title: Prevention of post-dural puncture headache in parturients: a systematic review and meta-analysis.
abstract: Post-dural puncture headaches (PDPHs) present an important clinical problem. We assessed methods to decrease accidental dural punctures (ADPs) and interventions to reduce PDPH following ADP. Multiple electronic databases were searched for randomised clinical trials (RCTs) of parturients having labour epidurals, in which the studied intervention could plausibly affect ADP or PDPH, and the incidence of at least one of these was recorded. Forty RCTs (n = 11,536 epidural insertions) were included, studying combined spinal-epidurals (CSEs), loss of resistance medium, prophylactic epidural blood patches, needle bevel orientation, ultrasound-guided insertion, epidural morphine, Special Sprotte needles, acoustic-guided insertion, administration of cosyntropin, and continuous spinal analgesia. The RCTs for CSE, loss of resistance medium, and prophylactic epidural blood patches were meta-analysed. Five methods reduced PDPH: prophylactic epidural blood patch {four trials, median quality score = 2, risk difference = -0.48 [95% confidence interval (CI): -0.88 to -0.086]}, lateral positioning of the epidural needle bevel upon insertion (one trial, quality score = 1), Special Sprotte needles [one trial, quality score = 5, risk difference = -0.44 (95% CI: -0.67 to -0.21)], epidural morphine [one trial, quality score = 4, risk difference = -0.36 (95% CI -0.59 to -0.13)], and cosyntropin [one trial, quality score = 5, risk difference = -0.36 (95% CI -0.55 to -0.16)]. Several methods potentially reduce PDPH. Special Sprotte needles, epidural morphine, and cosyntropin are thus far each supported by a single, albeit good quality trial. Prophylactic blood patches are supported by three trials, but these had flawed methodology. Mostly, trials were of limited quality, and further well-conducted, large studies are needed.
authors.affiliation: Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, St Joseph's Health Care London, London, ON, Canada. carol.bradbury2@uhcw.nhs.uk
authors.forename: C L
authors.initials: CL
authors.lastname: Bradbury
authors.forename: S I
authors.initials: SI
authors.lastname: Singh
authors.forename: S R
authors.initials: SR
authors.lastname: Badder
authors.forename: L J
authors.initials: LJ
authors.lastname: Wakely
authors.forename: P M
authors.initials: PM
authors.lastname: Jones
mesh_terms: D015360:Analgesia, Epidural / Q000009:adverse effects*; D016362:Analgesia, Obstetrical / Q000009:adverse effects*; D017217:Blood Patch, Epidural; D005260:Female; D006801:Humans; D051299:Post-Dural Puncture Headache / Q000517:prevention & control*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D018084:Ultrasonography, Interventional