Regional vs. General Anesthesia for Hip Fracture Surgery: A Comprehensive Evidence Review Scope and Framing This review examines the totality of evidence comparing spinal/regional anesthesia (RA) with general anesthesia (GA) for hip fracture surgery in older adults, with a focus on the two landmark trials — REGAIN and RAGA — that fundamentally challenged the long-held teaching that regional anesthesia is inherently…
THE EVIDENCE
What each source contributes, and how strong it is
Study design first — a cohort and a randomised trial do not carry the same weight.
Design
Year
Journal
What it found
Meta-analysis
2024
Annals of emergency medicine
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours
Randomised trial
2021
The New England journal of medicin
In REGAIN, spinal anaesthesia was not superior to general for hip fracture
Randomised trial
2022
Annals of internal medicine
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in
Randomised trial
2023
Regional anesthesia and pain medic
Two randomised trials totalling 2,550 patients found no mortality benefit, no less
4 resolved citations behind this deck; every point above traces to one of them.
WHERE THE GUIDANCE SITS
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours
Meta-analysis · Annals of emergency medicine
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours, and the pericapsular nerve group block outperformed femoral and fascia iliaca blocks, though most evidence was low confidence.
Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis, Annals of emergency medicine 2024 · PMID 38385910
THE NUMBERS
Preoperative blocks work, and the newer block works best
63 trials, 4,778 participants; pain at 2 hours versus no block.
Blocks reduced pain at two hours; the ranking between block types rested on low or very low certainty comparisons.
Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis, Annals of emergency medicine 2024 · PMID 38385910
WHAT THE TRIALS FOUND
Where randomised evidence moved the question
3 findings, each on the slide that follows.
The New England journal of medicine 2021
In REGAIN, spinal anaesthesia was not superior to general for hip fracture
In REGAIN, spinal anaesthesia was not superior to general for hip fracture: death or inability to walk at 60 days occurred in 18.5% versus 18.0%
Annals of internal medicine 2022
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in the first 24 hours and more prescription analgesic use at 60 days…
Regional anesthesia and pain medicine 2023
Two randomised trials totalling 2,550 patients found no mortality benefit, no less
Two randomised trials totalling 2,550 patients found no mortality benefit, no less delirium and no better ambulation with spinal anaesthesia, so…
WHAT THE TRIALS FOUND
In REGAIN, spinal anaesthesia was not superior to general for hip fracture
Randomised trial · The New England journal of medicin
In REGAIN, spinal anaesthesia was not superior to general for hip fracture: death or inability to walk at 60 days occurred in 18.5% versus 18.0%, and delirium in 20.5% versus 19.7%.
Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults, The New England journal of medicine 2021 · PMID 34623788
THE NUMBERS
REGAIN: spinal was not superior to general
1,600 patients, hip fracture surgery.
A superiority trial that found no significant difference — which removes the basis for telling a patient spinal is safer, without proving the two identical.
Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults, The New England journal of medicine 2021 · PMID 34623788
WHAT THE TRIALS FOUND
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in
Randomised trial · Annals of internal medicine
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in the first 24 hours and more prescription analgesic use at 60 days (25% versus 18.8%) than general anaesthesia.
Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial, Annals of internal medicine 2022 · PMID 35696684
THE NUMBERS
Spinal gave slightly more pain and more analgesic use at 60 days
REGAIN pain analysis, 1,600 patients.
If anything the difference favours general anaesthesia — the opposite of the usual counselling.
Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial, Annals of internal medicine 2022 · PMID 35696684
WHAT THE TRIALS FOUND
Two randomised trials totalling 2,550 patients found no mortality benefit, no less
Randomised trial · Regional anesthesia and pain medic
Two randomised trials totalling 2,550 patients found no mortality benefit, no less delirium and no better ambulation with spinal anaesthesia, so telling a patient that spinal is the safer choice is not supported.
General Anesthesia Is an Acceptable Choice for Hip Fracture Surgery, Regional anesthesia and pain medicine 2023 · PMID 36977525
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours, and the pericapsular nerve group block outperformed femoral and fascia iliaca blocks, though most evidence was low confidence.
2
2
In REGAIN, spinal anaesthesia was not superior to general for hip fracture: death or inability to walk at 60 days occurred in 18.5% versus 18.0%, and delirium in 20.5% versus 19.7%.
