NEJM: Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

[vector2]

Abstract​

BACKGROUND​

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS​

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS​

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P=0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS​

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505. opens in new tab.)

https://www.nejm.org/doi/10.1056/NEJMoa2113514

The only thing that really surprises me is the lack of a delirium difference, but I gotta go download the full paper to see what the methodology and sedation was for the spinal group.

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[DocVapor]

I stopped reading at 666 patients in the spinal group. Will be doing GA from now on.


To be serious, I'm not surprised. At least someone tried though.

 

[nimbus]

If there was a difference, it would have been clear 40 years ago.

 

[vector2]

I stopped reading at 666 patients in the spinal group. Will be doing GA from now on.


To be serious, I'm not surprised. At least someone tried though.

Institutionally my shop has been a place where the standard for hip fracture has been GA. Ortho likes it and the anesthesiologists here didn't mind the speed of inducing GA + having a secure airway in place. Plus pain in older folks is just generally easier to treat so can get away with a bit of opioid +- FI or PENG.

In residency (and I think academics in general) though, listening to some of the staff you woulda thought doing GA on a hip fx meant certain death. Which is clearly not the case if you critically examine the academic dogma.

 

[woopedazz]

There is much wailing and gnashing of teeth in my hospital over this paper.

 

[Ezekiel2517]

Interesting. Simply anecdotally, based on patients (2 of them who were physicians) I've spoken to who have had one hip replaced under GA and the other under spinal, they all said they much preferred their overall experience w/ a spinal and would choose that route in the future if they had the choice. The outcomes evaluated in this study aren't the only significant outcomes when it comes to total joints IMO
Edit: I just noticed this study was for hip fractures, not THA.

 

[Urzuz]

Interesting. Simply anecdotally, based on patients (2 of them who were physicians) I've spoken to who have had one hip replaced under GA and the other under spinal, they all said they much preferred their overall experience w/ a spinal and would choose that route in the future if they had the choice. The outcomes evaluated in this study aren't the only significant outcomes when it comes to total joints IMO

This study isn't looking at total joints, it's looking at hip fractures (little old lady falls and breaks her hip). I do agree with your sentiment that patient satisfaction is an important consideration, though it seems like the vast majority of our hip fractures patients can barely remember their own names and think the year is 1957...

 

[Ezekiel2517]

This study isn't looking at total joints, it's looking at hip fractures (little old lady falls and breaks her hip). I do agree with your sentiment that patient satisfaction is an important consideration, though it seems like the vast majority of our hip fractures patients can barely remember their own names and think the year is 1957...

read my edit

 

[Ezekiel2517]

The no difference b/t the 2 groups (mean age 78 yrs old) in post op delirium makes no sense. Maybe POCD would have been a better metric to study.

 

[woopedazz]

The no difference b/t the 2 groups (mean age 78 yrs old) in post op delirium makes no sense. Maybe POCD would have been a better metric to study.

What part makes no sense? I haven't had a chance to go through the method/ definitions yet

 

[Mman]

The no difference b/t the 2 groups (mean age 78 yrs old) in post op delirium makes no sense. Maybe POCD would have been a better metric to study.

most postop delirium is probably due to age and simply being in the hospital (and getting plenty of meds). The 60 minutes of general anesthesia is probably a small enough risk factor overall that it did not outweigh the other important risks for delirium in that patient population.

 

[Ezekiel2517]

most postop delirium is probably due to age and simply being in the hospital (and getting plenty of meds). The 60 minutes of general anesthesia is probably a small enough risk factor overall that it did not outweigh the other important risks for delirium in that patient population.

Maybe, would be interesting to see how they defined/measured delirium. I think POCD would have been a better outcome to study and significant differences between the groups would have been found imo. Something that affects one's quality of life weeks/months/yrs after surgery holds more value than whether or not they had an episode of delirium in the immediate postop period.

