Neuraxial versus General Anesthesia

Key Question

Among older patients undergoing surgery and anesthesia, does neuraxial anesthesia as the primary anesthetic approach improve postoperative outcomes compared with general anesthesia?

Balance Tables

Benefits, harms, and strength of evidence (GRADE) for neuraxial versus general anesthesia.

Outcome	RCT	Neuraxial	General	GRADE*	Effect	Estimate (95% CI)
		N (Total)	N (Total)
Delirium	10	215 (1,840)	213 (1,908)	⨁⨁⨁◯	RR	1.06 (0.84–1.33)†,‡
Neurocognitive disorder <30 days	4	78 (336)	88 (355)	⨁⨁◯◯	RR	0.91 (0.56–1.48)
Neurocognitive disorder 30 days to 1 yr	1	23 (176)	25 (188)	⨁◯◯◯	RR	0.98 (0.58–1.67)
Physical function	3	(355)	(371)	⨁◯◯◯	SMD	0.01 (-0.39 to 0.42)§
Complications**	13			⨁⨁◯◯ ⨁◯◯◯		see below
Patient satisfaction	10	913 (1,055)	839 (991)	⨁⨁◯◯	RR	1.02 (0.98–1.05)††
Length of stay (days)	13	(2,355)	(2,373)	⨁⨁◯◯	MD	-0.4 (-1.1 to 0.3)
Discharged to institution	1	576 (777)	586 (777)	⨁◯◯◯	RR	0.98 (0.93-1.04)
Mortality (in-hospital and 30-day)
All procedures	6	19 (1,789)	32 (1,859)	⨁⨁◯◯	RR	0.66 (0.28–1.50)
	9	19 (1,926)	31 (1,942)		RD/1000	-5.4 (-12.3 to 1.5)
Hip fracture	4	19 (1,467)	28 (1,536)	—	RR	0.75 (0.34–1.64)
	5	19 (1,486)	27 (1,557)		RD/1000	-3.6 (-16.6 to 9.5)
Other	2	19 (322)	31 (323)	—	RR	0.20 (0.02–1.71)‡‡
	4	0 (440)	4 (443)		RD/1000	-8.8 (-21.1 to 3.6)
Mortality (90-day)	3	15 (427)	16 (499)	⨁◯◯◯	RR	1.12 (0.57–2.20)
	3	15 (427)	16 (499)		RD/1000	-3.1 (-15.4 to 9.1)
RCT: randomized clinical trial; GRADE: Grades of Recommendation, Assessment, Development, and Evaluation; RR: risk ratio; SMD: standardized mean difference; MD: mean difference; RD/1000: risk difference per 1000.
* Very low: ⨁◯◯◯; Low: ⨁⨁◯◯; Moderate: ⨁⨁⨁◯; High: ⨁⨁⨁⨁.
† Hip fracture trials (n = 6) RR 1.08 (95% CI, 0.87–1.35); other procedures (n = 4) RR 0.74 (95% CI, 0.35–1.57).
‡ RD per 100 for all surgeries 0.1 (-1.8 to 2.2); in hip fracture trials 1.3 (-1.3 to 3.9); others -2.2 (-9.2 to 4.8).
§ Using Neuman 2021 primary result of inability to walk 60 feet without human assistance in a sensitivity analysis including 1644 patients yield a pooled SMD -0.07 (95% CI, -0.25 to 0.12).
** Complications reported variously across the 13 trials.
†† Comparing higher/highest category or categories with lower ones.
‡‡ Common effects model (2 trials).

Included complications and strength of evidence (GRADE) for neuraxial versus general anesthesia.

Outcome	RCT	Neuraxial	General	GRADE*	Effect†	Estimate (95% CI)
		N (Total)	N (Total)
Myocardial infarction	5	12 (1,655)	12 (1,600)	⨁⨁◯◯	RR	0.86 (0.44–1.66)
					RD/1000	0.7 (-3.4 to 4.9)
Cardiac arrest	1	2 (783)	0 (793)	⨁◯◯◯	RD/1000	2.6 (-2.2 to 6.7)
Bradycardia	3	6 (67)	4 (67)	⨁◯◯◯	RR	1.33 (0.14–13.0)
	4	6 (107)	4 (107)		RD/1000	10.4 (-39.7 to 60.6)
Stroke	3	7 (1,365)	8 (1,370)	⨁◯◯◯	RR	0.83 (0.30–2.28)
					RD/1000	-1.6 (-6.8 to 3.5)
Acute Kidney Injury	4	33 (1,118)	58 (1,129)	⨁⨁◯◯	RR	0.59 (0.39–0.89)
					RD/1000	-21.7 (-38.1 to -5.3)
Pulmonary complications‡	1	5 (58)	9 (118)	⨁◯◯◯	RR	0.90 (0.29–2.81)
					RD/1000	-7.4 (-88.2 to 73.6)
Pneumonia	7	14 (1,714)	26 (1,659)	⨁⨁◯◯	RR	0.53 (0.31–0.92)
					RD/1000	-7.4 (-15.0 to 0.1)
Pulmonary congestion	1	9 (783)	8 (793)	⨁◯◯◯	RR	1.14 (0.44–2.94)
					RD/1000	1.4 (-8.8 to 11.6)
Pulmonary embolism	6	7 (1,455)	13 (1,406)	⨁◯◯◯	RR	0.56 (0.27–1.16)
					RD/1000	-4.9 (-11.4 to 1.7)
Reintubation	1	4 (783)	7 (793)	⨁◯◯◯	RR	0.37 (0.17–1.97)
					RD/1000	-3.7 (-11.9 to 4.5)
RCT: randomized clinical trial; GRADE: Grades of Recommendation, Assessment, Development, and Evaluation; AKI: acute kidney injury; RR: risk ratio; RD/1000: risk difference per 1000.
* Very low: ⨁◯◯◯; Low: ⨁⨁◯◯; Moderate: ⨁⨁⨁◯; High: ⨁⨁⨁⨁.
† Fixed/common effects models when 2 studies.
‡ Complications reported included pneumonia, respiratory failure, or unspecified.

Outcomes Reported

Table 2. Publications reporting dichotomous or count outcomes (not necessarily unique studies)..

Outcome	RCT, N = 39a
ADL	3 (7.7%)
Complications	18 (46%)
DNCR/POCD	5 (13%)
Delirium	11 (28%)
Delirium duration	—
Discharge location	2 (5.1%)
Mortality	9 (23%)
Opioid use	1 (2.6%)
Pain	4 (10%)
QoR	—
Readmission	2 (5.1%)
Satisfaction	10 (26%)
ADL: activities of daily living; DNCR: delayed neurocognitive recovery; PND: postoperative neurocognitive disorder; QoR: quality of recovery; RCT: randomized clinical trial.
a Number of publications, not unique trials (see inlcuded studies below).

