Mark D. Neuman, University of Pennsylvania
Rui Feng, University of Pennsylvania
Jeffrey L. Carson, Rutgers Robert Wood Johnson Medical School
Lakisha J. Gaskins, University of Pennsylvania
Derek Dillane, University of Alberta Hospital
Daniel I. Sessler, Cleveland Clinic
Frederick Sieber, Johns Hopkins University
Jay Magaziner, University of Maryland at Baltimore
Edward R. Marcantonio, Harvard University
Samir Mehta, University of Pennsylvania
Diane Menio, Temple University
Sabry Ayad, Cleveland Clinic
Trevor Stone, University of British Columbia
Steven Papp, Ottawa Hospital
Eric S. Schwenk, Thomas Jefferson UniversityFollow
Nabil Elkassabany, University of Pennsylvania
Mitchell Marshall, New York University Langone Health
J. Douglas Jaffe, Wake Forest University School of Medicine
Charles Luke, University of Pittsburgh Medical Center
Balram Sharma, Lahey Hospital and Medical Center
Syed Azim, Stony Brook University
Robert A. Hymes, Inova Fairfax Medical Campus
Ki-Jinn Chin, University of Toronto, Faculty of Law
Richard Sheppard, Hartford Hospital
Barry Perlman, Oregon Health and Science University
Joshua Sappenfield, University of Florida
Ellen Hauck, Temple University
Mark A. Hoeft, University of Vermont
Mark Giska, Henry Ford Health System
Yatish Ranganath, The University of Iowa
Tiffany Tedore, New York-Presbyterian/Weill Cornell Medical Center
Stephen Choi, Sunnybrook Hospital
Jinlei Li, Yale University
M. Kwesi Kwofie, Dalhousie University
Antoun Nader, Northwestern University
Robert D. Sanders, University of Sydney
Brian F. S. Allen, Vanderbilt University
Kamen Vlassakov, Brigham and Women's Hospital
Stephen Kates, Virginia Commonwealth University
Lee A. Fleisher, University of Pennsylvania
James Dattilo, University of Pennsylvania
Ann Tierney, University of Pennsylvania
Alisa J. Stephens-Shields, University of Pennsylvania
Susan S. Ellenberg, University of Pennsylvania

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From The New England Journal of Medicine, Neuman et al., Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults, Vol. 385, No. 22, Copyright © 2021 Massachusetts Medical Society. Reprinted with permission.

The published version is available at


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 number, NCT02507505.).

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