• Journal: NEJM

• PMID: 34623788

• Type of study: Randomized, controlled trial

• Hypothesis: Subjects receiving spinal anesthesia would be more likely to be alive and walking independently at 60 days versus those receiving general anesthesia

• Methods

  • Multicenter, superiority trial

  • Modified intention-to-treat analysis

  • Groups

    • Spinal

      • Sedation titrated to arousability to tactile stimulus or voice

      • Conversion to GA allowed

    • General

      • Inhalational anesthetics

      • IV opioids

  • Inclusion criteria

    • Hip fracture requiring surgical treatment

    • Age ≥ 50 years

    • Ability to walk without human assistance before fracture

  • Exclusion criteria

    • Concurrent surgery not amenable to spinal anesthesia

    • Absolute contraindications to spinal anesthesia

    • Patients known or suspected to be at elevated risk for malignant hyperthermia

    • Periprosthetic fracture

• Results: Incidence of death or a new inability to walk 60 days after randomization did not differ significantly between patients assigned to receive spinal anesthesia and those assigned to receive general anesthesia.

• Strengths

  • Randomized

  • Large # of patients

  • Modified intention-to-treat

  • Validity

  • Data collection blinded

  • Multicenter

  • Generalizability

• Weaknesses

  • Missing outcome data

  • The primary outcome rate lower than expected

  • Crossover

  • Unable to blind treatment

  • Variability in patient management

• Key Point: Among older adults undergoing hip-fracture surgery, spinal anesthesia was not superior to general anesthesia with respect to survival and ability to walk independently at 60 days.

N Engl J Med. 2021 Nov 25;385(22):2025-2035