Table 3. Publications reporting continuous outcomes (not necessarily unique studies).

Outcome	RCT, N = 39a
Delirium duration	1 (2.6%)
Length of stay	12 (31%)
Opioid use	7 (18%)
RCT: randomized clinical trial.
a Number of publications, not unique trials (see inlcuded studies below).

Table 4. Publications reporting likert or ordinal outcomes (not necessarily unique studies).

Outcome	RCT, N = 39a
ADL	3 (7.7%)
DNCR/POCD	10 (26%)
Delirium	1 (2.6%)
Complications	1 (2.6%)
Pain	16 (41%)
Quality of life	1 (2.6%)
QoR	1 (2.6%)
Satisfaction	1 (2.6%)
ADL: activities of daily living; DNCR: delayed neurocognitive recovery; PND: postoperative neurocognitive disorder; QoR: quality of recovery; RCT: randomized clinical trial.
a Number of publications, not unique trials (see inlcuded studies below).

Included Studies

See Appendix for detailed summary study and patient characteristics including primary outcomes.

Table 5. Number of included trials.

Design	Studies
Randomized Clinical Trial	37
Total	37
One trial with three publications counted once.

Design, centers, country, and surgery

Table 6. Enrollment, centers, country, and surgical procedures (see References for citations).

ID	Study	Centers	Enrolled	Country	Surgery
4782	Liang 2017	1	198	Chinaa	Hip fracture
13141	Ren 2021	1	281	Chinaa	Hip fracture
7490	Li 2022	9	950	China	Hip fracture
6072	Meuret 2018	1	40	France	Hip fracture
1320	Tzimas 2018	1	72	Greece	Hip fracture
13669	Haghighi 2017	1	100	Irana	Hip fracture
14441	Casati 2003	1	30	Italy	Hip fracture
6109	Shin 2020	1	186	South Korea	Hip fracture
1335	Parker 2015	1	322	UK	Hip fracture
8117	Neuman 2021	46	1600	USA	Hip fracture
17100	Neuman 2022 (Neuman 2021)	46	1600	USA	Hip fracture
18678	O’Brien 2023 (Neuman 2021)	46	1600	USA	Hip fracture
6540	Bielka 2021	1	90	Ukrainea	Hip fracture
14566	Chu 2006	1	60	Chinaa	Ortho
1489	Zhang 2019a	1	80	Chinaa	Ortho
2020	Wang 2020b	1	25	Chinaa	Ortho
158	Xu 2020	1	240	Chinaa	Ortho
5894	Mandal 2011	1	60	Indiaa	Ortho
17971	Sciberras 2022	1	210	Malta	Ortho
208	Harsten 2013	1	124	Sweden	Ortho
269	Harsten 2015	1	120	Sweden	Ortho
2252	Edipoglu 2019	1	80	Turkey	Ortho
781	Silbert 2014	1	98	Australia	Urol
296	Salonia 2004	1	72	Italy	Urol
329	Salonia 2006	1	121	Italy	Urol
397	Nishikawa 2007b	1	80	Japan	Urol
737	Ornek 2010	1	60	Turkeya	Urol
3218	Alas 2020	1	61	USA	Urol
16573	Jia 2014	1	240	Chinaa	GI/Abdominal
6132	Wang 2016	1	206	Chinaa	GI/Abdominal
658	Wongyingsinn 2020	1	54	Thailand	GI/Abdominal
241	Mazul-Sunko 2010	1	57	Croatia	Neuro
15278	Apan 2016	1	52	Turkey	Neuro
262	Purwar 2015	1	60	UK	Gyn
1400	Papaiannou 2005	1	50	Greece	Gyn|Ortho|Urol|Vasc
7554	Brown 2021	1	219	USA	Spine
307	Nesek-Adam 2012	1	40	Croatia	Vasc
831	Rasmussen 2003	12	428	Denmark	Variousb
239	Carron 2007	1	40	Italy	Otherc
GI: gastrointestinal; Ortho: orthopedic; Urol: urological; Neuro: neurological; Vasc: vascular; Various: described as various/mixed or more than 4 different tyeps of procedures.
a Non very-high Human Development Index country.
b Described as various or more than 4 different types of surgery.
c Loco-regional antiblastic perfusion with circulatory block.

Country Summary

Table 7. Summary of trials by country where conducted.

	N = 37a
Country
China	9 (24%)
Italy	4 (11%)
Turkey	3 (8.1%)
USA	3 (8.1%)
Croatia	2 (5.4%)
Greece	2 (5.4%)
Sweden	2 (5.4%)
UK	2 (5.4%)
Australia	1 (2.7%)
Denmark	1 (2.7%)
France	1 (2.7%)
India	1 (2.7%)
Iran	1 (2.7%)
Japan	1 (2.7%)
Malta	1 (2.7%)
South Korea	1 (2.7%)
Thailand	1 (2.7%)
Ukraine	1 (2.7%)
a n (%)

Comparators

Table 8. Selected characteristics of randomized clinical trials comparing neuraxial to general anesthesia.

