Abstract
Background
Lumbar puncture (LP) is a common diagnostic procedure in the emergency department (ED). Post-dural puncture headache (PDPH) is the most frequent complication following LP. Despite evidence suggesting that strict bed rest does not prevent PDPH, patients in Taiwan are often required to remain in a supine position for 6 to 8 hours post-LP, leading to prolonged ED stays. This study aims to evaluate the impact of strict bed rest on the incidence of PDPH and ED length of stay (LOS).
Methods
A retrospective cohort study was conducted at a medical center in central Taiwan, involving all adult ED patients who underwent LP from September 1, 2023, to March 31, 2024. Emergency specialists determined the need for strict bed rest based on individual patient conditions. Nurse practitioners recorded the occurrence of PDPH and ED LOS. Patients with incomplete data were excluded.
Results
Out of 76,691 adult ED patients, 143 patients underwent LP, with 141 patients included in the final analysis. Among 68 assessable patients, 52 patients did not rest supine and 16 patients did, showing no significant difference in PDPH occurrence (p = 0.634). Overall, 55 patients did not rest supine, and 86 patients did, with significant differences in ED LOS: 9 hours for non-supine rest versus 19 hours for supine rest (p < 0.001).
Conclusion
Reducing routine post-LP bed rest does not increase the risk of PDPH and might reduce LOS in the ED.
Keywords: emergency department length of stay, lumbar puncture, post-dural puncture headache
Introduction
Traditionally, the lumbar puncture (LP) is a commonly performed diagnostic procedure in the emergency department (ED). The most frequent complication following the LP is post-dural puncture headache (PDPH), which is typically caused by cerebrospinal fluid (CSF) leaking from the puncture hole.1 Excessive loss of CSF leading to low intracranial pressure is considered a possible mechanism for the development of PDPH.2,3 Traditionally, the risk factors for PDPH after LP include young age, female gender, obstetric patients, larger needle size, use of cutting needles, multiple dural punctures, and not resting in a supine position.4-6
Historically, patients who underwent LP were recommended to remain in bed for a certain period to prevent the occurrence of PDPH. In 1902, Sicard suggested that such patients should rest in bed for 24 to 48 hours.7 In 1974, Jones proposed that at least 6 hours of bed rest was necessary to prevent PDPH, which became the guideline for many years.8 Subsequent studies have suggested that bed rest after LP can prevent PDPH.9,10 However, current studies indicate that strict bed rest does not prevent the occurrence of PDPH and may even increase the risk of deep vein thrombosis due to prolonged immobility.7,11-14 Despite this, patients in most hospitals in Taiwan and other Asian countries are still required to remain in a supine position for 6 to 8 hours post-LP.12,13,15,16
Consequently, patients undergoing LP in most EDs in Taiwan must stay supine for at least 8 to 10 hours. This also implies that the already overcrowded EDs could become even more congested. Additionally, patients undergoing LP may spend more time in overcrowded EDs, thereby facing increased stress. However, there appears to be no research investigating whether routine bed rest for patients who have undergone LP significantly increases the ED length of stay (LOS). This study aims to evaluate whether strict bed rest after LP in the ED impacts the incidence of PDPH and the ED LOS.
Materials and Methods
Study Design and Participants
This study was designed as a retrospective cohort study. At a medical center in central Taiwan (with an average monthly ED visit volume of approximately 11,000), all emergency department patients who underwent LP had their need for bed rest determined by emergency specialists based on individual patient conditions. We collected data on all adult patients (over 18 years old) who underwent LP in the ED of this medical center from September 1, 2023, to March 31, 2024 (a total of 9 months). Nurse practitioners (NPs) followed up with these patients to record the occurrence of PDPH and their ED LOS. Patients with incomplete data were excluded from the study.
Relevant Variables and Outcome Measurement
The primary outcome of this study was the occurrence of PDPH. The secondary outcome was ED LOS.
In addition to recording whether patients strictly adhered to supine rest after LP, we also documented cases in which patients could not be assessed for PDPH due to confusion or impaired consciousness etc. These patients were excluded from the analysis of PDPH occurrence. The ED LOS was defined as the time (in hours) from patient registration and triage in the ED until leaving the ED (including discharge, admission, or transfer).
