Post-dural Puncture Headache in Dural Puncture Epidural and Combined Spinal-Epidural Using 24- and 25-Gauge Needles Versus Conventional Epidural Labor Analgesia: A Systematic Review and Meta-analysis

BACKGROUND: Compared to standard labor epidurals, placement of a dural puncture epidural (DPE) has been shown to improve labor analgesia efficacy, speed onset of analgesia, and decrease failure rates. However, there is a concern of increased post-dural puncture headache (PDPH) risk. A 25-gauge or larger spinal needle is typically needed for a DPE to have improved efficacy over a standard epidural. A prior meta-analysis comparing combined spinal-epidurals (CSEs) with epidurals did not identify a difference in PDPH rates, but many of the included randomized controlled trials (RCTs) used smaller diameter (27–29 gauge) spinal needles. This systematic review and meta-analysis of RCTs evaluates headache frequency following CSE or DPE labor analgesia techniques with 24- or 25-gauge spinal needles. METHODS: Medline, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection, and Cochrane databases were searched on May 7, 2024, for RCTs comparing either DPE or CSE techniques using 24- or 25-gauge spinal needles with epidural labor analgesia. The primary outcome was headache. The risk-of-bias 2 tool was used to assess bias. The odds ratio (OR) was the chosen effect size using binomial family Bayesian estimation. The reference category for estimation was the conventional epidural technique group. RESULTS: Encompassing 3278 patients, 1765 (53.8%) received labor epidurals, 971 (29.6%) received DPEs, and 542 (16.5%) received CSEs. The rate of headaches in both groups was low, with headache rates of CSE/DPE and epidural groups (0.59% vs 0.34%), respectively. Headache was a secondary outcome in all the RCTs. In 10 of the 16 RCTs (62.5%), no patients of 1428 (0%; 95% credible interval [CI], 0.00–0.25) reported a headache. A total of nine (0.6%) headaches were reported in the DPE/CSE patients (denominator 1513) and six (0.3%) headaches were reported in the traditional epidural patients (denominator 1765). The posterior distribution of the treatment effect ( θ ) showed that the log OR of 0.35 favored the control group as having fewer events, but the number of events was rare, and the 95% CI was wide (−0.49 to 1.22). CONCLUSIONS: Headache was a rare event in both groups. Although these results are reassuring that either technique is clinically safe, they should be interpreted cautiously. A large RCT examining PDPH as the primary outcome with long-term follow-up is needed to more precisely determine if placement of a DPE or CSE with a 24- or 25-gauge spinal needle increases the risk of PDPH.