Study	N	Arm	ASA	Agea	MMSEa	Dementia N (%)b	General			Neuraxial
			PS				Vol	TIVA	NR	Spinal	Epid	CSE
Ortho — HipFx
Casati 2003	15	Gen	23	84.0 [67-88]	29 [24-29]		●
	15	Neur		84.0 [71-94]	28 [25-30]					●
Parker 2015	164	Gen	1234	83.0 [59-99]					●
	158	Neur		82.9 [25-105]						●
Haghighi 2017	50	Gen	123	66.0 (4.8)		0 (0)	●
	50	Neur		66.2 (5.2)		0 (0)				●
Liang 2017	66	Gen	123	68.0 (11.0)	26.7 (1.6)	0 (0)		●
	66	Neur		67.0 (12.0)	26.8 (2.0)	0 (0)					●
	66	Neur		66.0 (10.0)	26.6 (1.9)	0 (0)						●
Meuret 2018	21	Gen	123	85.0 (5.0)	21 [12-24]			●
	19	Neur		83.0 (6.0)	19 [12-26]					●
Tzimas 2018	33	Gen	123	75.1 (6.1)	25.7 (2.9)	0 (0)	●
	37	Neur		77.1 (6.5)	25.3 (0.9)	0 (0)				●
Shin 2020	60	Gen	NR	79.4 (7.7)		12 (20.0)	●
	58	Gen		80.5 (6.7)		7 (12.1)		●
	58	Neur		81.6 (6.7)		10 (17.2)				●
Bielka 2021	30	Gen	NR	73.0 {72-74}		0 (0)	●
	30	Neur		72.0 {70-73}		0 (0)				●
Neuman 2021	804	Gen	1234	78.4 (10.6)		94 (11.7)	●
	795	Neur		77.7 (10.7)		109 (13.7)				●
Ren 2021	154	Gen	123	74.1 (4.2)	25.6 (1.4)	0 (0)		●
	127	Neur		73.1 (6.2)	25.7 (1.2)	0 (0)				●
Li 2022	471	Gen	1234	77.0 {71-82}	20 {15-25}	190 (40.3)	●	●
	471	Neur		77.0 {72-82}	20 {15-24}	182 (38.6)				●	●	●
Neuman 2022c	796	Gen	1234	78.0 (11.0)		93 (11.7)	●
	785	Neur		78.0 (11.0)		109 (13.9)				●
O’Brien 2023 (dementia)c	211	Gen	NR			211 (100)	●	●
	225	Neur				225 (100)				●
O’Brien 2023 (no dementia)c	418	Gen	NR			0 (0)	●	●
	408	Neur				0 (0)				●
Ortho — HipFx|Other
Zhang 2019a	40	Gen	NR	69.4 (2.6)		0 (0)		●
	40	Neur		69.4 (2.6)		0 (0)				●
Ortho — TKA|THA|HipFx|Other
Mandal 2011	30	Gen	12	67.1 (7.1)	27.3 (1.8)	0 (0)	●
	30	Neur		66.6 (5.6)	28.0 (1.3)	0 (0)					●
Ortho — TKA
Chu 2006	30	Gen	123	69.0 {62-74}			●
	30	Neur		65.0 {62-68}								●
Harsten 2013	60	Gen	123	68.0 (7.0)				●
	60	Neur		67.0 (7.0)						●
Edipoglu 2019	26	Gen	NR	68.8 (4.9)	22.6 (3.0)	0 (0)	●
	31	Neur		69.8 (4.4)	22.6 (2.7)	0 (0)				●
Sciberras 2022	101	Gen	12	68.0 {61-71}			●	●
	99	Neur		68.0 {62-70}						●
Ortho — THA
Harsten 2015	60	Gen	123	68.0 (9.0)				●
	58	Neur		66.0 (7.8)						●
Xu 2020	80	Gen	NR	75.4 (5.6)				●
	80	Neur		75.6 (5.5)								●
	80	Neur		75.0 (5.2)						●
Ortho
Wang 2020b	13	Gen	NR	58.4 (7.3)			●
	12	Neur		62.7 (8.7)						●
Urol
Salonia 2004	34	Gen	NR	66.0 (6.8)			●
	36	Neur		65.3 (6.9)						●
Salonia 2006	34	Gen	NR	66.0 (7.0)			●
	30	Neurd		59.5 (10.4)						●
	29	Neure		64.1 (8.1)						●
	28	Neurf		65.3 (6.3)						●
Nishikawa 2007b	40	Gen	12	73.0 (6.0)		0 (0)		●
	40	Neur		71.0 (6.0)		0 (0)				●
Ornek 2010	30	Gen	23	70.0 (9.6)			●
	30	Neur		76.4 (11.8)						●
Silbert 2014	50	Gen	NR	63.9 [55-78]		0 (0)	●
	48	Neur		66.9 [56-75]		0 (0)				●
Alas 2020	29	Gen	NR	63.7 (11.4)			●
	29	Neur		67.3 (10.9)						●
GI/Abdominal
Jia 2014	116	Gen	NR	74.8 (4.0)		0 (0)		●
	117	Neur		75.7 (4.2)		0 (0)					●
Wang 2016	103	Gen	NR	71.9 (8.4)				●
	103	Neur		71.2 (7.9)								●
Wongyingsinn 2020	18	Gen	123	67.7 (15.1)			●
	18	Neur		64.9 (10.3)						●
Neuro
Mazul-Sunko 2010	28	Gen	NR	66.0 (8.7)			●
	29	Neur		66.2 (8.3)						●
Apan 2016	25	Gen	123	62.7 (14.3)		0 (0)	●
	25	Neur		67.0 (10.4)		0 (0)					●
Gyn
Purwar 2015	28	Gen	123	65.1 (12.5)			●
	31	Neur		60.6 (11.5)						●
Gyn|Ortho|Urol|Vasc
Papaiannou 2005	28	Gen	1234	≥60	28.1	0 (0)	●	●
	19	Neur		≥60	27.6	0 (0)				●	●
Spine
Brown 2021	106	Gen	NR	72.0 {69-76}	28 {27-29}	0 (0)	●
	111	Neur		73.0 {69-78}	29 {27-29}	0 (0)				●
Vasc
Nesek-Adam 2012	20	Gen	23	61.2 (10.5)			●
	20	Neur		60.6 (9.7)						●
Various
Rasmussen 2003	217	Gen	1234	70.8 [61-84]		0 (0)			●
	211	Neur		71.1 [61-84]		0 (0)				●	●
Other
Carron 2007	20	Gen	123	62.6 (10.7)			●
	20	Neur		65.5 (16.8)						●
Gen: general; Neur: neuraxial; PS: physical stutus; Vol: volatile; TIVA: total intravenous anesthesia; NR: not reported; Epid: epidural; CSE: combined spinal and epidural; Ortho: orthopedic; Urol: urological; GI: gastrointestinal; Neuro: neurologic; Gyn: gynecologic; Vasc: vascular; Ophtho: opthalomogic; Fx: fracture; TKA: total knee arthroplasty; THA: total hip arthroplasty.
a Mean Med (SD)[Range]{IQR}.
b Blank if no information provided.
c Analysis of Neuman 2021.
d Propofol.
e Midazolam.
f Diazepam.

Delirium Incidence

Table 9. Delirium incidence and ascertainment during hospitalization in randomized clinical trials comparing neuraxial to general anesthesia.