 

[Hoya11]

Abstract​

BACKGROUND​

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS​

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS​

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P=0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS​

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505. opens in new tab.)

https://www.nejm.org/doi/10.1056/NEJMoa2113514

The only thing that really surprises me is the lack of a delirium difference, but I gotta go download the full paper to see what the methodology and sedation was for the spinal group.

personally i agree with this and always do GA for these cases with an LMA - nice and clean and simple

spinal for 3 hrs on an arthritic spine with a demented patient up on a fracture table - who you then have to sedate anyways - i never understood it

 

[Hoya11]

Maybe, would be interesting to see how they defined/measured delirium. I think POCD would have been a better outcome to study and significant differences between the groups would have been found imo. Something that affects one's quality of life weeks/months/yrs after surgery holds more value than whether or not they had an episode of delirium in the immediate postop period.

there is no evidence to what you are suggesting, and it seems like it would be very difficult to study such a long and multifactorial process amongst such a large set of patients with different characteristics

 

[Planktonmd]

The problem with spinal anesthesia in ortho is likely that anesthesiologists end up giving deep sedation. Most of these elderly partially demented patients might not tolerate staying still on the fracture table for an ORIF or in the lateral position for THA and hearing the hammers and saws. That heavy sedation is very close to GA and probably why the post-op delirium is the same in both techniques.

 

[deleted875186]

The problem with spinal anesthesia in ortho is likely that anesthesiologists end up giving deep sedation. Most of these elderly partially demented patients might not tolerate staying still on the fracture table for an ORIF or in the lateral position for THA and hearing the hammers and saws. That heavy sedation is very close to GA and probably why the post-op delirium is the same in both techniques.

I agree, I have done spinals for hip fractures in elderly patients with no sedation at all, they do great, and it is a super clean anesthetic. They get some acetaminophen and a small dose of opioid three hours after and that’s it. Of course there needs to be no agitated delirium, if there is then I would just do GA.

Didn’t read the paper, but these studies need to do some standardized delirium or neuropsych assessments, and they need to select patients based off their preop cognitive status, probably too time consuming to do in clinical practice. The intraop sedation is a huge confounder.

 

[BLADEMDA]

No difference in outcome. That means GA with LMA 90% of the time. Simple. Easy. Fast. If you are concerned with too much SEVO then place a BIS as well.
I don't bother with the BIS either. These are 30-40 minute cases.

Spinals are reserved for the worst bunch, ASA 4, patients who can't tolerate a GA with LMA.

 

[woopedazz]

The problem with spinal anesthesia in ortho is likely that anesthesiologists end up giving deep sedation. Most of these elderly partially demented patients might not tolerate staying still on the fracture table for an ORIF or in the lateral position for THA and hearing the hammers and saws. That heavy sedation is very close to GA and probably why the post-op delirium is the same in both techniques.

They describe a OASS score between 5 and 2 for nearly all spinal cases. 5 = awake. 2 = chats to you if you prod them a bit.

 

[Planktonmd]

They describe a OASS score between 5 and 2 for nearly all spinal cases. 5 = awake. 2 = chats to you if you prod them a bit.

If you really want to compare GA to Neuraxial you probably need to give no sedation at all with the Neuraxial. Otherwise what you are comparing is the outcome of variable degree of sedation versus GA.

 

[DocVapor]

If you really want to compare GA to Neuraxial you probably need to give no sedation at all with the Neuraxial. Otherwise what you are comparing is the outcome of variable degree of sedation versus GA.

Right. My biggest problem with EBM on these large trials is the reliability of the data that has been inputted. How can you truly rely on that OASS of 2 to truly be a 2 and not "Patient grunted during a sternal rub" that was charted as a 2 to make things look like the protocol was followed.

Anyone that blindly trusts this stuff needs to contact me about a bridge I have for sale.

 

[vector2]

Right. My biggest problem with EBM on these large trials is the reliability of the data that has been inputted. How can you truly rely on that OASS of 2 to truly be a 2 and not "Patient grunted during a sternal rub" that was charted as a 2 to make things look like the protocol was followed.

Anyone that blindly trusts this stuff needs to contact me about a bridge I have for sale.

