Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.
Level 2 - randomized trial
Multicenter pragmatic randomized controlled trial
PubMed 34623788 · doi:10.1056/NEJMoa2113514
What was done
A pragmatic, randomized superiority trial compared spinal anesthesia to general anesthesia in 1600 previously ambulatory patients aged 50 years or older undergoing surgery for hip fracture across 46 hospitals in the United States and Canada (795 assigned to spinal, 805 to general). The primary outcome was a composite of death or inability to walk approximately 10 feet (3 meters) independently or with an assistive device (walker or cane) at 60 days post-randomization. Secondary outcomes included 60-day mortality, delirium, time to discharge, and ambulation at 60 days.
What was found
In the modified intention-to-treat population, the primary composite outcome occurred in 132 of 712 patients (18.5%) in the spinal group and 132 of 733 (18.0%) in the general anesthesia group (RR 1.03; 95% CI, 0.84 to 1.27; P = 0.83). Inability to walk independently at 60 days occurred in 15.2% (104/684) vs 14.4% (101/702) (RR 1.06; 95% CI, 0.82 to 1.36). Mortality at 60 days was 3.9% (30/768) vs 4.1% (32/784) (RR 0.97; 95% CI, 0.59 to 1.57). Delirium was recorded in 20.5% (130/633) vs 19.7% (124/629) (RR 1.04; 95% CI, 0.84 to 1.30).
Why it matters
Spinal anesthesia is frequently hypothesized to improve recovery and reduce delirium compared with general anesthesia in older adults. This large pragmatic trial indicates that choice of anesthetic technique between spinal and general does not meaningfully alter functional recovery, delirium risk, or 60-day survival after hip fracture surgery.
Limits
Crossover occurred predominantly in the spinal group, where only 83.8% received spinal anesthesia compared to 95.5% receiving general anesthesia in the assigned general group. Outcome data were missing or uncollected for a subset of randomized participants (e.g., primary composite outcome assessed in 1445 of 1600; delirium evaluated in 1262 of 1600). Long-term functional outcomes beyond 60 days were not evaluated.
Cited by
- supports In the REGAIN study of 1,800 patients aged 50 and older undergoing hip fracture surgery, postoperative delirium incidence was 20.5% with spinal anesthesia compared to 19.1% with general anesthesia.