Study	N	Arm	MMSE (preop)a	Dementia N (%)b	Scale	Day(s)c	Incidence Proportion		RR (95% CI)
							N (%)	0 – 100%
Hip Fx
Parker 2015	164	Gen			unspecified	Stay	0 (0)		—
	158	Neur					3 (1.9)		Not estimated
Tzimas 2018	33	Gen	25.7 (2.9)	0 (0)	CAM	Stay	4 (12.1)		—
	37	Neur	25.3 (0.9)	0 (0)			10 (27.0)		2.23 (0.77-6.44)
Shin 2020d	118	Gen		22 (18.6)	unspecified	Stay	17 (14.4)		—
	58	Neur		10 (17.2)			8 (13.8)		0.96 (0.44-2.09)
Bielka 2021	30	Gen		0 (0)	DSM	Stay	1 (3.3)		—
	30	Neur		0 (0)			1 (3.3)		1.00 (0.07-15.26)
Neuman 2021d	629	Gen		94 (11.7)	CAM	3	124 (19.7)		—
	633	Neur		109 (13.7)			130 (20.5)		1.04 (0.84-1.30)e
Li 2022d	467	Gen	20 {15-25}	190 (40.3)	CAM	7	21 (4.5)		—
	466	Neur	20 {15-24}	182 (38.6)			24 (5.2)		1.15 (0.65-2.03)
Li 2022 (dementia)	190	Gen		18 (100)	CAM	7	18 (9.5)		—
	182	Neur		21 (100)			21 (11.5)		1.22 (0.67-2.21)
Li 2022 (no dementia)	281	Gen		0 (0)	CAM	7	6 (2.1)		—
	289	Neur		0 (0)			8 (2.8)		1.30 (0.46-3.69)
O’Brien 2023 (dementia)	211	Gen		64 (100)	CAM	Stay	64 (30.3)		—
	225	Neur		71 (100)			71 (31.6)		1.04 (0.79-1.38)f
O’Brien 2023 (no dementia)	418	Gen		0 (0)	CAM	Stay	60 (14.4)		—
	408	Neur		0 (0)			59 (14.5)		1.01 (0.72-1.40)g
GI/Abd
Jia 2014	116	Gen		0 (0)	DRS	Stay	15 (12.9)		—
	117	Neur		0 (0)			4 (3.4)		0.26 (0.09-0.77)
Spine
Brown 2021	106	Gen	28 {27-29}	0 (0)	CAM	Stay	20 (18.9)		—
	111	Neur	29 {27-29}	0 (0)			28 (25.2)		1.34 (0.80-2.22)
Various
Rasmussen 2003	217	Gen		0 (0)	unspecified	Stay	5 (2.3)		—
	211	Neur		0 (0)			4 (1.9)		0.82 (0.22-3.02)
Papaiannou 2005	28	Gen	28.1	0 (0)	DSM	3	6 (21.4)		—
	19	Neur	27.6	0 (0)			3 (15.8)		0.74 (0.21-2.59)
Gen: general anesthesia; Neur: neuraxial; RR: risk ratio; MMSE: Mini-Mental State Examination; CAM: Confusion Assessment Method; DRS: Delirium Rating Scale; DSM: Diagnostic and Statistical Manual of Mental Disorders; NR: not reported.
a Mean Med (SD)[Range]{IQR}.
b Blank if no information provided.
c Day(s) over which incidence proportion assessed. Stay indicates duration of hospitalization.
d Included patients with dementia (O'Brien 2023 report of Neuman 2021; 16.5% of patients in Shin 2020 had dementia, but subgroup results were unreported).
e Adjusted for sex, fracture type and country.
f Odds ratio adjusted for sex, fracture type and country 1.08 (95% CI, 0.72–1.62).
g Odds ratio adjusted for sex, fracture type and country 1.01 (95% CI, 0.69–1.50).

Pooled

Figure 1. Delirium incidence for neuraxial versus general anesthesia.

RR: risk ratio; D1: bias arising from the randomization process; D2: bias due to deviations from intended interventions; D3: bias due to missing outcome data; D4: bias in measurement of the outcome; D5: bias in selection of the reported result: All: overall risk of bias.
Risk of bias ratings: low +, some concerns ?, high – .
Random effects pooled estimate weights — Neuman 2021 (63.6%), Brown 2021 (11.9%), Li 2022 (9.4%), and Shin 2020 (5.1%).
Harbord test for small study effects P = 0.87.
Delirium was designated a primary or secondary outcome in 45.5% and 18.2% of trials, respectively.
In subgroups from O’Brien 2023 (Neuman 2021) and Li 2022 of patients with dementia RR 1.08 (95% CI, 0.83–1.39; common effects model).
In 8 studies including or reporting results for patients without dementia RR 1.03 (95% CI, 0.67–1.57; prediction interval 0.54–1.97).

Meta-analysis methods detail.

- Mantel-Haenszel method (common effect model)
- Inverse variance method (random effects model)
- Restricted maximum-likelihood estimator for τ²
- Q-Profile method for confidence interval of τ² and τ
- Hartung-Knapp adjustment for random effects model (df = 9)
- Hartung-Knapp prediction interval (df = 8)
- Continuity correction of 0.5 in studies with zero cell frequencies

Figure 2. Neuraxial versus general anesthesia (risk difference per 100).

Pooled incidence of postoperative delirium with general anesthesia (common effects models):
Overall 14.7 per 100 (95% CI, 13.0 to 16.6)
Hip fracture 15.1 per 100 (95% CI, 13.1 to 17.4)
Other 13.3 per 100 (95% CI, 10.5 to 17.3)

Figure 3. Neuraxial versus general anesthesia cumulative meta-analysis by study size.

Figure 4. Neuraxial versus general anesthesia small study effects.

Estimates (odds ratios and 95% CIs) from random effects models. Limit meta-analysis shown in light grey — unadjusted 1.06 (0.80–1.41); adjusted for small study effects: 1.06 (0.75–1.49).

Figure 5. General anesthesia event rate (control arm/baseline risk) and risk ratios.

No suggestion for RR dependence on baseline risk. Asterisks indicate trials limited to hip fracture repair.
The overall pooled incidence of postoperative delirium (common effect model) with general anesthesia was 14.7 per 100 (95% CI, 13.0 to 16.6), following hip fracture was 15.1 per 100 (95% CI, 13.1 to 17.4), and for other surgical procedures 13.3 per 100 (95% CI, 10.5 to 17.3).

Figure 6. Summary risk of bias from randomized clinical trials reporting delirium (weighted).

Neurocognitive Disorder
  <30 days

Table 10. Neurocognitive disorder <30 days incidence and ascertainment.