What you're hoping for is that the sample size is large enough and that there's enough different participants (i.e. different anesthesiologists doing these cases) that the fudge factor can only be so much. I mean, it's certainly possible that 5 or 10 or whatever different anesthesiologists are just totally lying about their depth of sedation assessment, but it just becomes less likely as the number of patients and participants goes up.

That being said, that's why having a multicenter trial or a second reproductory trial done by different investigators is so important.

 

[DocVapor]

What you're hoping for is that the sample size is large enough and that there's enough different participants (i.e. different anesthesiologists doing these cases) that the fudge factor can only be so much. I mean, it's certainly possible that 5 or 10 or whatever different anesthesiologists are just totally lying about their depth of sedation assessment, but it just becomes less likely as the number of patients and participants goes up.

That being said, that's why having a multicenter trial or a second reproductory trial done by different investigators is so important.

I do get that. I'm just a bit of a skeptic.

 

[nimbus]

If you really want to compare GA to Neuraxial you probably need to give no sedation at all with the Neuraxial. Otherwise what you are comparing is the outcome of variable degree of sedation versus GA.

But people rarely do their spinals that way. It’s more useful to compare a typical spinal vs a typical GA.

 

[IMGASMD]

But people rarely do their spinals that way. It’s more useful to compare a typical spinal vs a typical GA.

Then you get to the problem of a “typical” spinal vs “typical” GA.

12mg, no narcotics.
2 of fent, prop LMA, 2% sevo

Are my typical. But then I am sure there will be people calling foul…. Or my patient is sicker than yours….

To conduct a well designed and well carried out clinical trial is serious business.
Glad I ain’t doing it.

 

[Airway]

For those that don't believe/trust papers. Why even bother reading papers? A skeptical nature is fine but it sounds like you just want to keep on believing what you believe. This is nejm, not the Madagascar journal of made up science.


Edit: feel free to criticize the methodology, statistics, end point measurements, study design etc. But saying the data is falsified without evidence?

If you really want to compare GA to Neuraxial you probably need to give no sedation at all with the Neuraxial. Otherwise what you are comparing is the outcome of variable degree of sedation versus GA.

There was a urology (stone) paper earlier neuraxial vs ga paper where there was little or no sedation given that showed no benefit for spinal (can't find it right now - if someone recalls it would greatly appreciate a link).

 

[DocVapor]

For those that don't believe/trust papers. Why even bother reading papers? A skeptical nature is fine but it sounds like you just want to keep on believing what you believe. This is nejm, not the Madagascar journal of made up science.


Edit: feel free to criticize the methodology, statistics, end point measurements, study design etc. But saying the data is falsified without evidence?

Just being skeptical doesn't mean the papers are worthless. Even if you don't believe the paper results are valid, you still need to know what the prevailing trends are so that you're not left behind flapping alone in the wind. I don't want to be skeptical of papers, but already in my short career I've come to realize that even at major academic centers there are real pressures to move the meat, and frankly those pressures mean academic rigor takes a back seat. Nurses that have more and more documentation needs, overcrowded PACUs that routinely turn into ICU overflow, publish or perish, etc etc. The idea is there that "big enough studies causes randomness to eliminate this bias.". In theory that works great, but it's not like these pressures are different from one center to another (especially among studies strictly from the U.S.), and thus I've come to the conclusion that it's impossible to eliminate this bias.

That doesn't even get into the highly politicized process of paper acceptance, idolatry, quid pro quo, that are rampant in the academic sphere.

 

[vector2]

Just being skeptical doesn't mean the papers are worthless. Even if you don't believe the paper results are valid, you still need to know what the prevailing trends are so that you're not left behind flapping alone in the wind.

I think his more specific point was that it's fine to be skeptical of papers- it's the reason that you're skeptical which is important. If you have a specific methodologic issue, great. That's valid criticism.

If your issue is that you believe the whole anesthesiology dept at UPenn just flat-out lied about the depth of sedation during spinal and still got their results published in NEJM, but you don’t have any evidence to support that claim.... well that's a whole different can of worms.

