/practice/journal-club / 2021
REGAIN: Spinal vs General Anesthesia for Hip-Fracture Surgery
Neuman MD et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults. NEJM 2021;385:2025-2035.
geriatric · hip-fracture · regional · delirium
Hook
No difference in 60-day mortality, ambulation, or delirium — pick what fits the patient.
Population, Intervention, Comparison, Outcome
- Population
- 1,600 adults ≥50 yo undergoing surgery for hip fracture across 46 US/Canada centers.
- Intervention
- Spinal anesthesia (with or without sedation).
- Comparison
- General anesthesia (with or without LMA/ETT).
- Outcome
- Composite of death OR new inability to walk ~10 ft independently at 60 days; secondary: delirium incidence.
Methods
Pragmatic, multicenter RCT. Randomization at the patient level. Anesthesia provider chose technique within the assigned arm. Outcomes by blinded telephone follow-up at 60 days.
Findings
- Primary composite: 18.5% spinal vs 18.0% general (RR 1.03, 95% CI 0.84-1.27, P=0.83).
- Death alone: 3.9% spinal vs 4.1% general.
- New inability to walk: 15.2% vs 14.4%.
- Delirium incidence similar between groups (≈21%).
Clinical takeaway
Pre-REGAIN: 'spinal is better for elderly hip fx' was widely believed. REGAIN debunked it. Choose technique based on patient comorbidities (severe AS → consider spinal contraindication, sympathetic surge with GA), provider experience, anticipated case length, anticoagulation status. Both are reasonable. Optimization across both arms (preop fascia iliaca block, normothermia, judicious fluids, time-to-OR <48 hr) drives outcomes more than technique choice.
Limitations
- Pragmatic design — providers chose specific drugs/dosing, increasing variability.
- Excluded patients with absolute contraindication to either technique, so highest-risk patients aren't represented.
- Did not capture long-term cognitive outcomes beyond delirium screening.
- Composite endpoint dominated by 'unable to walk' — may not capture quality-of-life nuances.
Discussion questions
- What patient factors push you toward spinal vs GA for hip fx in your practice?
- Should the field reframe 'best anesthetic for hip fx' as 'best PERIOPERATIVE BUNDLE' (block + early surgery + multimodal) rather than the spinal/GA debate?
- Does REGAIN change your stance on spinal for octogenarians with multiple comorbidities?