Study	N	Arm	Dementiaa	Preop	Instrument				Dayc	Neurocognitive Disorder <30 days
				MMSEb	MMSE	DST	MoCA	Other		N (%)	0 — 100%	RR (95% CI)
Casati 2003	15	Gen		29 [24-29]	✓d				7	3 (20.0)		—
	15	Neur		28 [25-30]						1 (6.7)		0.33 (0.04-2.85)
Rasmussen 2003	188	Gen	0 (0)			e			7	37 (19.7)		—
	176	Neur	0 (0)							22 (12.5)		0.64 (0.39-1.03)
Silbert 2014	49	Gen	0 (0)			e			7	2 (4.1)		—
	42	Neur	0 (0)							5 (11.9)		2.92 (0.60-14.26)
Wang 2016	103	Gen	f					g	7	46 (44.7)		—
	103	Neur	f							50 (48.5)		1.09 (0.81-1.46)
Mini-Mental State Exam; DST: Digit Span Test; MoCA: Montreal Cognitive Assessment; RR: risk ratio; Gen: general anesthesia.
a Blank if no information provided.
b Mean Med (SD)[Range]{IQR}.
c Day of assessment (excluded Zhang 2019a conducting assessment at day 1).
d Difference from baseline >2 points.
e Z ≥1.96.
f Did not state excluding patients with dementia, but peformed neuropsycholgical testing prior to surgery
g Not reported.

Pooled

Figure 7. Delayed neurcognitive recovery.

Meta-analysis methods detail.

- Mantel-Haenszel method (common effect model)
- Inverse variance method (random effects model)
- Restricted maximum-likelihood estimator for τ²
- Q-Profile method for confidence interval of τ² and τ
- Prediction interval based on t-distribution (df = 2)

Figure 8. Summary risk of bias from randomized clinical trials reporting delayed neurocognitive recovery (weighted).

- Mantel-Haenszel method (common effect model)
- Inverse variance method (random effects model)
- Restricted maximum-likelihood estimator for τ²
- Q-Profile method for confidence interval of τ² and τ
- Prediction interval based on t-distribution (df = 2)

Neurocognitive Disorder
  30 days to 1 year

Table 11. Neurocognitive disorder ≥30 days incidence and ascertainment in a randomized clinical trial comparing neuraxial to general anesthesia.

Study	N	Arm	Dementia	Preop	Instrument				Dayb	Postoperative Neurocognitive Disorder
				MMSEa	MMSE	DST	MoCA	Other		N (%)	0 — 100%	RR (95% CI)
Randomized Clinical Trial
Rasmussen 2003	188	Gen	0 (0)			c			90	25 (13.3)		—
	176	Neur	0 (0)							23 (13.1)		0.98 (0.58-1.67)
Mini-Mental State Exam; DST: Digit Span Test; MoCA: Montreal Cognitive Assessment; RR: risk ratio; Gen: general anesthesia.
a Mean Med (SD)[Range]{IQR}.
b Day of assessment.
c Z ≥1.96.

Physical Function

Table 12. Neuman et al 2021 primary outcome — unable to walk without human assistance at 60 days.

Study	N	Arma	Unable to   Walk N (%)b	0 — 100%	RR (95% CI)
Neuman 2021	701	Gen	101 (14.4)
	684	Neur	104 (15.2)		1.05 (0.82–1.36)c
a Gen: general anesthesia; Neur: neuraxial anesthesia.
b Inability to walk without human assistance at 60 days.
c Equivalent standardized mean difference: 0.04 (95% CI, -0.13 to 0.20).

Table 13. Physical functional status and instrument in randomized clinical trials comparing neuraxial to general anesthesia.

Study	N	Arm	Agea	Scaleb	Range	Days	Ratinga	SMD (95% CI)
30-90 days
Purwar 2015	28	Gen	65.1 (12.5)	SF-36 physical	0→100	84	44.2 (8.3)
	31	Neur	60.6 (11.5)				47.1 (12.7)	0.26 (-0.25 to 0.78)
Neuman 2021	242	Gen	78.4 (10.6)	WHODAS 2.0	0←100	60	18 [6-32]
	225	Neur	77.7 (10.7)				23 [8-43]	0.36 (0.18 to 0.55)
Sciberras 2022	101	Gen	68.0 {61-71}	WOMACc	0←96	90	17.5 (14.6)d
	99	Neur	68.0 {62-70}				15.0 (13.9)d	-0.18 (-0.45 to 0.10)
>90 days
Sciberras 2022	101	Gen	68.0 {61-71}	WOMACc	0←96	180	13.8 (15.3)d
	99	Neur	68.0 {62-70}				13.6 (14.6)d	-0.01 (-0.29 to 0.26)
SMD: standardized mean difference; Gen: general; Neur: neuraxial.
a Mean Med (SD)[Range]{IQR}.
b Arrow direction indicates better functional outcome.
c Composite WOMAC includes pain, stiffness, and physical function. Physical function accounts for 68 of the 96 points.
d Standard deviations derived from confidence intervals and appear small, but are consistent with reported statistical results.

Pooled

Figure 9. Pooled standardized mean differences for physical functional status at 30 to 90 days. Lower represents better with neuraxial anesthesia.

Equivalent OR 1.02 (95% CI, 0.50–2.14).
Using Neuman 2021 primary result from 1385 participants in a sensitivity analysis yield a pooled SMD -0.07 (95% CI, -0.25 to 0.12) and equivalent OR 0.89 (95% CI, 0.63–1.24).

Complications

Table 14. Complications reported for neuraxial versus general anesthesia — cardiovascular, stroke, renal, pulmonary, and reintubation.