Patient responses after undergoing LP were categorized as follows:
New onset of headache or worsening of existing headache (indicative of PDPH)
No headache or no worsening of existing headache
Unable to assess (due to altered consciousness or confusion, among other reasons).
The initial triage category, Glasgow Coma Scale (GCS), and patient disposition were also recorded. These details were recorded retrospectively by NPs reviewing the medical records.
Statistical Analysis
Patients were divided into two groups according to whether they strictly adhered to supine rest after LP. The occurrence of PDPH was presented with cases and percentage, and analyzed with Pearson’s chi-squared test. The ED LOS was presented with median and interquartile range (IQR). A Mann-Whitney U test was conducted to analyze the average ED LOS (hours). Subgroup analysis of ED LOS was also performed according to patient triage category (triage level 1, level 2, and level 3), GCS at the time of lumbar puncture (categorized as 15 and ≤ 14), and final disposition (either admission or discharge). All statistical analyses were performed using the Statistical Analysis System (SAS) version 9.4 (SAS Institute, Cary, NC, USA). A p-value < 0.05 was considered statistically significant.
Results
During the study period (September 1, 2023, to March 31, 2024), there were a total of 76,691 adult patients who visited the ED. Among these, 143 patients underwent LP. Two patients were excluded due to incomplete data collection, resulting in a final study population of 141 patients in 7 months. The details of patients who underwent LP (including whether they had bed rest) and their PDPH status or inability to be assessed are presented in Fig. 1. “Inability to be assessed" indicates that patients were already confused or unconscious before undergoing LP, making it impossible for them to clearly answer questions and define the occurrence of PDPH. Therefore, the occurrence of PDPH could not be recorded after the procedure. Among them, 86 patients were deemed by emergency physicians to require bed rest, while 55 patients were not. However, of the 86 patients who required bed rest, 70 patients could not be assessed for PDPH, almost entirely due to impaired consciousness.
Fig. 1.
Patient enrollment flowchart. ED: emergency department; PDPH: post-dural puncture headache.
Table 1 shows that, without excluding patients who could not be assessed, those with a more severe initial triage category, lower GCS level at the time of lumbar puncture, and those requiring hospitalization had a significantly higher likelihood of being assigned to bed rest.
Table 1.
Patient condition with or without bed resta
| Patient condition | With supine bed rest (n = 86) | Without supine bed rest (n = 55) | p |
| Patient triage level | < 0.001*,b | ||
| 1 | 52 (60.5) | 3 (5.4) | |
| 2 | 23 (26.7) | 14 (25.5) | |
| 3 | 11 (12.8) | 38 (69.1) | |
| GCS, median (IQR) | 9.0 (6.0–13.0) | 15.0 (15.0–15.0) | < 0.001*,c |
| Patient GCS | < 0.001*,b | ||
| GCS = 15 | 12 (13.9) | 50 (90.9) | |
| GCS < 14 | 74 (86.1) | 5 (9.1) | |
| Disposition | 0.001*,b | ||
| Admission | 74 (86.1) | 35 (63.6) | |
| Discharge | 12 (13.9) | 20 (36.4) |
p-value of < 0.05 indicates significant differences between groups.
Values are presented as number (%) unless otherwise indicated.
Pearson’s chi-square test.
Mann-Whitney U test.
IQR: interquartile range; GCS: Glasgow Coma Scale.
After excluding the 73 patients who could not be assessed, 68 patients were evaluated for the occurrence of PDPH and presented in Table 2. Among them, 16 patients did rest in a supine position, while 52 patients didn’t. A total of 6 (37.5%) patients in the bed rest group and 23 (44.2%) patients in the non-bed rest group developed PDPH. Statistical analysis showed that supine bed rest after LP did not result in a significant difference in the occurrence of PDPH between the two groups (p = 0.634).
Table 2.
Occurrence of post-dural puncture headache (PDPH) with or without bed resta
| Occurrence of PDPH | With supine bed rest (n = 16) | Without supine bed rest (n = 52) | p |
| Yes | 6 (37.5) | 23 (44.2) | 0.634b |
| No | 10 (62.5) | 29 (55.8) |
Values are presented as number (%).
Pearson’s chi-squared test.
