Neuraxial anesthesia for orthopedic surgery: systematic
               review and meta-analysis of randomized clinical trials

Barbosa, Fabiano Timbó; Castro, Aldemar Araújo; Sousa-Rodrigues, Célio Fernando de

doi:10.1590/1516-3180.2013.1316667

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Sao Paulo Medical Journal

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Original Article • Sao Paulo Med. J. 131 (06) • 2013 • https://doi.org/10.1590/1516-3180.2013.1316667 copy

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials

Anestesia neuroaxial para cirurgia ortopédica: revisão sistemática e metanálise de ensaios clínicos randomizados

Authorship SCIMAGO INSTITUTIONS RANKINGS

CONTEXT AND OBJECTIVE:

Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery.

DESIGN AND SETTING:

Systematic review at Universidade Federal de Alagoas.

METHODS:

We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included.

RESULTS:

Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167).

CONCLUSION:

So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia.

Mortality; Anesthesia, general; Anesthesia, epidural; Anesthesia, spinal; Review [publication type]

Database	Search strategy
PubMed	(Therapy/Broad[filter])
	AND
	("anesthesia, general"[MeSH Terms] OR "anesthesia, inhalation"[MeSH Terms] OR "anesthesia, intravenous"[MeSH Terms] AND "anesthesia, conduction"[MeSH Terms] OR "anesthesia, epidural"[MeSH Terms] OR "anesthesia, spinal" [MeSH Terms])
	AND
	"orthopedics"[MeSH Terms] OR Orthopedics [Text Word])

Study (year)	Anesthesia	n	Surgery	Outcomes studied	Remark
Berggren et al.15	GA	29	Femoral neck fracture surgery	Stroke, cognitive dysfunction, pneumonia	Only fully lucid patients were included in the study
Berggren et al.15	EA	28	Femoral neck fracture surgery	Stroke, cognitive dysfunction, pneumonia	Only fully lucid patients were included in the study
Bigler et al.16	GA	20	Hip surgery	Mortality, cognitive dysfunction	Patients with severe dementia, cancer and psychiatric or disseminated neurological disease were not studied
Bigler et al.16	SA	20	Hip surgery	Mortality, cognitive dysfunction
Casati et al.18	GA	15	Hemiarthroplasty of the hip	Length of hospitalization, cognitive dysfunction	One woman in each group
Casati et al.18	USA	15	Hemiarthroplasty of the hip	Length of hospitalization, cognitive dysfunction	One woman in each group
Davis et al.22	GA	68	Emergency hip surgery	Mortality, stroke, myocardial infarction	General anesthetic technique may not have been the same for all patients
Davis et al.22	SP	64	Emergency hip surgery	Mortality, stroke, myocardial infarction
Davis et al.23	GA	279	Hip fracture surgery	Mortality, length of hospitalization	Multicenter study; the length of follow-up was not the same for all patients
Davis et al.23	SA	259	Hip fracture surgery	Mortality, length of hospitalization
Eroglu et al.25	GA	20	Total hip replacement	Blood transfusion requirements	Hypotensive anesthesia was used in both groups
Eroglu et al.25	EA	20	Total hip replacement	Blood transfusion requirements	Hypotensive anesthesia was used in both groups
Hole et al.27	GA	31	Total hip arthroplasty	Mortality, myocardial infarction, degree of satisfaction	Only changes in mental status were analyzed, such as amnesia regarding personal data and disorientation relating to time, place and situation
Hole et al.27	EA	29	Total hip arthroplasty	Mortality, myocardial infarction, degree of satisfaction
Jones et al.29	GA	72	Elective hip or knee replacement	Mortality, cognitive dysfunction	Patients over the age of 60 years
Jones et al.29	SA	74	Elective hip or knee replacement	Mortality, cognitive dysfunction	Patients over the age of 60 years
Juelsgaard et al.30	GA SA	14 15	Hip fracture surgery	Mortality, myocardial infarction, length of hospitalization	The authors quote: "Patients with known coronary artery disease scheduled for osteosynthesis of a femoral neck fracture were included in the study". The exclusion criteria were: uncooperative patients, recent myocardial infarction, unstable angina pectoris, significant aortic stenosis and other established contraindications for spinal anesthesia
McKenzie et al.34	GA	51	Femoral neck fracture surgery	Mortality, myocardial infarction	Patients over the age of 65 years
McKenzie et al.34	SA	49	Femoral neck fracture surgery	Mortality, myocardial infarction	Patients over the age of 65 years
McLaren et al. 35	GA	29	Femoral neck fracture surgery	Mortality	More patients in the spinal anesthesia group had respiratory problems
McLaren et al. 35	SA	26	Femoral neck fracture surgery	Mortality
Nielson et al. 37	GA	39	Elective knee arthroplasty	Cognitive dysfunction	Patients between 60 and 86 years of age
Nielson et al. 37	SA	25	Elective knee arthroplasty	Cognitive dysfunction	Patients between 60 and 86 years of age
Racle et al. 38	GA	35	Hip surgery	Mortality, myocardial infarction, stroke, cognitive dysfunction	The patients were women
Racle et al. 38	SA	35	Hip surgery		The patients were women
Riis et al. 39	GA	10	Total hip replacement arthroplasty	Cognitive dysfunction	The authors reported data from a third group with GA and EA combined
Riis et al. 39	EA	10	Total hip replacement arthroplasty	Cognitive dysfunction
Valentin et al.41	GA		Hip fracture surgery	Mortality	Premedication was not given to high-risk patients; there were more high-risk patients in the spinal anesthesia group
Valentin et al.41	SA		Hip fracture surgery	Mortality
White et al.42	GA	20	Femoral neck fracture surgery	Mortality, cognitive dysfunction, pneumonia	Patients in the spinal anesthesia group received general anesthetic drugs reported as "light anesthesia"
White et al.42	SA	19	Femoral neck fracture surgery	Mortality, cognitive dysfunction, pneumonia
Williams-Russo et al.44	GA	134	Total knee replacement	Mortality, length of hospitalization, cognitive dysfunction	The authors developed their own questionnaire to evaluate cognitive dysfunction
Williams-Russo et al.44	EA	128	Total knee replacement	Mortality, length of hospitalization, cognitive dysfunction

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[1] Address for correspondence: Fabiano Timbó Barbosa Universidade Federal de Alagoas Faculdade de Medicina Avenida Lourival Melo Mota, s/no Tabuleiro do Martins - Maceió (AL) - Brasil CEP 57072-970 Tel. (+55 82) 3202-3800 E-mail: fabianotimbo@yahoo.com.br