Strong evidence supports similar outcomes for general or spinal anesthesia for patients undergoing hip fracture surgery.

Two high strength (Casati et al39, Davis et al40) and seven moderate strength (De Visme et al 41, Honkonen et al42, Koval et al43, Koval et al44, McKenzie et al45, Sutcliffe et al46, and Valentin et al47) studies compared spinal anesthesia to general anesthesia in patients undergoing hip fracture surgery.
Meta-analysis showed no difference in mortality. McKenzie et al 45 demonstrated a decreased mortality rate at two weeks post operatively in the spinal anesthesia group; however, this difference did not persist at two months.  Valentin et al47, Sutcliffe et al 46, Davis et al 40 and Koval et al 43 did not demonstrate a difference in mortality between the two groups. De Visme et al 41 and Casati et al 39 found no differences in postoperative confusion.
Casati et al 39, McKenzie et al 45, and Valentin et al47, demonstrated decreased blood loss in those patients receiving spinal anesthesia..  Finally, Koval et al43, Valentin et al47, Sutcliffe et al46, McKenzie et al45, and Casati et al39 all did not demonstrate a difference in hospital length of stay. 
The work group recognizes that anesthetic techniques described in several of these articles which were published decades ago may have changed when compared with modern methods.  In addition, there was significant heterogeneity in the patient populations studied, including multiple studies in which patients were not randomized.

Risks and Harms of Implementing this Recommendation
Both general anesthesia and spinal anesthesia carry risks and benefits, which should be assessed on an individual basis. Because both forms of anesthesia appear to have similar mortality profiles, providers can consider specific circumstances that would favor one form or the other for their particular patient.

Future Research
Future research involving appropriately randomized patients may yet delineate which anesthesia technique is more appropriate in this patient population.

  1. (39) Casati A, Aldegheri G, Vinciguerra E, Marsan A, Fraschini G, Torri G. Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery. Eur J Anaesthesiol 2003;20(8):640-646.
  2. (40) Davis FM, Laurenson VG. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Anaesth Intensive Care 1981;9(4):352-358.
  3. (41) de V, V, Picart F, Le JR, Legrand A, Savry C, Morin V. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Reg Anesth Pain Med 2000;25(2):158-162.
  4. (42) Honkonen K, Tarkkanen L, Julkunen H. Femoral neck fracture during and after surgery, with special reference to the type of anaesthesia used. Acta Med Scand 1971;189(3):173-178.
  5. (43) Koval KJ, Aharonoff GB, Rosenberg AD, Bernstein RL, Zuckerman JD. Functional outcome after hip fracture. Effect of general versus regional anesthesia. Clin Orthop Relat Res 1998;(348):37-41.
  6. (44) Koval KJ, Aharonoff GB, Rosenberg AD, Schmigelski C, Bernstein RL, Zuckerman JD. Hip fracture in the elderly: the effect of anesthetic technique. Orthopedics 1999;22(1):31-34.
  7. (45) McKenzie PJ, Wishart HY, Smith G. Long-term outcome after repair of fractured neck of femur. Comparison of subarachnoid and general anaesthesia. Br J Anaesth 1984;56(6):581-585.
  8. (46) Sutcliffe AJ, Parker M. Mortality after spinal and general anaesthesia for surgical fixation of hip fractures. Anaesthesia 1994;49(3):237-240.
  9. (47) Valentin N, Lomholt B, Jensen JS, Hejgaard N, Kreiner S. Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. Br J Anaesth 1986;58(3):284-291.