3
3
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in the first 24 hours and more prescription analgesic use at 60 days (25% versus 18.8%) than general anaesthesia.
4
4
Two randomised trials totalling 2,550 patients found no mortality benefit, no less delirium and no better ambulation with spinal anaesthesia, so telling a patient that spinal is the safer choice is not supported.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours
Annals of emergency medicine 2024
In REGAIN, spinal anaesthesia was not superior to general for hip fracture
The New England journal of medicine 2021
REGAIN's pain analysis found spinal anaesthesia gave slightly worse worst-pain in
Annals of internal medicine 2022
Two randomised trials totalling 2,550 patients found no mortality benefit, no less
Regional anesthesia and pain medicine 2023
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours
Questions I'll ask you in the room
How does your plan change if the patient is not optimised?
What is the physiology behind what we just did?
Talk me through the trade-off you made there.
What would make you abandon this plan and do something else?
Oral boards stem
An 87-year-old with dementia and aortic stenosis presents for hemiarthroplasty after a hip fracture. The orthopaedic team asks for a spinal because it is "safer for her head".
Board questions
1. In the REGAIN trial of spinal versus general anaesthesia for hip fracture surgery, name the composite outcome reported at 60 days, give the rate in each group, and state the trial's conclusion about superiority.
Show answer
Death or inability to walk independently at 60 days occurred in 18.5% of spinal patients versus 18.0% of general anaesthesia patients, and delirium occurred in 20.5% versus 19.7%; spinal anaesthesia was not superior to general anaesthesia for hip fracture surgery.
REGAIN's rates sit close enough together that you cannot promise a family the spinal will keep her walking or keep her from becoming delirious.
Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults, The New England journal of medicine 2021 · PMID 34623788
2. A patient with a hip fracture is waiting for surgery. What does the network meta-analysis evidence show about preoperative peripheral nerve blocks for pain at two hours, which block ranked best, and how confident is that evidence?
Show answer
Preoperative peripheral nerve blocks reduce hip fracture pain at two hours; the pericapsular nerve group block outperformed femoral and fascia iliaca blocks, but most of the evidence supporting this was low confidence.
The two-hour analgesic benefit is worth acting on, but the ranking of the pericapsular nerve group block over femoral and fascia iliaca rests mostly on low-confidence evidence.
Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis, Annals of emergency medicine 2024 · PMID 38385910
3. REGAIN included an analysis of pain and analgesic use. Describe how spinal anaesthesia compared with general anaesthesia for worst pain in the first 24 hours and for prescription analgesic use at 60 days, including the numbers.
Show answer
Spinal anaesthesia gave slightly worse worst-pain scores in the first 24 hours and more prescription analgesic use at 60 days, 25% versus 18.8%, compared with general anaesthesia.
If anything the pain data run against spinal: slightly worse early worst pain, and more patients still on prescription analgesics at 60 days.
Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial, Annals of internal medicine 2022 · PMID 35696684
4. The surgical team asks you to tell a hip fracture patient that a spinal is the safer anaesthetic. Citing the randomised evidence, state how many patients have been randomised, which outcomes were compared, and what you can honestly tell the patient.
Show answer
Two randomised trials totalling 2,550 patients compared mortality, delirium and ambulation and found no mortality benefit, no reduction in delirium and no better ambulation with spinal anaesthesia, so telling a patient that spinal is the safer choice is not supported by that evidence.
Two trials and 2,550 patients later, 'spinal is safer' is a claim the randomised data do not support — tell the patient these outcomes looked the same.
General Anesthesia Is an Acceptable Choice for Hip Fracture Surgery, Regional anesthesia and pain medicine 2023 · PMID 36977525
The bottom linePreoperative peripheral nerve blocks reduce hip fracture pain at two hours
Sources
[1] Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis, Annals of emergency medicine 2024 · PMID 38385910 open
[2] Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults, The New England journal of medicine 2021 · PMID 34623788 open
[3] Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial, Annals of internal medicine 2022 · PMID 35696684 open
[4] General Anesthesia Is an Acceptable Choice for Hip Fracture Surgery, Regional anesthesia and pain medicine 2023 · PMID 36977525 open