Study	N	Arm	Age	Surgery	N (%)	0 – 100%	RD (95% CI)
MI
Parker 2015	164	Gen	83.0 [59-99]	Ortho	1 (0.6)		—
	158	Neur	82.9 [25-105]		1 (0.6)		0.0% (-1.7, 1.7)
Liang 2017	66	Gen	68.0 (11.0)	Ortho	2 (3.0)		—
	66	Neur	67.0 (12.0)		1 (1.5)		-1.5% (-6.6, 3.6)
	66	Neur	66.0 (10.0)		2 (3.0)		0.0% (-5.8, 5.8)
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	9 (1.1)		—
	783	Neur	77.7 (10.7)		6 (0.8)		-0.4% (-1.3, 0.6)
Li 2022	471	Gen	77.0 {71-82}	Ortho	0 (0)		—
	471	Neur	77.0 {72-82}		1 (0.2)		0.2% (-0.4, 0.8)
Brown 2021	106	Gen	72.0 {69-76}	Spine	0 (0)		—
	111	Neur	73.0 {69-78}		1 (0.9)		0.9% (-1.6, 3.4)
Cardiac Arrest
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	0 (0)		—
	783	Neur	77.7 (10.7)		2 (0.3)		0.3% (-0.2, 0.7)
Other Cardiac
Wongyingsinn 2020a	18	Gen	67.7 (15.1)	GI/Abd	3 (16.7)		—
	18	Neur	64.9 (10.3)		2 (11.1)		-5.6% (-28.1, 17.0)
Chu 2006b	30	Gen	69.0 {62-74}	Ortho	2 (6.7)		—
	30	Neur	65.0 {62-68}		0 (0)		-6.7% (-17.2, 3.9)
Parker 2015c	164	Gen	83.0 [59-99]	Ortho	3 (1.8)		—
	158	Neur	82.9 [25-105]		0 (0)		-1.8% (-4.2, 0.5)
Shin 2020d	60	Gen	79.4 (7.7)	Ortho	3 (5.0)		—
	58	Gen	80.5 (6.7)		2 (3.4)		-1.6% (-8.8, 5.7)
	58	Neur	81.6 (6.7)		2 (3.4)		-1.6% (-8.8, 5.7)
Bielka 2021a	29	Gen	73.0 {72-74}	Ortho	1 (3.4)		—
	29	Neur	72.0 {70-73}		3 (10.3)		6.9% (-6.0, 19.8)
Li 2022e,f	471	Gen	77.0 {71-82}	Ortho	4 (0.8)		—
	471	Neur	77.0 {72-82}		3 (0.6)		-0.2% (-1.3, 0.9)
Carron 2007a	20	Gen	62.6 (10.7)	Other	0 (0)		—
	20	Neur	65.5 (16.8)		1 (5.0)		5.0% (-7.8, 17.8)
Nishikawa 2007ba	40	Gen	73.0 (6.0)	Urol	0 (0)		—
	40	Neur	71.0 (6.0)		0 (0)		0.0% (-4.8, 4.8)
Rasmussen 2003g	217	Gen	70.8 [61-84]	Various	2 (0.9)		—
	211	Neur	71.1 [61-84]		3 (1.4)		0.5% (-1.5, 2.5)
Stroke
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	7 (0.9)		—
	783	Neur	77.7 (10.7)		5 (0.6)		-0.2% (-1.1, 0.6)
Li 2022	471	Gen	77.0 {71-82}	Ortho	1 (0.2)		—
	471	Neur	77.0 {72-82}		0 (0)		-0.2% (-0.8, 0.4)
Brown 2021	106	Gen	72.0 {69-76}	Spine	0 (0)		—
	111	Neur	73.0 {69-78}		2 (1.8)		1.8% (-1.2, 4.8)
AKI/Renal Failure
Parker 2015h	164	Gen	83.0 [59-99]	Ortho	2 (1.2)		—
	158	Neur	82.9 [25-105]		0 (0)		-1.2% (-3.3, 0.8)
Liang 2017h	66	Gen	68.0 (11.0)	Ortho	1 (1.5)		—
	66	Neur	67.0 (12.0)		0 (0)		-1.5% (-5.6, 2.6)
	66	Neur	66.0 (10.0)		0 (0)		-1.5% (-5.6, 2.6)
Neuman 2021i	793	Gen	78.4 (10.6)	Ortho	55 (6.9)		—
	783	Neur	77.7 (10.7)		32 (4.1)		-2.8% (-5.1, -0.6)
Brown 2021i	106	Gen	72.0 {69-76}	Spine	0 (0)		—
	111	Neur	73.0 {69-78}		1 (0.9)		0.9% (-1.6, 3.4)
Pulmonary
Shin 2020	60	Gen	79.4 (7.7)	Ortho	4 (6.7)		—
	58	Gen	80.5 (6.7)		5 (8.6)		2.0% (-7.6, 11.5)
	58	Neur	81.6 (6.7)		4 (6.9)		0.2% (-8.8, 9.3)j,k
Pneumonia
Chu 2006	30	Gen	69.0 {62-74}	Ortho	1 (3.3)		—
	30	Neur	65.0 {62-68}		0 (0)		-3.3% (-12.1, 5.4)
Parker 2015	164	Gen	83.0 [59-99]	Ortho	3 (1.8)		—
	158	Neur	82.9 [25-105]		2 (1.3)		-0.6% (-3.3, 2.1)
Liang 2017	66	Gen	68.0 (11.0)	Ortho	1 (1.5)		—
	66	Neur	67.0 (12.0)		0 (0)		-1.5% (-5.6, 2.6)
	66	Neur	66.0 (10.0)		1 (1.5)		0.0% (-4.2, 4.2)
Bielka 2021	29	Gen	73.0 {72-74}	Ortho	4 (13.8)		—
	29	Neur	72.0 {70-73}		1 (3.4)		-10.3% (-24.5, 3.9)
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	16 (2.0)		—
	783	Neur	77.7 (10.7)		8 (1.0)		-1.0% (-2.2, 0.2)
Li 2022	471	Gen	77.0 {71-82}	Ortho	1 (0.2)		—
	471	Neur	77.0 {72-82}		0 (0)		-0.2% (-0.8, 0.4)
Brown 2021	106	Gen	72.0 {69-76}	Spine	0 (0)		—
	111	Neur	73.0 {69-78}		2 (1.8)		1.8% (-1.2, 4.8)
Pulmonary Congestion
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	8 (1.0)		—
	783	Neur	77.7 (10.7)		9 (1.1)		0.1% (-0.9, 1.2)
Pulmonary Embolism
Harsten 2013	60	Gen	68.0 (7.0)	Ortho	1 (1.7)		—
	60	Neur	67.0 (7.0)		1 (1.7)		0.0% (-4.6, 4.6)
Parker 2015	164	Gen	83.0 [59-99]	Ortho	2 (1.2)		—
	158	Neur	82.9 [25-105]		0 (0)		-1.2% (-3.3, 0.8)
Liang 2017	66	Gen	68.0 (11.0)	Ortho	2 (3.0)		—
	66	Neur	67.0 (12.0)		0 (0)		-3.0% (-8.0, 2.0)
	66	Neur	66.0 (10.0)		1 (1.5)		-1.5% (-6.6, 3.6)
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	5 (0.6)		—
	783	Neur	77.7 (10.7)		4 (0.5)		-0.1% (-0.9, 0.6)
Brown 2021	106	Gen	72.0 {69-76}	Spine	1 (0.9)		—
	111	Neur	73.0 {69-78}		1 (0.9)		-0.0% (-2.6, 2.5)
Rasmussen 2003	217	Gen	70.8 [61-84]	Various	2 (0.9)		—
	211	Neur	71.1 [61-84]		0 (0)		-0.9% (-2.5, 0.6)
Reintubation
Neuman 2021	793	Gen	78.4 (10.6)	Ortho	7 (0.9)		—
	783	Neur	77.7 (10.7)		4 (0.5)		-0.4% (-1.2, 0.4)
Gen: general anesthesia; Neur: neuraxial; RD: risk difference; Ortho: orthopedic; GI: gastrointestinal; Abd: abdominal; PE: pulmonary embolism; Ophtho: ophthalmologic; AKI: acute kidney injury.
a Bradycardia.
b Tachycardia.
c Arrhythmia.
d MI, heart failure, new onset arrhythmia.
e Bradycardia or tachycardia.
f Also reported hypo- (12.3% vs. 9.8%) or hypertension (3.8% vs. 12.8%), and left heart failure (0.9% vs. 0%).
g Unspecified adverse cardiac events.
h Renal failure
i AKI
j Verus combined general arms — RD 0.7% (-8.8 to 7.4), RR 0.90 (0.28–2.81).
k With general arms combined RR 0.90 (95% CI, 0.29–2.81).

