Spinal anesthesia during THA may reduce pain scores, oral morphine equivalent use
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Use of spinal anesthesia during total hip arthroplasty may reduce postoperative pain scores and oral morphine equivalent use compared with general anesthesia, according to published results.
“In this study of over 14,000 primary total hip arthroplasties completed at the Mayo Clinic, we found that spinal anesthesia was associated with reduced pain scores and oral morphine equivalents postoperatively. In addition, there were few altered mental status events and ICU admissions,” Matthew P. Abdel, MD, the Andrew A. and Mary S. Sugg Professor of Orthopedic Surgery and chair of the division of orthopedic surgery research at the Mayo Clinic in Rochester, Minnesota, told Healio.
Abdel and colleagues assessed patient-reported pain with the numeric pain rating scale (NPRS) and opioid utilization by oral morphine equivalents in a retrospective cohort of patients who underwent primary THA and received either general anesthesia (58%) or spinal anesthesia (42%) from 2001 to 2016. Researchers collected postoperative outcomes, including altered mental status events, blood transfusion requirements, postoperative urinary retention requiring catheterization, ICU admissions, 90-day venous thromboembolic events and 30- and 90-day readmissions, through an institutional anesthesia database using ICD-10 codes and admission transfer data. Researchers also collected arthroplasty-specific complications, such as all-cause revisions and all-cause reoperations. Researchers used an inverse probability of treatment-weighted model based on a propensity score that accounted for numerous patient and operative factors to analyze data.
Results showed a trend toward increased utilization of spinal anesthesia and decreased utilization of general anesthesia during the study period. Researchers found the maximum utilization of general anesthesia occurred in 2007 at 67% and the lowest recorded utilization occurred in 2015 at 47%, while the maximum utilization of spinal anesthesia occurred in 2015 at 53% and the lowest recorded utilization occurred in 2002 and 2007 at 33%.
At all evaluated time points, patients who received spinal anesthesia had lower NPRS scores and fewer postoperative oral morphine equivalents, according to results. Researchers also found a shorter hospital length of stay, fewer altered mental status events and fewer ICU admissions among patients who received spinal anesthesia. However, researchers noted no differences in the incidences of deep vein thrombosis, pulmonary embolism, 30- and 90-day readmissions, all-cause revisions or all-cause reoperations between the spinal and general anesthesia groups.
“In conclusion, the results of this study further support the use of spinal anesthesia in primary THAs when medically appropriate,” Abdel said. “This is particularly pertinent during a nationwide push to ambulatory surgery centers in the COVID-19 pandemic.”
Perspective
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The study by Aaron R. Owen, MD, and colleagues is a well-executed, propensity score-matched, retrospective study that included pain outcomes all the way until the end of hospitalization, which is something lacking in many other database studies. Their results were similar to those reported by other authors who performed database studies and suggest that spinal anesthesia could confer some benefits in terms of postoperative opioid use and length of stay. They also observed a trend of increasing spinal anesthesia use in their practice, which mirrors that of many other practices around the U.S.
While propensity score matching attempts to control for confounders, it is unable to control for local selection bias and unknown confounders. The trend in more recent years in the authors’ practice of a greater proportion of patients receiving spinal anesthesia occurred as broad advances in orthopedic practice, such as routine use of multimodal analgesia, newer peripheral nerve blocks and a general push to reduce length of stay, also occurred. Short-acting spinal drugs have also grown in popularity in recent years, and this could have played a role as well in earlier ambulation in that cohort.
I applaud the authors for undertaking a major effort and for the inclusion of so many patients. I do believe, however, that the only way to truly know if spinal anesthesia is superior to general anesthesia for these outcomes is to perform a multicenter, randomized-controlled trial that eliminates the selection bias present in almost every practice. Until that study is performed, we will continue to rely on important studies, like this one by Owen and colleagues, and our clinical judgment in conjunction with patient preferences to decide the anesthesia type we will use for total hip arthroplasty.
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