Zorrilla-Vaca Andres, Makkar Jeetinder Kaur
Faculty of Health, Universidad del Valle, School of Medicine, Cali, Colombia; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
Pain fellow, Department of Anesthesia, University of Manitoba, Winnipeg, Canada.
Pain Physician. 2017 May;20(4):E521-E529.
Post-dural puncture headache (PDPH) is a relatively common complication of lumbar punctures for spinal anesthesia or neurologic diagnosis. For many years, a high number of drugs has been evaluated to treat PDPH, yet there is a minority to prevent this complication. The lateral decubitus position instead of sitting position during lumbar puncture has become an interesting approach because of its feasibility and patient satisfaction.
In this meta-analysis we hypothesized that lateral decubitus position is an effective manner to prophylactically reduce the incidence of PDPH.
This meta-analysis pooled all data published in randomized controlled trials (RCTs) examining the impact of position (sitting versus lateral decubitus) during lumbar puncture and the incidence of PDPH.
This work was performed at Universidad del Valle, in Cali, Colombia, in collaboration with the Department of Anesthesiology at The Johns Hopkins Hospital.
Our group searched in PubMed, EMBASE, Cochrane Library and Google Scholar for relevant RCTs, dating from 1990 to July 2016, that compared the sitting and lateral decubitus position with regards to the incidence of PDPH in adult patients (age > 18 years) undergoing lumbar puncture for spinal anesthesia or neurologic diagnosis.
Literature search identified 7 eligible RCTs (6 on spinal anesthesia and only one on neurologic diagnosis) with 1,101 patients, of which 557 had lumbar punctures in lateral decubitus position and 544 in sitting position. Only 3 (out of 7) RCTs favored the lateral decubitus position to significantly reduce the PDPH. Meta-analysis showed that the lateral decubitus position was associated with a significant reduction of the incidence of PDPH (risk ratio [RR] = 0.61, 95% confidence interval [CI] = 0.44-0.86, P = 0.004, I2 = 25%, P for heterogeneity = 0.24) compared with the sitting position. Subgroup analysis showed that lateral decubitus position is also associated with reduction of PDPH in spinal anesthesia (RR = 0.69, 95% CI = 0.50-0.95, I2 = 0%, P for heterogeneity = 0.42). We found no statistically significant association between lateral decubitus position and successful placement of spinal needle at first attempt (RR = 1.00, 95% CI = 0.92-1.09, P = 0.94, I2 = 73%, P for heterogeneity = 0.01). There was no evidence of publication bias in our analyses (Egger's bias = -0.05, P = 0.96).
The low number of RCTs might be an important limitation on our results.
Our results indicate that lateral decubitus position during lumbar puncture seems to be a good alternative for preventing PDPH. Further research should focus on the new prophylactic alternatives to reduce the incidence of PDPH.
腰穿后头痛（PDPH）是脊髓麻醉或神经诊断性腰穿相对常见的并发症。多年来，已有大量药物被评估用于治疗PDPH，但预防该并发症的药物较少。由于其可行性和患者满意度，腰穿时采用侧卧位而非坐位已成为一种有趣的方法。
在本荟萃分析中，我们假设侧卧位是预防性降低PDPH发生率的有效方式。
本荟萃分析汇总了随机对照试验（RCT）中发表的所有数据，这些试验研究了腰穿时体位（坐位与侧卧位）对PDPH发生率的影响。
本研究在哥伦比亚卡利的瓦尔大学进行，并与约翰霍普金斯医院麻醉科合作。
我们的研究小组在PubMed、EMBASE、Cochrane图书馆和谷歌学术中搜索了1990年至2016年7月期间比较坐位和侧卧位对接受脊髓麻醉或神经诊断性腰穿的成年患者（年龄>18岁）PDPH发生率影响的相关RCT。
文献检索确定了7项符合条件的RCT（6项关于脊髓麻醉，仅1项关于神经诊断），共1101例患者，其中557例采用侧卧位腰穿，544例采用坐位腰穿。7项RCT中只有3项支持侧卧位能显著降低PDPH。荟萃分析表明，与坐位相比，侧卧位与PDPH发生率显著降低相关（风险比[RR]=0.61，95%置信区间[CI]=0.44-0.86，P=0.004，I²=25%，异质性P=0.24）。亚组分析表明，侧卧位在脊髓麻醉中也与PDPH降低相关（RR=0.69，95%CI=0.50-0.95，I²=0%，异质性P=0.42）。我们发现侧卧位与首次尝试成功置入脊髓穿刺针之间无统计学显著关联（RR=1.00，95%CI=0.92-1.09，P=0.94，I²=73%，异质性P=0.01）。我们的分析中没有发表偏倚的证据（Egger偏倚=-0.05，P=0.96）。
RCT数量较少可能是我们研究结果的一个重要局限性。
我们的结果表明，腰穿时侧卧位似乎是预防PDPH的一个良好选择。进一步的研究应聚焦于新的预防方法以降低PDPH的发生率。
