papers were found that had been published after the systematic reviews. One relevant paper was found from before 2001 that was not included in either of the review papers and a further controlled trial that was excluded by the Cochrane review (not randomised) has been listed here.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Carbaat PA and van Crevel H, 1981, Netherlands	100 neurological patients undergoing LP all done by same investigator with 18G needle. 50 ambulant, 50-24 hour bed rest.	Controlled Trial	Incidence of headache	Ambulant- 38% bed rest- 36% (NS)	p not stated Small numbers. Not randomised.
Vimala J et al, 1998, Country not stated but ? India	204 patients undergoing diagnostic LP. 100 ambulant 104 24 hour bed rest.	PRCT	Headache considered severe	Ambulant 57% Bed rest 12% (p=0.02)	Randomisation method unclear but possibly highly flawed Discrepancies in needle size and operator experience
			Incidence of headache	Ambulant 15% (95% CI 12-22%) bed rest 18% (95%CI 8-22%)
Sudlow, C; Warlow, C 2001	Review of randomised trials comparing either bedrest versus immediate mobilisation or a shorter period of bedrest versus a longer period following lumbar puncture.	1254 patients from 11 trials reviewed had data available comparing either bedrest with immediate mobilisation or bedrest for a shorter period of time versus a longer period of time with the primary outcome of headache.	Presence of headache following dural puncture.	319/857 (37%) of patients with bedrest had headache vs. 294/836 (35%) of patients with immediate mobilisation
Thoennissen, J; Herkner, H; Lang, W; et al 2001 Austria	Systematic review of 16 randomised controlled trials involving 2211 patients who were assigned immediate mobilisation or a short period of bed rest versus a longer period of bedrest.	1083 patients were assigned to immediate mobilisation or a short period of bedrest and 1128 patients were assigned to a prolonged period of bedrest.	Presence of headache following dural puncture.	392/1128 (35%) of patients with prolonged bedrest had headache vs. 337/1083 (31%) of patients with early mobilisation.
Ebinger, F; Kosel, C; Pietz, J; Rating, D 2004 Germany	Patients aged between 2 & 17y who underwent diagnostic lumbar puncture at one of 5 hospitals over an eight month period were eligible. Patients who had idiopathic intracranial hypertension, those receiving intrathecal medication and those who were considered too ill to mobilise were excluded. Patients were asked daily about their symptoms for 4 days following the procedure.	111 patients were recruited. The patients were randomised to be free to mobilise immediately following the procedure or to maintain strict bed rest for 24h.	Headache following procedure	23/59 (39%) of patients who had a period of bed rest vs. 11/52 (21%) of patients who were allowed to mobilise	No standardisation of lumbar puncture procedure. Assessor not blinded to intervention group.
Tejavanija, S; Sithinamsuwan, P; Sithinamsuwan, N; Nidhinandana, S; Suwantamee, J 2006 Thailand	Patients over the age of 14y undergoing lumbar puncture over a 13 month period at one hospital in Thailand. Exclusion criteria included technically difficult procedures and patients with very severe headaches.	Patients were randomised to either early ambulation (<1h) or 6h in a supine position. Patients were followed up for 7 days in hospital or by telephone if discharged.	Presence of PDP Headache	6/33 (18%) patients who remained in supine position vs. 5/32 (15.6%) of patients who were randomised to early ambulation.	Excluded patients with very severe headaches. Only included Post-Dural Puncture Headaches, defined as bilateral headaches, worse on standing and improved on lying down.

Comment(s)

Two systematic reviews and three individual studies looking at this question do not find any benefit for prolonged bed rest following dural puncture. In fact there was a non-significant tendency for prolonged bed rest to increase the incidence of headaches. The included studies deal with patients who are having dural puncture for different reasons, broadly speaking, diagnostic tests, anaesthetic and myelography. Not only did these patients have different underlying pathologies but they are very heterogenous groups, some being patients undergoing gynaecological procedures while others were being investigated for suspected meningitis. Despite these facts there was no obvious benefit to prolonged bed rest in any of the groups who were looked at. Publication bias is unlikely to be an issue in this search as one would expect studies showing clear evidence of a benefit of the intervention to be published preferentially.

Editor Comment

Earlier published version: Emerg. Med. J., Sep 2002; 19: 432 - 433.

Clinical Bottom Line

Bed rest does not decrease the incidence of post lumbar puncture headache.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Carbaat PA, van Crevel H. Lumbar Puncture Headache: controlled study on the preventive effect of 24 hours' bed rest. Lancet 1981:2(8256)Nov;1133-1136.
2. Vimala J, Peter JV, Jeyaseelan L, et al. Post lumbar puncture headache: Is bed rest essential? J Assoc Physicians India 1998:46(11);930-932.
3. Sudlow, C; Warlow, C Posture and fluids for preventing post-dural puncture headache (Review) Cochrane Database of Systematic Reviews 2001, Issue 2 Art No.: CD001790
4. Thoennissen, J; Herkner, H; Lang, W; et al Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta-analysis Canadian Medical Association Journal 2001; 165 (10): 1311-6
5. Ebinger, F; Kosel, C; Pietz, J; Rating, D Strict bed rest following lumbar puncture in children and adolescents is of no benefit Neurology 2004; 62: 1003-5
6. Tejavanija, S; Sithinamsuwan, P; Sithinamsuwan, N; Nidhinandana, S; Suwantamee, J Comparison of Prevalence of Post-Dural Puncture Headache between Six hour- Supine Recumbence and Early Ambulation after Lumbar Puncture in Thai Patients: A Randomized Controlled Study J Med Assoc Thai 2006; 89(6): 814-20