Table 3 showed the ED LOS of two groups. Among the total 141 patients who underwent LP, 86 patients did rest in a supine position, while 55 patients did not. The median ED LOS was 19.0 hours (IQR, 10.0–30.5) for patients in the bed rest group, compared with 9.0 hours (IQR, 5.0–17.0) for those in the non-bed rest group. ED LOS was significantly longer in the bed rest group than in the non-bed rest group (p < 0.001). Subgroup analysis according to patients’ triage category, GCS at the time of lumbar puncture, and final disposition revealed significantly reduced ED LOS among patients with triage level 2 and those with GCS ≤ 14. ED LOS was also decreased in patients without supine bed rest orders in both the hospital admission group and the ED discharge group.
Table 3.
Average emergency department (ED) length of stay (LOS) (hours)a
| Patient subgroup | With supine bed rest (n = 86) | Without supine bed rest (n = 55) | p |
| Overall ED LOS | 19.0 (10.0–30.5) | 9.0 (5.0–17.0) | < 0.001* |
| Subgroup analysis | |||
| Patient triage level 1, n | 52 | 3 | |
| ED LOS | 19.0 (10.8–29.5) | 14.0 (3.0–16.0) | 0.170 |
| Patient triage level 2, n | 23 | 14 | |
| ED LOS | 17.0 (8.0–36.0) | 5.0 (3.0–15.0) | 0.019* |
| Patient triage level 3, n | 11 | 38 | |
| ED LOS | 20.0 (8.0–26.0) | 11.0 (6.0–17.0) | 0.146 |
| Patients GCS = 15, n | 12 | 50 | |
| ED LOS | 10.0 (4.8–23.0) | 11.0 (5.0–17.0) | 0.755 |
| Patients GCS ≤ 14, n | 74 | 5 | |
| ED LOS | 19.0 (11.0–31.0) | 7.0 (5.0–8.0) | 0.019* |
| Patients with admission, n | 74 | 35 | |
| ED LOS | 19.0 (11.0–31.0) | 13.0 (5.0–19.5) | 0.014* |
| Patients with discharge, n | 12 | 20 | |
| ED LOS | 11.3 (8.0–26.0) | 6.3 (4.3–10.8) | 0.007* |
p-value of < 0.05 indicates significant differences between groups.
Values are presented as median (interquartile range, Q1-Q3) in hours.
Mann-Whitney U test.
Discussion
This study reaffirms that there is no correlation between bed rest after LP in the ED and the occurrence of PDPH.13 Therefore, routine bed rest after LP in the ED should not be required. Instead, the need for bed rest should be determined by the emergency physician based on the patient’s specific medical condition.
As previously mentioned, it has long been believed that patients should rest in bed for at least 6 hours after an LP. However, a systematic review published in 2001 was the first to indicate that there was no evidence suggesting that longer bed rest after LP is more effective than immediate mobilization or short bed rest in reducing the incidence of headache.7 A more recent systematic review, published in 2016 and including 2,477 subjects, indicated that there was no significant difference in the incidence of PDPH between patients who rested in bed and those who mobilized early.11
Additionally, bed rest after LP significantly increases the ED LOS. Given the varying degrees of ED overcrowding worldwide—particularly severe in Taiwan—avoiding routine bed rest after LP may help alleviate the pressure on patients by ED overcrowding.
This study analyzed data from patients who underwent LP in the ED of a single medical center. Since LPs are relatively uncommon in the emergency setting, the sample size was limited. Furthermore, this study is not a randomized controlled trial. Whether patients who underwent LP were subsequently required to rest in bed was a professional decision made by their emergency physician based on the patient’s medical condition, which could introduce selection bias. Additionally, this study only found that complete supine bed rest after LP increases the ED LOS. The base characteristics and patient comorbidities were not included in the analysis. Further research is needed to determine whether avoiding bed rest can effectively reduce ED LOS and alleviate ED overcrowding.
In conclusion, based on this observational study, bed rest after LP in the ED does not prevent the occurrence of PDPH in patients with normal consciousness. Additionally, a strict bed rest policy may increase ED LOS among patients who undergo LP.
Conflict of Interest Statement
The authors declare that they have no conflicts of interest.
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