Spinal or General Anesthesia for Hip Surgery

Nov 29, 2021
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Authors:
Neuman MD, Feng R, Carson JL, et al., on behalf of the REGAIN Investigators.
Citation:
Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. N Engl J Med 2021;385:2025-2035.
Summary By:
Rachel Eshima McKay, MD

Quick Takes

  • Use of spinal anesthesia for hip fracture surgery offered no advantage compared to general anesthesia in reducing risk of death within 60 days or recovery or independent ambulation at 60 days in a randomized trial of 1,600 patients aged ≥50 years who were able to ambulate independently prior to the fracture event.
  • Incidence of delirium and hospital length of stay did not differ according to anesthetic technique in this population.
  • 15% of patients randomized to receive spinal anesthesia instead received general anesthesia, whereas 3.5% randomized to general anesthesia received spinal anesthesia.

Study Questions:

Among patients with the ability to ambulate independently prior to hip fracture, does spinal anesthesia during corrective surgery decrease the risk of death or inability to ambulate at 60 days compared to general anesthesia (GA)?

Methods:

In REGAIN, a multicenter, pragmatic, randomized superiority trial, previously ambulatory patients aged ≥50 years were assigned to receive spinal anesthesia versus GA for hip fracture surgery. The primary outcome was a composite of death or inability to walk ≥3 m without assistance at 60 days. Secondary outcomes were death within 60 days, incidence of new-onset delirium, hospital length of stay, and inability to ambulate ≥3 m independently at 60 days. All available outcome data were analyzed according to the original anesthetic assignment.

Results:

Among 1,600 patients, 795 were randomized to spinal and 805 to GA. Mean patient age was 78 years. Complete outcome data 60 days from randomization were available in 1,446 patients: 712 in the spinal and 733 in GA arms.

The primary outcome did not differ (composite of death or inability to independently ambulate), occurring in 18.5% versus 18.0% of patients receiving spinal versus GA (relative risk [RR], 1.03; 95% confidence interval [CI], 0.84-1.27).

Secondary outcomes likewise did not differ by assignment to spinal versus GA (RR, 95% CI):

  • Inability to ambulate independently occurred in 15.2% versus 14.4% (1.06, 0.82-1.36).
  • Death within 60 days occurred in 3.9% versus 4.1% (0.97, 0.59-1.57).
  • Delirium occurred in 20.5% versus 19.7%.
  • Median (interquartile range) hospital length of stay was 3 (2-5) versus 3 (2-4) days among US patients and 6 (4-9) versus 6 (5-10) among Canadian patients.

Conclusions:

Among ambulatory patients aged ≥50 years sustaining hip fracture, spinal anesthesia was not superior to GA in reducing risks of death or inability to ambulate independently at 60 days. In this population, spinal anesthesia was likewise not superior in reducing death within 60 days, reducing inability to ambulate at 60 days, decreasing incidence of postoperative delirium, or shortening hospital length of stay.

Perspective:

Although hip fracture in older adults confers significant risk of mortality, further injury, and a wide array of life-altering adverse consequences, the scope of previous clinical studies was mostly limited to morbid events occurring during hospitalization. The REGAIN trial offers novel information by its focus on outcomes with tangible importance to patients, family members, and caregivers. Previous data suggesting a benefit to spinal anesthesia for hip fracture surgery were based on observational studies or underpowered trials that reported contradictory findings.

Nonadherence to the assigned anesthetic protocol was more frequent among patients randomized to spinal anesthesia, where 15% of subjects received GA, often after unsuccessful attempts were made to administer the spinal anesthesia. The practicality of spinal anesthesia may be limited in some instances, especially when pain may be imposed on the patient during positioning. Despite the prevalence of cross-over, the primary and secondary outcomes were consistent in the intention-to-treat and per-protocol populations.

Clinical Topics: Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Exercise

Keywords: Ambulatory Surgical Procedures, Anesthesia, General, Anesthesia, Spinal, Anesthetics, Delirium, Geriatrics, Hip Fractures, Length of Stay, Pain, Primary Prevention, Risk, Spine, Walking


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