Spinal anaesthesia no better than general anaesthesia for hip surgery

In patients undergoing surgery for hip fracture, the use of spinal anaesthesia was not better than general anaesthesia in terms of post-surgical outcomes such as death and mobility, according to results of the REGAIN* trial presented at Anesthesiology 2021.

“What our study offers is reassurance that general anaesthesia can represent a safe option for hip fracture surgery for many patients,” said lead investigator Associate Professor Mark Neuman from the Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, US.

“This is information that patients, families, and clinicians can use together to make the right choice for each patient’s personalized care,” he continued.

In this multicentre (46 hospitals in US and Canada), superiority trial, 1,600 previously ambulatory patients aged ≥50 years (mean age 78 years, 67 percent female) who were undergoing surgery for hip fracture** were randomized 1:1 to receive spinal or general anaesthesia, of whom 666 and 769, respectively, received their assigned treatments. Median total anaesthesia time was similar between the spinal and general anaesthesia groups (132 vs 131 minutes).

Sixty days after randomization, the composite of death or a new inability to walk approximately 10 feet (3 m) independently or with a walker or cane but without the assistance of another person did not significantly differ between patients assigned to spinal and general anaesthesia (modified intention-to-treat population of patients with complete data; 18.5 percent vs 18.0 percent; relative risk [RR], 1.03, 95 percent confidence interval [CI], 0.84–1.27; p=0.83). [N Engl J Med 2021;doi:10.1056/NEJMoa2113514]

When assessing the individual components of the primary outcome, the incidence of death within 60 days was similar between patients in the spinal and anaesthesia groups (3.9 percent vs 4.1 percent; RR, 0.97, 95 percent CI, 0.59–1.57), as was the incidence of inability to walk independently at 60 days (15.2 percent vs 14.4 percent; RR, 1.06, 95 percent CI, 0.82–1.36).

New-onset delirium, as per the 3-Minute Diagnostic Interview for Confusion Assessment Method, also did not differ between the spinal and general anaesthesia groups (20.5 percent vs 19.7 percent; RR, 1.04, 95 percent CI, 0.84–1.30).

The time between randomization and hospital discharge was 6 days in each group in Canada (RR, 0.92) and 3 days in each group in the US (RR, 1.06).

Acute kidney injury occurred in 4.5 and 7.6 percent of patients assigned to spinal and general anaesthesia, respectively, and admission to the critical care unit in 2.3 and 3.7 percent, respectively. In-hospital death occurred in 0.6 and 1.6 percent, respectively (n=5 vs 13). Postoperative transfusion was required in 16.6 and 18.4 percent, respectively, and urinary tract infection occurred in 4.5 and 3.5 percent, respectively.

“Available evidence has not definitively addressed the question of whether spinal anaesthesia is safer than general anaesthesia for hip fracture surgery, an important question to clinicians, patients, and families,” said Neuman.

“Our study argues that, in many cases, either form of anaesthesia appears to be safe,” he added. “This is important because it suggests that choices can be guided by patient preference rather than anticipated differences in outcomes in many cases.”

The researchers acknowledged that several factors may have limited the power to identify between-group differences. One factor was nonadherence due to crossover from spinal to general anaesthesia which primarily occurred due to the inability to place a spinal block, or physician, patient, or proxy decision. Another factor was differences in sedation practices by site.