Pooled

Myocardial Infarction

Figure 10. Risk ratio for myocardial infarction.

Bradycardia

Figure 11. Risk ratio for bradycardia.

Carron 2007: ≤40 bpm, Nishikawa 2007b: <50 bpm, Wongyingsinn 2020: <60 bpm or ↓, Bielka 2021: NR.
Prediction interval not displayed due to limited events.

Stroke

Figure 12. Risk ratio for stroke.

Acute Kidney Injury

Figure 13. Risk ratio for acute kidney injury.

Pneumonia

Figure 14. Risk ratio for pneumonia.

Pulmonary Embolism

Figure 15. Risk ratio for pulmonary embolism.

Patient Satisfaction

Table 15. Patient satisfaction comparing higher versus lower categories according to neuraxial or general anesthesia.

Study	N	Anesth	ASA	Agea	N (%)	0 – 100%	RD (95% CI)
			PS
Orthopedic
Harsten 2015	60	Gen	123	68.0 (9.0)	55 (91.7)b		—
	58	Neur		66.0 (7.8)	45 (77.6)b		-14.1% (-26.9, -1.3)
Meuret 2018	21	Gen	123	85.0 (5.0)	15 (71.4)c		—
	19	Neur		83.0 (6.0)	17 (89.5)c		18.0% (-5.7, 41.8)
Xu 2020	80	Gen	NR	75.4 (5.6)	69 (86.2)d		—
	160	Neur		75.6 (5.5)	66 (82.5)d		3.1% (-5.8, 12.1)
Neuman 2022	661	Gen	1234	78.0 (11.0)	564 (85.3)e		—
	647	Neur		78.0 (11.0)	562 (86.9)e		1.5% (-2.2, 5.3)
Urologic
Salonia 2004	34	Gen	NR	66.0 (6.8)	32 (94.1)b		—
	36	Neur		65.3 (6.9)	35 (97.2)b		3.1% (-6.5, 12.7)
Nishikawa 2007b	40	Gen	12	73.0 (6.0)	32 (80.0)f		—
	40	Neur		71.0 (6.0)	28 (70.0)f		-10.0% (-28.9, 8.9)
Ornek 2010	30	Gen	23	70.0 (9.6)	22 (73.3)g		—
	30	Neur		76.4 (11.8)	25 (83.3)g		10.0% (-10.7, 30.7)
Neurosurgical
Apan 2016	25	Gen	123	62.7 (14.3)	24 (96.0)b		—
	25	Neur		67.0 (10.4)	22 (88.0)b		-8.0% (-22.9, 6.9)
Vascular
Nesek-Adam 2012	20	Gen	23	61.2 (10.5)	12 (60.0)b		—
	20	Neur		60.6 (9.7)	18 (90.0)b		30.0% (4.8, 55.2)
Other
Carron 2007	20	Gen	123	62.6 (10.7)	14 (70.0)b		—
	20	Neur		65.5 (16.8)	18 (90.0)b		20.0% (-4.0, 44.0)
Gen: general; Neur: neuraxial; Anesth: anesthetic; ASA PS: ASA Physical Status; RD: risk difference.
a Mean (SD).
b Satisfied.
c Excellent/good
d Not specified
e Satisfaction with all aspects of anesthesia care
f Very satisfied
g Very good

Pooled

Figure 16. Risk ratio comparing higher versus lower categories of patient satisfaction.

Pooled effect weights dominated by Neuman 2022 (62%), Salonia (12%), and Xu 2020 (11%).

Length of Stay

Table 16. Length of stay according to procedure classification.

Study	N	Anesth	PSa	Ageb	LOSb	0 – 20 days	Country
Orthopedic
Chu 2006	30	Gen	123	69.0 {62-74}	9.0 {7-10}		China
	30	Neur	123	65.0 {62-68}	7.5 {6-11}
Harsten 2013	60	Gen	123	68.0 (7.0)	3.0 [1-4]		Sweden
	60	Neur	123	67.0 (7.0)	3.0 [1-4]
Parker 2015	164	Gen	1234	83.0 [59-99]	15.9 (13.7)		UK
	158	Neur	1234	82.9 [25-105]	16.2 (14.6)
Tzimas 2018	33	Gen	123	75.1 (6.1)	8.2		Greece
	37	Neur	123	77.1 (6.5)	8.2
Shin 2020	60	Gen	NR	79.4 (7.7)	6.5 {5-9}		South Korea
	58	Gen	NR	80.5 (6.7)	7.0 {5-9}
	58	Neur	NR	81.6 (6.7)	7.0 {5-11}
Xu 2020	80	Gen	NR	75.4 (5.6)	4.3 (0.9)		China
	80	Neur	NR	75.6 (5.5)	4.1 (1.1)
	80	Neur	NR	75.0 (5.2)	4.2 (0.9)
Neuman 2021 (Canada)	211	Gen			6.0 {5-10}		Canada
	210	Neur			6.0 {4-9}
Neuman 2021 (USA)	593	Gen			3.0 {3-5}		USA
	585	Neur			3.0 {2-5}
Ren 2021	154	Gen	123	74.1 (4.2)	9.2 (2.1)		China
	127	Neur	123	73.1 (6.2)	9.0 (2.1)
Li 2022	471	Gen	1234	77.0 {71-82}	7.0 {6-10}		China
	471	Neur	1234	77.0 {72-82}	7.0 {5-10}
Various
Rasmussen 2003	217	Gen	1234	70.8 [61-84]	8.0 [2-20]		Denmark
	211	Neur	1234	71.1 [61-84]	9.0 [2-21]
Gastrointestinal/Abdominal
Jia 2014	116	Gen	NR	74.8 (4.0)	13.2 (1.3)		China
	117	Neur	NR	75.7 (4.2)	9.0 (1.8)
Other
Carron 2007	20	Gen	123	62.6 (10.7)	9.1 (6.3)		Italy
	20	Neur	123	65.5 (16.8)	7.2 (3.4)
Spine
Brown 2021	106	Gen	NR	72.0 {69-76}	3.0 {2-3}		USA
	111	Neur	NR	73.0 {69-78}	3.0 {2-3}
Anesth: anesthetic; NR: not reported.
a ASA Physical Status.
b Mean Med (SD)[Range]{IQR}.

