Anesthesia

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.