Anesthesia in the News
  • Post-op Pain by Anesthesia Type in Hip Fracture Surgery

    For some surgeries, spinal anesthesia has increasingly been used instead of general anesthesia as a method to increase comfort for patients and minimize painkiller use.  But recent research among hip fracture patients shows that this may actually be resulting in the reverse of its intended objectives.

    The randomized trial, dubbed the REGAIN Trial and led by Mark D. Neuman, MD, an anesthesiologist and health services researcher with the University of Pennsylvania, Philadelphia, was published in the July issue of Annals of Internal Medicine.  In it, the investigators sought to confirm whether assumptions about spinal anesthesia and lessened pain were accurate.

    Spinal vs general

    Their study group was comprised of 1,600 patients aged 50 year and older (mean age 78 years, 77% female) from 46 hospitals across the United States and Canada who’d had hip fracture surgery between 2016 and 2021.  Approximately half of the enrollees had spinal anesthesia for their surgery while the other half had general anesthesia.  Each patient was asked to assess their levels of pain (on a scale of 1 to 10) at varying intervals, and to indicate their prescription painkiller use following the procedure.

    Aims beyond safety

    Surgery is necessary for most hip fractures in order to restore function and resolve pain.  But while previous studies have found that general anesthesia is just as safe as spinal anesthesia for hip fracture surgery, the authors note that few studies that characterize differences in pain by anesthesia type or which describe patients’ satisfaction with care following spinal versus general anesthesia have been conducted on this scale to date.

    Clinical practice guidelines of the American Academy of Orthopedic Surgeons for the management of hip fracture in older adults state that either spinal or general anesthesia is appropriate for patients with a hip fracture.  However, the guidelines are based, in part, on studies that focused on mortality.  In terms of pain, the guidelines cite a 2017 study (Haghighi 2017) in which lower postoperative pain scores were associated with spinal versus general anesthesia.

    First-day pain after hip fracture surgery

    Much of the published data on pain levels within the first 24 hours of a hip fracture surgery differs.  One small Italian study found similar pain scores for spinal versus general anesthesia within 12 hours of surgery.  A study of 387 patients from two hospitals in Iran documented lower pain scores with spinal versus general anesthesia within 48 hours of surgery.

    This new analysis found that >70% of patients reported severe pain within 24 hours of surgery, in particular, patients who received spinal anesthesia versus general anesthesia.  Not only was the procedure found to be more painful during the first 24 hours for patients who received spinal anesthesia, but these patients had higher rates of prescription analgesic use at 60 days, according to the research.

    Overall, patients rated their worst pain in the day following their procedure, with the spinal anesthesia patients indicating slightly higher levels of their worst pain, averaging 7.9 out of 10 compared to 7.6 among those who’d undergone general anesthesia.  Specifically, 73.5% of all patients rated their pain as severe (at least 7 on a scale of 1 to 10) within 24 hours of after the surgery.  Interestingly, there was no difference in pain levels between the 2 groups at other time points.

    Patients who received spinal anesthesia were 25% (141 of 563) more likely to require prescription analgesics 60 days later, compared to 18.8% (108 of 574) of patients assigned to general anesthesia.  There was not a significant difference noticed in prescription pain medicine use at 6 and 12 months from the surgery and patient satisfaction was similar across groups.

    Greater pain—but why?

    The authors posit that perhaps the differences in pain levels between the 2 groups could be due to not adequately treating the pain of patients who received spinal anesthesia.

    “It is possible that these differences may have been due to relative undertreatment of pain for patients in the spinal anesthesia group at the time of spinal block resolution during the first 24 hours after surgery,” the authors hypothesize.  “We did not find differences in pain by anesthesia type at other time points during hospitalization or after discharge.”

    In addition, the research has some limitations, such as having incomplete data on all patients in the study and failure to collect data on nonopioid analgesics used prior to surgery, among other factors.  As a result, the authors caution that the findings should be considered “exploratory and hypothesis generating” and suggest that future research should explore postoperative pain in greater detail accounting for opioid use and physical therapy.

    Care need beyond anesthesia type

    Information about the patient experience after hip fracture surgery can help to inform choices about care, the authors note in summarizing the broader implications of their data.  “As a large proportion of patients in each group reported high levels of pain over the first 3 days after surgery, our results also highlight the need for additional efforts to better manage postoperative pain regardless of whether patients receive general or spinal anesthesia.”

    In future work, stated a release from the institution, the investigators hope to improve pain care for patients with hip fracture and dementia by finding ways to increase use of peripheral nerve blocks—a form of local anesthetic injection that “remains under-used despite recommendations encouraging their use for all hip fracture patients.”

    In addition, they want to apply the same comparative anesthetic methodology (spinal versus general) they used in the REGAIN trial to total joint replacements, such as hip replacements.

    Find more about the REGAIN Trial findings in “Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery: A Randomized Clinical Trial,” at https://pubmed.ncbi.nlm.nih.gov/35696684/

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