By Gene Emery
NEW YORK (Reuters Health) - A test of 1,600 hip-fracture surgery patients has found that the type of anesthesia - spinal or general - makes little difference in the result.
In the primary outcome that combined death and an inability to walk three meters after 60 days, even with a walker, the rates were 18.5% with spinal anesthesia and 18.0% with general anesthesia, a non-significant difference.
The findings, reported at the annual meeting of the American Society of Anesthesiologists and simultaneously in the New England Journal of Medicine, also show no difference between the individual outcomes or the rates of delirium.
Observational studies have suggested that spinal anesthesia is superior. "Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type, but most of these trials were conducted more than 30 years ago and do not reflect current practice, had small numbers of participants, or were not designed to assess outcomes beyond the hospital stay," according to the authors of the study, known as REGAIN.
"Going in, our hypothesis was that spinal anesthesia would be associated with better outcomes," chief author Dr. Mark Neuman told Reuters Health in a telephone interview. "But when we saw the results, it was surprising to see how similar the groups were in terms of walking after surgery, delirium and survival."
"We did see some differences in exploratory outcomes in some complications, but these were very rare altogether and by 60 days they hadn't seemed to influence outcomes," he said.
In the United States, about 75% of the operations are done with general anesthesia. In some countries, spinal is favored and elsewhere it's evenly split, said Dr. Neuman, an associate professor of anesthesiology and critical care at the Perelman School of Medicine at the University of Pennsylvania.
The pragmatic test was done at 46 hospitals in the United States and Canada. Patients were at least 50 years old, but the mean age was 78. They could request to be switched to a different anesthesia group. Ultimately, 15% of those assigned to spinal anesthesia received general anesthesia and 3.5% switched from general to spinal.
On individual measures, the rates for death at 60 days were 3.9% with spinal anesthesia and 4.1% with general anesthesia.
The rates for being unable to walk without human assistance at 60 days were 15.2% and 14.4%, respectively. Postoperative delirium surfaced in 20.5% and 19.7%.
None of the differences were statistically significant.
Rates of death during hospitalization were 0.6% with spinal anesthesia and 1.6% with general anesthesia.
Respective rates of acute kidney injury were 4.5% and 7.6%.
Among spinal-anesthesia patients, 2.3% were admitted to a critical-care unit; the rate was 3.7% with general anesthesia.
"It seemed that the number of people who died while hospitalized was higher with general anesthesia, but by 60 days the number of deaths was almost exactly the same in both groups," said Dr. Neuman. "It could just be random chance. There could be more deaths at an earlier stage than later, but this study wasn't big enough to tell us that."
"There are reasons for patients to prefer either type of anesthesia and I think the value of our work is it gives patients some numbers to use in making those decisions," he said. "In spinal anesthesia, some people may not want to have an injection in their back. Some may not want to have a breathing tube. So there are tradeoffs on either side."
SOURCE: https://bit.ly/3DmmcLK The New England Journal of Medicine, online October 9, 2021.