Spinal vs General Anesthesia in Hip Fracture Surgeries: It's a Draw

Older adults who underwent hip fracture surgery fared about the same at 60 days post-procedure regardless of whether they received spinal or general anesthesia, a randomized study found.

Among patients in the intention-to-treat population, the composite primary outcome -- death or an inability to walk approximately 10 feet independently or with a walker or cane at 60 days after randomization -- occurred in 18.5% of the spinal anesthesia group and 18.0% of the general anesthesia group (relative risk [RR] 1.03, 95% CI 0.84-1.27, P=0.83), reported Mark D. Neuman, MD, MSc, of the University of Pennsylvania in Philadelphia, at the American Society of Anesthesiologists annual meeting, as well as in the New England Journal of Medicine.

In addition, an inability to walk independently at 60 days was noted in 15.2% of the spinal group and 14.4% of the general group (RR 1.06, 95% CI 0.82-1.36), and death within 60 days occurred in 3.9% and 4.1%, respectively (RR 0.97, 95% CI 0.59-1.57). Postoperative delirium was reported in 20.5% and 19.7% (RR 1.04, 95% CI 0.84-1.30).

"We saw very similar outcomes for both types of anesthesia. Physicians can safely offer choices between the two and let patients decide what they prefer," Neuman told MedPage Today.

There's long been a debate over spinal versus general anesthesia in hip fracture surgeries, but little actual data, Neuman said. It's reasonable to expect that general anesthesia may cause cognitive problems due to complications linked to the need for mechanical breathing, but this topic hasn't been studied, he added.

The authors pointed out that "in the United States, the use of spinal anesthesia for hip-fracture surgery increased by 50% between 2007 and 2017, potentially reflecting a belief that spinal anesthesia is superior to general anesthesia. Our finding of similar outcomes at 60 days with either technique suggests that anesthesia choices for hip-fracture surgery may be based on patient preference rather than on anticipated differences in clinical outcomes."

Neuman said the current study results were unexpected. "You might hypothesize that spinal would be better, and that's been the historical teaching, but our trial showed that it's pretty hard to tell from the results at 60 days which anesthesia someone might have gotten," he noted.

In their multicenter study, Neuman and colleagues randomly assigned 1,600 hip fracture surgery patients at 46 U.S. and Canadian hospitals to receive spinal anesthesia (n=795) or general anesthesia (n=805) from February 2016 to February 2021.

The patients were all over 50 years (mean age 78), 67% were women, 7.6% were Black, and only about 1.9% were Hispanic. A total of 712 patients in the final analysis received spinal anesthesia compared with 733 who underwent general anesthesia.

Francesca Kayser Enneking, MD, of the University of Florida in Gainesville, who treated some of the patients in the study, praised the research but told MedPage Today that "it does highlight the difficulty in doing high-quality randomized studies at multiple institutions."

As she noted, fewer than 1,600 of 22,000 assessed patients completed the study protocol. Some reasons for exclusion included refusal to consent, language barriers, ages under 50, and lack of enrollment due to unavailable staff.

Kayser Enneking said she doubts that the findings will resolve the spinal versus general anesthesia debate. "The differences between the two techniques are subtle and probably more dependent on local hospital culture and personal comfort of the anesthesiologist attending each patient than on overt differences in outcomes," she added.

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