Anesthesia
Either spinal or general anesthesia is appropriate for patients with a hip fracture.

Rationale

Two high quality studies (Shin 2020, Tzimas 2018) and five moderate strength studies (Haghighi 2017, Parker 2015, McKenzie 1984, Davis 1981, Valentin 1986) compared mortality and complications among patients undergoing hip fracture surgery with spinal versus general anesthesia. One high quality study included in the prior guideline version was excluded due to low sample size (Casati); one study graded as high quality (Davis 1981) in the prior version was classified as moderate quality in the present guideline. 

One high quality study (Shin 2020) and two moderate quality studies (Davis 1981, Valentin 1986) found no difference in mortality at up to 120 days for spinal versus general anesthesia. One moderate quality study (McKenzie 1984) found a decreased mortality rate at two weeks postoperatively in the spinal anesthesia group; however, this difference did not persist at two months. One moderate quality study (Parker 2015) found increased mortality with spinal versus general anesthesia at 1 year. One high quality study (Shin 2020) and one moderate quality study (Parker 2015) found no difference in in-hospital complications with spinal versus general anesthesia. One high quality study (Tzimas 2018) and two moderate quality studies (Parker 2015, McKenzie 1984) found no difference in length of stay by anesthesia type. One moderate quality study (Haghighi 2017) found lower postoperative pain scores with spinal versus general anesthesia. 

Benefits/Harms of Implementation

Spinal anesthesia and general anesthesia each have a longstanding record of use with established safety in appropriately selected patients. In patients undergoing anticoagulation, available external guidance should be consulted regarding the timing of block placement relative to anticoagulant dosing to limit potential harms for patients undergoing spinal anesthesia. 

Outcome Importance

Mortality and complications occur commonly after hip fracture surgery; therefore, identifying interventions to improve these outcomes represents an important public health priority.

Cost Effectiveness/Resource Utilization

No data were identified to characterize the relative cost-effectiveness of spinal versus general anesthesia. 

Acceptability

Both spinal and general anesthesia may be acceptable to patients and providers. Acceptability of spinal versus general anesthesia for a given case may vary depending on patient preferences, provider experience, and case characteristics. 

Feasibility

Both spinal and general anesthesia are in widespread use in the United States.

Future Research

Most identified randomized trials were small and may have lacked power to detect important differences between groups. Future research including appropriately randomized patients may provide more information on risks and benefits of spinal anesthesia versus general anesthesia with regard to mortality, complications, and other important patient-centered outcomes such as delirium, functional outcomes, and discharge location.