 

[DocVapor]

I think his more specific point was that it's fine to be skeptical of papers- it's reason you're skeptical which is important. If you have a specific methodologic issue, great. That's valid criticism.

If your issue is that you believe the whole anesthesiology dept at UPenn just flat-out lied about the depth of sedation during spinal and still got their results published in NEJM, but you don’t have any evidence to support that claim.... well that's a whole different can of worms.

Sure. I'm not trying to say they falsified data. I don't have any evidence to support that claim as I wasn't there watching every single one of those anesthetics. But let's not pretend major journals don't publish papers that they have to retract. It's the process that is inherently flawed. It may be the best we can do though.

 

[vector2]

Sure. I'm not trying to say they falsified data. I don't have any evidence to support that claim as I wasn't there watching every single one of those anesthetics. But let's not pretend major journals don't publish papers that they have to retract. It's the process that is inherently flawed. It may be the best we can do though.

They definitely publish papers which are subsequently retracted. Or you have flawed papers like Rivers et al with surviving sepsis that take over a decade and 3 landmark papers to refute.

But honestly one of the biggest problems in today's literature is the pressure to publish positive results. .

I applaud the fact they spent all this time doing a study and still published a "there was no difference" result even though there are big GA and regional camps

 

[Radetzky]

The question you have to ask is is there any scientific plausibility that the mode of anesthesia for a couple of hours is going to influence the primary outcome - mortality and ambulation, or even the secondary outcome of delirium, for all patients over 50 with hip fractures when we know that there are about one million other factors during their hospital stay that influence these outcomes. Most patients who have delirium or death I dare say the die was cast at the time when they broke their hip.

If you really wanted to stand a chance of finding an important difference you would study octogenarians with at least moderate comorbidities- but then you would never recruit enough patients to power your study- hence the clinical trial “cycle of futility”

 

[Airway]

@DocVapor agree with all of your criticisms of the academic way. Definitely why I will not be working anywhere with publish or perish mentality.

 

[Mman]

The question you have to ask is is there any scientific plausibility that the mode of anesthesia for a couple of hours is going to influence the primary outcome - mortality and ambulation, or even the secondary outcome of delirium, for all patients over 50 with hip fractures when we know that there are about one million other factors during their hospital stay that influence these outcomes.

If people have very strong feelings about one technique or another for this, well they probably need to reassess their feelings.

 

[nimbus]

Another one comparing spinal vs general in back surgery patients. Again no difference in postop delirium.

https://watermark.silverchair.com/aln.0000000000004015.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAyAwggMcBgkqhkiG9w0BBwagggMNMIIDCQIBADCCAwIGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMAFaDjbJyOmU6iL_MAgEQgIIC076lQEJRTMtEUa6rg0WRZU3l91AFCcoCkr2HtuldhzQVvmUF5VNd9mD0jqf_RFmRvSyt1JOTcovPVP4AfU5T_jNIdHYJzV_wgoftP-NHPWFfhLLU5MMPfs-s5m6e-ZbnSOMhDrOtS6KjEi9QRa_NgR-DLRx34cN42nvsrs2utN6BTMvY2KgyMWlPKMMJXgDhdv97UufL-5PUMgdVB-c2jbJckHqQkkMUSvTLwq0hBhR9ILnnSwEkBZVZWziPcjN8KZWwlrZLr8y4yQLrrRIhcicyfCd6WhEw27-E1yal377aF2yECYv4NplV6KNfcB080NC-grj55lkJ6TNDH-1Ba2S4yQtvw3IFCUe8QNb1fTVvgKppF-3nUQV7SDZYggMHkY5QhgOlEk-yuMQF-05KgPHWgfkP3Dd_t5YTvSBKbjNcutQDytlW0s5VjHtQROPQncSdARi7KbraZ2aWmZ5iAbSvXNTN0hxelLPgYVVRzsc8I1mjS_hAm3ik3DDQhaqzhrx_FL-LthFBAbAWftjg9BPryO2y0Rf_Y4OVA6xl2C-JHp3FALmY4Qnstq3gY4cstDIf4vo_3-K_3pM0Xf20Lpu7oloxAZj0FJb_TDSnSiQTS9aUgljk7FOTg0RjX6enfsgebg9flpQqAVBHA7IsfGHt_et3r5QkF3MOfE0LIucyiI-YrHsKQGvkE0WwexvZQ9jQ9oQF6mVKfS1DKPn0TpSJ2AYPeEKvZMp3z70wv0K5y03VlgGUMZNiuho-MWyEeId7gWImxcKdPslg5DbmU5ApWCVkep_0VIQ94n-p-bLBm2RUpgVhtGhvB0hNiT5meq0-NknRaJyNC-ukzr8MdDP8f4UGpq4hqD-0z4voZVrpEWHU5tv5Bf2oqMeLDvzJyMRujYP_GGp0w4RbSKH6kpxrjPDTESkceEQv9bFwMPyRQuSzjxDDoEC1GL73hyLjDsmRzg

