More pain, medication use seen with spinal vs. general anesthesia for hip fracture surgery
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Published results showed use of spinal anesthesia during hip fracture surgery led to more pain in the first 24 hours and use of more prescription analgesia at 60 days compared with general anesthesia.
“In our study, patients who got spinal anesthesia did get fewer opioids in the operating room, but they ended up having more pain and more prescription pain medication use after surgery,” Mark D. Neuman, MD, MSc, lead author of the study and associate professor of anesthesiology and past chair of the Penn Medicine Opioid Task Force, said in a press release from the University of Pennsylvania. “While our study can’t determine conclusively whether this was due to the spinal anesthesia itself or the fact that fewer opioids were given up front, this is a result that should make people examine some of the assumptions informing current care pathways.”
Neuman and colleagues randomly assigned 1,600 patients aged 50 years or older scheduled to undergo surgical repair of a clinically or radiographically diagnosed femoral neck, intertrochanteric or subtrochanteric hip fracture to receive either spinal anesthesia (n=795) or general anesthesia (n=805). Outcome measurements included patient pain on postoperative days 1 through 3, patient pain and prescription analgesic use at 60-, 180- and 365-days and patient satisfaction with care.
Results showed 73% of patients reported severe pain during the first 24 hours after surgery, with patients who received spinal anesthesia reporting worse pain during the first 24 hours after surgery. However, researchers found the groups had no differences in pain at other time points. Researchers noted 25% of patients in the spinal anesthesia group and 18.8% of patients in the general anesthesia group reported prescription analgesic use at 60 days postoperatively. Both groups reported similar satisfaction, according to results.
References
Neuman MD, et al. Ann Intern Med. 2022;doi:10.7326/M22-0320.
Spinal anesthesia linked to higher painkiller use in hip fracture patients. https://www.pennmedicine.org/news/news-releases/2022/june/spinal-anesthesia-linked-to-higher-painkiller-use-in-hip-fracture-patients. Published June 13, 2022. Accessed June 13, 2022.
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Mike R. Reed, MBBS, MD, FRCS, FRCS(Tr & Orth)
This key study found no difference in its primary outcome, but the authors reasonably argue that the trial’s secondary outcomes become more important in that context. Severe pain occurs in 70% of these patients, and the key finding is the increase in reported pain in the spinal anesthesia group in the first 24 hours post-surgery and also an increase in analgesia use at the 2-month point. This is a surprising but important finding and perhaps not what would have been predicted. It may reflect poor pain control when the spinal anesthesia wears off, and this may have a lasting effect up to 2 months. In addition, patients who received spinal anesthesia had almost double the risk of the severe shivering postoperatively. There are some previously known benefits to spinal anesthesia such as reduced thromboembolism (in the absence of thromboprophylaxis) that may mean that the debate will still rage among anesthetists and, as ever, further studies are required.
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This paper has two take-home points for the practicing orthopedic surgeon. First, hip fracture patients can be expected to have a fair amount of pain on postoperative day 1 regardless on anesthetic choice. So, when you’re rounding the next day, don’t be surprised. It reliably improves of the following days. Second, about 25% of hip fracture patients are still using narcotics at 2 months. These are some easy points to remember when managing hip fractures.
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