Efficacy and Safety of Prophylactic Intrathecal or Epidural Normal Saline for Preventing Post-Dural Puncture Headache After Dural Puncture: A Meta-Analysis and Systematic Review.

Background: Post-dural puncture headache (PDPH) is the most common and troublesome complication following iatrogenic puncture of the dura. This study aims to evaluate the efficacy and safety of intrathecal or epidural saline injection to prevent PDPH.

Methods: A systematic literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by a manual search of reference lists of related articles. Studies were eligible if they compared intrathecal or epidural injection or continuous saline infusion with no intervention in patients with accidental or intentional dural puncture. Trials reporting PDPH outcomes were considered eligible. The type of surgeries and patient populations were not restricted. Risk ratios (RRs) with 95% confidence intervals (CI) were calculated for the risk estimate of dichotomous outcomes. The funnel plot, Egger, and Begg tests were performed to assess the publication bias.

Results: We identified 13 studies involving 1589 patients, revealing a high publication bias. Normal saline injection reduced the incidence of PDPH (RR=0.57, 95% CI: 0.43 to 0.74, P<0.0001, I=66%, P-heterogeneity=0.0004) and the requirement for an epidural blood patch (RR=0.37, 95% CI: 0.25 to 0.54, P<0.00001, I=29%, P-heterogeneity=0.23).

Conclusion: Saline administration after dural puncture appears to be a promising option for preventing PDPH. However, heterogeneity among the studies and publication bias with positive results limits the available evidence. Therefore, further large-scale randomized controlled trials are needed to confirm our findings.

Register: CRD42022342509.