Pooled

Figure 17. Mean difference in lengths of stay.

Discharge Location

Table 17. Discharge location in studies comparing neuraxial with general anesthesia.

Study	N	Arm	Agea	Country	Discharge to Institution		RR (95% CI)
					N (%)	0 — 100%
Randomized Clinical Trial — Orthopedic
Neuman 2021	777	Gen	78.4 (10.6)	USA	586 (75.4)
	777	Neur	77.7 (10.7)		576 (74.1)		0.98 (0.93-1.04)
O’Brien 2023 (dementia)	279	Gen		USA	233 (83.5)
	292	Neur			208 (71.2)		0.85 (0.78-0.93)
O’Brien 2023 (no dementia)	437	Gen		USA	297 (68.0)
	431	Neur			297 (68.9)		1.01 (0.93-1.11)
Gen: general; Neur: neuraxial; RR: risk ratio.
a Mean Med (SD)[Range]{IQR}.

Mortality

Table 18. Reported in-hospital, 30-day, and 1-year mortality.

Study	N	Arm	Surgery	ASA	Agea	Mortality		RD (95% CI)
				PS		N (%)	0 - 100%
Hospital
Rasmussen 2003	217	Gen	Various	1234	70.8 [61-84]	3 (1.4)		—
	211	Neur			71.1 [61-84]	0 (0)		-1.4% (-3.2, 0.4)
Harsten 2013	60	Gen	Ortho	123	68.0 (7.0)	0 (0)		—
	60	Neur			67.0 (7.0)	0 (0)		0.0% (-3.2, 3.2)
Shin 2020	60	Gen	Ortho	NR	79.4 (7.7)	1 (1.7)		—
	58	Gen			80.5 (6.7)	0 (0)		-1.7% (-6.2, 2.9)
	58	Neur			81.6 (6.7)	2 (3.4)		1.8% (-3.9, 7.5)
Brown 2021	106	Gen	Spine	NR	72.0 {69-76}	1 (0.9)		—
	111	Neur			73.0 {69-78}	0 (0)		-0.9% (-3.5, 1.6)
Neuman 2021	790	Gen	Ortho	1234	78.4 (10.6)	13 (1.6)		—
	782	Neur			77.7 (10.7)	5 (0.6)		-1.0% (-2.1, 0.0)
30-day
Parker 2015	164	Gen	Ortho	1234	83.0 [59-99]	8 (4.9)		—
	158	Neur			82.9 [25-105]	5 (3.2)		-1.7% (-6.0, 2.6)
Harsten 2015	60	Gen	Ortho	123	68.0 (9.0)	0 (0)		—
	58	Neur			66.0 (7.8)	0 (0)		0.0% (-3.3, 3.3)
Meuret 2018	21	Gen	Ortho	123	85.0 (5.0)	0 (0)		—
	19	Neur			83.0 (6.0)	0 (0)		0.0% (-9.3, 9.3)
Shin 2020	60	Gen	Ortho	NR	79.4 (7.7)	2 (3.3)		1.7% (-3.9, 7.2)
	58	Gen			80.5 (6.7)	1 (1.7)		0.1% (-4.6, 4.7)
	58	Neur			81.6 (6.7)	1 (1.7)		0.1% (-4.6, 4.7)
Li 2022	464	Gen	Ortho	1234	77.0 {71-82}	4 (0.9)		—
	469	Neur			77.0 {72-82}	8 (1.7)		0.8% (-0.6, 2.3)
90-day
Rasmussen 2003	217	Gen	Various	1234	70.8 [61-84]	1 (0.5)		-0.9% (-2.7, 0.9)
	211	Neur			71.1 [61-84]	0 (0)		-1.4% (-3.2, 0.4)
Parker 2015	164	Gen	Ortho	1234	83.0 [59-99]	12 (7.3)		2.4% (-2.7, 7.6)
	158	Neur			82.9 [25-105]	12 (7.6)		2.7% (-2.6, 8.0)
Shin 2020	60	Gen	Ortho	NR	79.4 (7.7)	3 (5.0)		3.3% (-3.1, 9.7)
	58	Gen			80.5 (6.7)	2 (3.4)		1.8% (-3.9, 7.5)
	58	Neur			81.6 (6.7)	3 (5.2)		3.5% (-3.1, 10.1)
1-year
Parker 2015	164	Gen	Ortho	1234	83.0 [59-99]	19 (11.6)		6.7% (0.8, 12.6)
	158	Neur			82.9 [25-105]	32 (20.3)		15.4% (8.3, 22.5)
ASA PS: American Society of Anesthesiologists Physical Status; RD: risk difference; GI: gastrointestinal; Abd: abdominal (includes hepatic); Various: more that one procedure category.
a Mean Med (SD)[Range]{IQR}.

Pooled

Figure 18. Risk ratio for hospital or 30-day mortality.

Hip fracture RR 0.75 (95% CI, 0.34–1.64)
Other RR 0.20 (95% CI, 0.02–1.71)

Figure 19. Risk difference (per 1000) for hospital or 30-day mortality.

Hip fracture RD -3.6 (95% CI, -16.6 to 9.5)
Other RD -8.8 (95% CI, -21.1 to 3.6)

Figure 20. Risk ratio for 90-day mortality.

Figure 21. Risk difference (per 1000) for 90-day mortality.

Risk of Bias

Figure 22. Summary risk of bias assessments for randomized clinical trials (unweighted).

Figure 23. Summary risk of bias assessments for randomized clinical trials (weighted by sample size).

Figure 24. Risk of bias assessments for randomized clinical trials.

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