Spinal anaesthesia should be selected in preference to general anaesthesia.

Rationale

Spinal anaesthesia:

  • is associated with significantly lower 30-day mortality compared to general anaesthesia in recent meta-analyses [1, 2] and RCT [3],
  • but not in recent, large observational studies of UK [4, 5] or US [6-8] data.
  • morbidity is lower after spinal anaesthesia in meta-analyses [1, 2, 9]
  • NICE support the use of either spinal or general anaesthesia, + nerve block [10]
  • the type of anaesthesia is probably less relevant than the care taken administering it [11]
  • evidence favouring each type of anaesthesia is summarised in the table below

 

BUT:

  • ASAP 2 found that 30-day postoperative mortality was lower after spinal compared to general anaesthesia, but not significantly (30-day 4.68% v. 5.37%, respectively) [5]
  • extrapolating from these rates, 233 fewer associated deaths would occur in the UK each year, if spinal anaesthesia was given instead to patients given general anaesthesia
  • spinal anaesthesia is cheaper than general anaesthesia [10]
  • the relative effect of spinal anaesthesia is obscured by the effect of concurrent sedation
  • research needs to focus on differences in early postoperative outcomes (confusion, hypotension, analgesia, renal function, rhythm abnormalities)

 

Type of evidence Source Mortality Morbidity
Guidelines SIGN 111 [12] SA
NICE CG124 (10]
AAGBI 2011 [11] SA
Meta-analysis Parker (Cochrane) [9] SA=GA SA
Luger 1 [1] SA SA
Luger 2 [2] SA SA
Recent RCT Parker [3] SA SA=GA
Observational NHFD [4] GA=(SA)
ASAP 1 [13] + 2 [5] SA=(GA) SA (hypotension)
US (NSQIP data) [6-8, 14-16] SA=GA SA=GA
Anecdote Anaesthetists SA (would prefer for themselves)
Geriatricians SA (less confused)
Allied Health Professionals SA (more mobile)

Evidence

1.Luger TJ, Kammerlander C, Gosch M, et al. Luger MF, Kammerlander-Knauer U, Roth T, Kreutziger J. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Osteoporosis International 2010; 21(Suppl 4): S555-72.

2. Luger TJ, Kammerlander C, Luger MF, Kammerlander-Knauer U, Gosch M. Mode of anesthesia, mortality and outcome in geriatric patients. Zeitschrift für Gerontologie und Geriatrie 2014; 47: 110-24.

3. Parker MJ, Griffiths R. General versus regional anaesthesia for hip fractures. A pilot randomised controlled trial of 322 patients. Injury 2015; 46: 1562-6.

4. White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65, 535 patients in a national dataset. Anaesthesia 2014; 69: 224-30.

5. White SM, Moppett IK, Griffiths R et al. Outcomes after anaesthesia for hip fracture surgery. Secondary analysis of prospective observational data from 11 085 patients included in the UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.

6. Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology 2012; 117: 72-92.

7. Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. Journal of the American Medical Association 2014; 311: 2508-17.

8. Patorno E, Neuman MD, Schneeweiss S, Mogun H, Bateman BT. Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study. British Medical Journal 2014; 348: g4022.

9. Parker M, Handoll HHG, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2004; 4: CD000521.

10. National Institute for Health and Clinical Excellence. The management of hip fracture in adults. 2011. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf (accessed 01/01/2016).

11. Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85-98.

12. Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people. National clinical guideline 111. 2009. sign.ac.uk/pdf/sign111.pdf (accessed 01/01/2016).

13. Royal College of Physicians and the Association of Anaesthetists of Great Britain and Ireland. National Hip Fracture Database. Anaesthesia Sprint Audit of Practice. 2014.

14. Fields AC, Dieterich JD, Buterbaugh K, Moucha CS. Short-term complications in hip fracture surgery using spinal versus general Injury 2015; 46: 719-23.

15. Basques BA, Bohl DD, Golinvaux NS, Samuel AM, Grauer JG. General versus spinal anaesthesia for patients aged 70 years and older with a fracture of the hip. Bone and Joint Journal 2015; 97-B: 689-95.

16. Whiting PS, Molina CS, Greenberg SE, Thakore RV, Obremskey WT, Sethi MK. Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia. International Orthopaedics 2015; 39: 1321-7.