 

[narcotics999]

Another one comparing spinal vs general in back surgery patients. Again no difference in postop delirium.

https://watermark.silverchair.com/aln.0000000000004015.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAyAwggMcBgkqhkiG9w0BBwagggMNMIIDCQIBADCCAwIGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMAFaDjbJyOmU6iL_MAgEQgIIC076lQEJRTMtEUa6rg0WRZU3l91AFCcoCkr2HtuldhzQVvmUF5VNd9mD0jqf_RFmRvSyt1JOTcovPVP4AfU5T_jNIdHYJzV_wgoftP-NHPWFfhLLU5MMPfs-s5m6e-ZbnSOMhDrOtS6KjEi9QRa_NgR-DLRx34cN42nvsrs2utN6BTMvY2KgyMWlPKMMJXgDhdv97UufL-5PUMgdVB-c2jbJckHqQkkMUSvTLwq0hBhR9ILnnSwEkBZVZWziPcjN8KZWwlrZLr8y4yQLrrRIhcicyfCd6WhEw27-E1yal377aF2yECYv4NplV6KNfcB080NC-grj55lkJ6TNDH-1Ba2S4yQtvw3IFCUe8QNb1fTVvgKppF-3nUQV7SDZYggMHkY5QhgOlEk-yuMQF-05KgPHWgfkP3Dd_t5YTvSBKbjNcutQDytlW0s5VjHtQROPQncSdARi7KbraZ2aWmZ5iAbSvXNTN0hxelLPgYVVRzsc8I1mjS_hAm3ik3DDQhaqzhrx_FL-LthFBAbAWftjg9BPryO2y0Rf_Y4OVA6xl2C-JHp3FALmY4Qnstq3gY4cstDIf4vo_3-K_3pM0Xf20Lpu7oloxAZj0FJb_TDSnSiQTS9aUgljk7FOTg0RjX6enfsgebg9flpQqAVBHA7IsfGHt_et3r5QkF3MOfE0LIucyiI-YrHsKQGvkE0WwexvZQ9jQ9oQF6mVKfS1DKPn0TpSJ2AYPeEKvZMp3z70wv0K5y03VlgGUMZNiuho-MWyEeId7gWImxcKdPslg5DbmU5ApWCVkep_0VIQ94n-p-bLBm2RUpgVhtGhvB0hNiT5meq0-NknRaJyNC-ukzr8MdDP8f4UGpq4hqD-0z4voZVrpEWHU5tv5Bf2oqMeLDvzJyMRujYP_GGp0w4RbSKH6kpxrjPDTESkceEQv9bFwMPyRQuSzjxDDoEC1GL73hyLjDsmRzg

View attachment 344865View attachment 344866View attachment 344867

People do prone back surgery under spinal? Fancy.

 

[nimbus]

People do prone back surgery under spinal? Fancy.

It’s an old technique. One of my mentors told me that Ingrid Bergman’s former husband who practiced neurosurgery in the 1960’s and 1970’s preferred to do his spine cases this way. And if the case went long, it was easy to redose.